Missed Serious Neurologic Conditions in Emergency Department Patients Discharged With Nonspecific Diagnoses of Headache or Back Pain

Abstract

Twitter: @ndubosh.Study objective: Serious neurologic conditions can be missed on initial emergency department (ED) visit and discharge diagnosis oftentimes remains a nonspecific symptom. We aim to examine the incidence of potential harm from serious neurologic conditions in ED patients discharged with a nonspecific diagnosis of headache or back pain, identify specific missed conditions, and determine risk factors for potential misdiagnosis-related harm.Methods: This was a retrospective analysis using the population-based data of 6 US states from the State Emergency Department Databases and State Inpatient Databases from 2006 through 2012. We identified adults (18 years) discharged from the ED with a diagnosis of atraumatic headache or back pain. The primary outcome was a composite of return ED visit and hospitalization for primary diagnosis of a serious neurologic condition or inhospital death within 30 days of ED discharge.Results: There were 2,101,081 ED discharges with a nonspecific diagnosis of headache and 1,381,614 discharges with a nonspecific diagnosis of back pain. Overall, 0.5% of the headache patients and 0.2% of back pain patients had a primary outcome. The most common missed condition for headache was ischemic stroke (18.1%). The most common missed condition for back pain was intraspinal abscess (41%). In both populations, advanced age, male sex, non-Hispanic white, and comorbidities (eg, neurologic disorders, HIV/AIDS, malignancy) were associated with higher odds of outcome.Conclusion: A small proportion of ED patients discharged with nonspecific diagnoses of headache or back pain returned with a serious neurologic condition or inhospital death within 30 days.

Rates of Presentation, Treatments and Serious Neurologic Disorders Among Children and Young Adults Presenting to US Emergency Departments With Headache

“…We identified the presence of serious neurologic disorders using International Classification of Diseases, 9th and 10th Revision ( ICD-9 and ICD-10 ) , Clinical Modification diagnosis codes. For this, we used a list of codes developed based on prior studies 25 -27 (Supplementary Table 1). NHAMCS allows the assignment of 3 emergency department diagnosis codes to each encounter.…”

Diagnostic Challenges in Outpatient Stroke: Stroke Chameleons and Atypical Stroke Syndromes

“… 71 Similarly, a study using administrative claims data from six states estimated that around 0.5% of all ED headache patients may be misdiagnosed at index ED visit, as evidenced by a hospitalization for dangerous neurological disease shortly after their index ED visit. 72 Rates of stroke misdiagnosis among patients who complain of headache in the outpatient setting are, to our knowledge, unknown.…”

Akuter Kopfschmerz als Notfallsymptom

“…Manchem besorgten Patienten mit einem offenbar primären, jedenfalls harmlosen Kopfschmerzsyndrom mag die Auskunft helfen, dass ein Hirntumor bei isoliertem Kopfschmerz im Alter unter 50 Jahren nur bei 0,1 % zu finden sein wird [8,18]. Werden Patienten mit unspezifischen Kopfschmerzen ohne eingehende Diagnostik aus der Notaufnahme entlassen, wird in nur 0,5 % eine Wiederaufnahme wegen einer gravierenden neurologischen Erkrankung (v. a. Schlaganfall) innerhalb der nächsten 30 Tage notwendig [9].…”