Incidence, duration and risk factors associated with delayed and missed diagnostic opportunities related to tuberculosis: a population-based longitudinal study

Abstract

ObjectivesMissed opportunities to diagnose tuberculosis are costly to patients and society. In this study, we (1) estimate the frequency and duration of diagnostic delays among patients with active pulmonary tuberculosis and (2) determine the risk factors for experiencing a diagnostic delay.DesignA retrospective cohort study of patients with tuberculosis using longitudinal healthcare encounters prior to diagnosis.SettingCommercially insured enrollees from the Commercial Claims and Encounters or Medicare Supplemental IBM Marketscan Research Databases, 2001–2017.ParticipantsAll patients diagnosed with, and receiving treatment for, pulmonary tuberculosis, enrolled at least 365 days prior to diagnosis.Primary and secondary outcome measuresWe estimated the number of visits with tuberculosis-related symptoms prior to diagnosis that would be expected to occur in the absence of delays and compared this estimate to the observed pattern. We computed the number of visits representing a delay and used a simulation-based approach to estimate the number of patients experiencing a delay, number of missed opportunities per patient and duration of delays (ie, time between diagnosis and earliest missed opportunity). We also explored risk factors for missed opportunities.ResultsWe identified 3371 patients diagnosed and treated for active tuberculosis that could be followed up for 1 year prior to diagnosis. We estimated 77.2% (95% CI 75.6% to 78.7%) of patients experienced at least one missed opportunity; of these patients, an average of 3.89 (95% CI 3.65 to 4.14) visits represented a missed opportunity, and the mean duration of delay was 31.66 days (95% CI 28.51 to 35.11). Risk factors for delays included outpatient or emergency department settings, weekend visits, patient age, influenza season presentation, history of chronic respiratory symptoms and prior fluoroquinolone use.ConclusionsMany patients with tuberculosis experience multiple missed diagnostic opportunities prior to diagnosis. Missed opportunities occur most commonly in outpatient settings and numerous patient-specific, environment-specific and setting-specific factors increase risk for delays.

A comprehensive framework to estimate the frequency, duration and risk factors for diagnostic delays using simulation-based methods

“…This work expands upon the basic conceptual framework described as SPADE by Liberman et al 20 It also builds upon the methodological approach utilized by Waxman et al 17 to separate observed and expected trends in symptomatic visits prior to diagnosis. Moreover, this study generalizes the methods that the study authors have previously developed to investigate diagnostic delays associated with tuberculosis 18 and herpes simplex encephalitis. 19 The following sections summarize our approach along with three empirical applications and is organized as follows.…”

“…We build upon the distinction between observed and expected trends outlined by Waxman et al (2018) and our prior empirical work 18,19 to distinguish missed opportunities from coincidental care. Specifically, the red line in Figure 2, depicts the expected number of SSD visits -these represent SSD-related visits that would be expected to occur in the absence of diagnostic delays.…”

“…Numerous investigations have relied on algorithms to identify diagnostic delays based on commonly occurring symptom criteria such as cough, fever, pain, headaches, malaise and fatigue 8,9,12,16 , yet only a few have attempted to account for a coincidental or expected occurrence of such symptoms. [17][18][19] A growing number of investigators have begun to use longitudinal administrative and EMR-based data to identify diagnostic delays. 11,[20][21][22] These data allow both inpatient, outpatient or emergency department (ED) records to be used in a "look back" approach, where evidence of a disease (e.g., symptom codes) is identified in visits prior to the definitive diagnosis.…”

“…For example, visits associated with dizziness may be identified prior to a stroke diagnosis, 9,13 or cough and fever may be identified prior to a tuberculosis diagnosis. 16,18 Such visits are then considered potential missed opportunities if they occur during a specified diagnostic opportunity window -the time before the initial diagnosis where clinical disease may be present and where a diagnostic delay may occur (e.g., 10-days prior to a stroke diagnosis or 90-days prior to a tuberculosis diagnosis). This "look back" approach has been used to study a variety of diseases, including acute myocardial infarctions, strokes, subarachnoid hemorrhages, abdominal aortic aneurysms and tuberculosis, [8][9][10][11][12][13]16,17 and has recently been formalized more broadly as the SPADE (Symptom-Disease Pair Analysis of Diagnostic Error) framework.…”

Incidence, Duration, and Risk Factors Associated With Missed Opportunities to Diagnose Herpes Simplex Encephalitis: A Population-Based Longitudinal Study

“…To estimate the frequency and duration of missed opportunities, we used an approach similar to Waxman et al [ 19 ], which has also been used to identify diagnostic delays associated with tuberculosis [ 20 ]. This approach begins by using a case-crossover-type approach to estimate the likely number of missed opportunities based on SSD-associated visits.…”