Delayed diagnosis of serious paediatric conditions in 13 regional emergency departments

Abstract

ObjectiveTo evaluate rates, risk factors and outcomes of delayed diagnosis of seven serious paediatric conditions.MethodsThis was a retrospective, cross-sectional study of children under 21 years old visiting 13 community and tertiary emergency departments (EDs) with appendicitis, bacterial meningitis, intussusception, mastoiditis, ovarian torsion, sepsis or testicular torsion. Delayed diagnosis was defined as having a previous ED encounter within 1 week in which the condition was present per case review. Patients with delayed diagnosis were each matched to four control patients without delay by condition, facility and age. Conditional logistic regression models evaluated risk factors of delay. Complications were compared between by delayed diagnosis status.ResultsAmong 14 972 children, delayed diagnosis occurred in 1.1% (range 0.3% for sepsis to 2.6% for ovarian torsion). Hispanic (matched OR 2.71, 95% CI 1.69 to 4.35) and non-Hispanic black (OR 2.40, 95% CI 1.21 to 4.79) race/ethnicity were associated with delayed diagnosis, whereas Asian and other race/ethnicity were not. Public (OR 2.21, 95% CI 1.42 to 3.44) and other (OR 2.43, 95% CI 1.50 to 3.93) insurance were also associated with delay. Non-English language was associated with delay (OR 1.65, 95% CI 1.02 to 2.69). Abnormal vital signs were associated with a lower likelihood of delay (OR 0.15, 95% CI 0.09 to 0.25). In an adjusted model, Hispanic race/ethnicity, other insurance, abnormal vital signs and complex chronic conditions (CCCs) were associated with delay. The odds of a complication were 2.5-fold (95% CI 1.6 to 3.8) higher among patients with a delay.ConclusionDelayed diagnosis was uncommon across 13 regional EDs but was more likely among children with Hispanic ethnicity, CCCs or normal vital signs. Delays were associated with a higher risk of complications.

Moving upstream to address diagnostic disparities

“…While individual studies of both cardiovascular and neurologic symptoms demonstrated diagnostic disparities linked with ethnicity or insurance status, in pooled analysis, no consistent associations were identified. These findings add to the growing evidence base of diagnostic disparities across many clinical conditions such as delayed appendicitis diagnosis in Black children, overdiagnosis of schizophrenia in Black individuals, and delayed dementia diagnosis in Asian and Hispanic/Latinx individuals 4–9…”

Emergency Department Volume and Delayed Diagnosis of Serious Pediatric Conditions

“…We then performed conditional logistic regression with the outcome of possible delayed diagnosis and sole covariate of log 2 pediatric ED volume, conditioned on the matched set. 3 The goal of this matched analysis was to control for condition, CCC, and age, which we believed to be the most important risks for delayed diagnosis. We used log volume to report the relative odds of delayed diagnosis with each 2-fold increase in volume.…”

“…In the all-conditions model, we matched each case patient (those with possible delayed diagnoses) to 4 control patients by condition (exact match), CCC (exact match), and age (nearest neighbor matched on continuous age). We then performed conditional logistic regression with the outcome of possible delayed diagnosis and sole covariate of log 2 pediatric ED volume, conditioned on the matched set . The goal of this matched analysis was to control for condition, CCC, and age, which we believed to be the most important risks for delayed diagnosis.…”

“…Children are at particular risk of diagnostic delays because serious illness may be more subtle, varying developmental states render children less able to communicate specific symptoms, and pediatric clinical presentations overlap with far more common, nonserious illness. Diagnostic delays put children at higher risk of illness complications . Structural differences between EDs may also play a role in diagnostic delays and illness complications: most EDs primarily provide clinical care for adults, and one-third of US EDs evaluate fewer than 5 children per day, leading to variable experience and clinician comfort caring for children …”

“…Diagnostic delays put children at higher risk of illness complications. 3,4 Structural differences between EDs may also play a role in diagnostic delays and illness complications: most EDs primarily provide clinical care for adults, and one-third of US EDs evaluate fewer than 5 children per day, leading to variable experience and clinician comfort caring for children. 5,6 Pediatric volume is a measure of EDs' pediatric experience.…”