Now you see me: a pragmatic cohort study comparing first and final radiological diagnoses in the emergency department

Mattsson, Björn; Ertman, David; Exadaktylos, Aristomenis K.; Martinolli, Luca; Hautz, Wolf E.

doi:10.1136/bmjopen-2017-020230

Cited by 11 publications

(16 citation statements)

References 28 publications

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“…A previous retrospective record review in internal medicine [15] and a review of diagnostic error in primary care [66] found similar associations. Previous studies also found patient age [67–69], gender [66, 68], or chief complaint [42, 44, 61, 62] to be associated with diagnostic error, others, [67] including ours, did not.…”

Section: Discussionsupporting

confidence: 64%

Diagnostic error increases mortality and length of hospital stay in patients presenting through the emergency room

Hautz

Kämmer

Hautz

et al. 2019

Scand J Trauma Resusc Emerg Med

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Background Diagnostic errors occur frequently, especially in the emergency room. Estimates about the consequences of diagnostic error vary widely and little is known about the factors predicting error. Our objectives thus was to determine the rate of discrepancy between diagnoses at hospital admission and discharge in patients presenting through the emergency room, the discrepancies’ consequences, and factors predicting them. Methods Prospective observational clinical study combined with a survey in a University-affiliated tertiary care hospital. Patients’ hospital discharge diagnosis was compared with the diagnosis at hospital admittance through the emergency room and classified as similar or discrepant according to a predefined scheme by two independent expert raters. Generalized linear mixed-effects models were used to estimate the effect of diagnostic discrepancy on mortality and length of hospital stay and to determine whether characteristics of patients, diagnosing physicians, and context predicted diagnostic discrepancy. Results 755 consecutive patients (322 [42.7%] female; mean age 65.14 years) were included. The discharge diagnosis differed substantially from the admittance diagnosis in 12.3% of cases. Diagnostic discrepancy was associated with a longer hospital stay (mean 10.29 vs. 6.90 days; Cohen’s d 0.47; 95% confidence interval 0.26 to 0.70; P = 0.002) and increased patient mortality (8 (8.60%) vs. 25(3.78%); OR 2.40; 95% CI 1.05 to 5.5 P = 0.038). A factor available at admittance that predicted diagnostic discrepancy was the diagnosing physician’s assessment that the patient presented atypically for the diagnosis assigned (OR 3.04; 95% CI 1.33–6.96; P = 0.009). Conclusions Diagnostic discrepancies are a relevant healthcare problem in patients admitted through the emergency room because they occur in every ninth patient and are associated with increased in-hospital mortality. Discrepancies are not readily predictable by fixed patient or physician characteristics; attention should focus on context. Trial registration https://bmjopen.bmj.com/content/6/5/e011585 Electronic supplementary material The online version of this article (10.1186/s13049-019-0629-z) contains supplementary material, which is available to authorized users.

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Section: Discussionsupporting

confidence: 64%

Diagnostic error increases mortality and length of hospital stay in patients presenting through the emergency room

Hautz

Kämmer

Hautz

et al. 2019

Scand J Trauma Resusc Emerg Med

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“…The study thus compares the EDs radiology based diagnoses to a gold standard. When compared to this gold standard of a certified radiologist, one third of the differences identified were judged clinically relevant by two independent expert raters [ 2 ].…”

Section: Introductionmentioning

confidence: 99%

Patient safety culture in a university hospital emergency department in Switzerland – a survey study

Ricklin

Hess

Hautz

2019

GMS Journal for Medical Education; 36(2):Doc14

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“…The authors also noted that EPs have the benefit of making a diagnosis on clinical grounds rather than just a static image and, therefore, the EP treatment may have been appropriate 7. In a 2018 study performed in Switzerland the authors examined discrepancies in interpretations for various imaging modalities, and in subgroup analysis of radiographs they found a discrepancy rate of 17.9% with a clinically significant disagreement rate of 5.67% 13…”

Section: Discussionmentioning

confidence: 99%

Radiograph Interpretation Discrepancies in a Community Hospital Emergency Department

Tranovich

Gooch

Dougherty

2019

WestJEM

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Introduction In many hospitals, off-hours emergency department (ED) radiographs are not read by a radiologist until the following morning and are instead interpreted by the emergency physician (EP) at the time of service. Studies have found conflicting results regarding the radiographic interpretation discrepancies between EPs and trained radiologists. The aim of this study was to identify the number of radiologic interpretation discrepancies between EPs and radiologists in a community ED setting. Methods Using a pre-existing logbook of radiologic discrepancies as well as our institution’s picture archiving and communication system, all off-hours interpretation discrepancies between January 2012 and January 2015 were reviewed and recorded in a de-identified fashion. We recorded the type of radiograph obtained for each patient. Discrepancy grades were recorded based on a pre-existing 1–4 scale defined in the institution’s protocol logbook as Grade 1 (no further action needed); Grade 2 (call to the patient or pharmacy); Grade 3 (return to ED for further treatment, e.g., fracture not splinted); Grade 4 (return to ED for serious risk, e.g., pneumothorax, bowel obstruction). We also recorded the total number of radiographs formally interpreted by EPs during the prescribed time-frame to determine overall agreement between EPs and radiologists. Results There were 1044 discrepancies out of 16,111 EP reads, indicating 93.5% agreement. Patients averaged 48.4 ± 25.0 years of age and 53.3% were female; 25.1% were over-calls by EPs. The majority of discrepancies were minor with 75.8% Grade 1 and 22.3% Grade 2. Only 1.7% were Grade 3, which required return to the ED for further treatment. A small number of discrepancies, 0.2%, were Grade 4. Grade 4 discrepancies accounted for two of the 16,111 total reads, equivalent to 0.01%. A slight disagreement in finding between EP and radiologist accounted for 8.3% of discrepancies. Conclusion Results suggest that plain radiographic studies can be interpreted by EPs with a very low incidence of clinically significant discrepancies when compared to the radiologist interpretation. Due to rare though significant discrepancies, radiologist interpretation should be performed when available. Further studies are needed to determine the generalizability of this study to EDs with differing volume, patient population, acuity, and physician training.

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Now you see me: a pragmatic cohort study comparing first and final radiological diagnoses in the emergency department

Cited by 11 publications

References 28 publications

Diagnostic error increases mortality and length of hospital stay in patients presenting through the emergency room

Diagnostic error increases mortality and length of hospital stay in patients presenting through the emergency room

Patient safety culture in a university hospital emergency department in Switzerland – a survey study

Radiograph Interpretation Discrepancies in a Community Hospital Emergency Department

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