Unrecognized Cardiovascular Emergencies Among Medicare Patients

Abstract

described diagnostic error as the next frontier in patient safety and highlighted a critical need for better measurement tools.OBJECTIVES To estimate the proportions of emergency department (ED) visits attributable to symptoms of imminent ruptured abdominal aortic aneurysm (AAA), acute myocardial infarction (AMI), stroke, aortic dissection, and subarachnoid hemorrhage (SAH) that end in discharge without diagnosis; to evaluate longitudinal trends; and to identify patient characteristics independently associated with missed diagnostic opportunities. DESIGN, SETTING, AND PARTICIPANTS This was a retrospective cohort study of all Medicare claims for 2006 to 2014. The setting was hospital EDs in the United States. Participants included all fee-for-service Medicare patients admitted to the hospital during 2007 to 2014 for the conditions of interest. Hospice enrollees and patients with recent skilled nursing facility stays were excluded. MAIN OUTCOMES AND MEASURESThe proportion of potential diagnostic opportunities missed in the ED was estimated using the difference between observed and expected ED discharges within 45 days of the index hospital admissions as the numerator, basing expected discharges on ED use by the same patients in earlier months. The denominator was estimated as the number of recognized emergencies (index hospital admissions) plus unrecognized emergencies (excess discharges). RESULTS There were 1 561 940 patients, including 17 963 hospitalized for ruptured AAA, 304 980 for AMI, 1 181 648 for stroke, 19 675 for aortic dissection, and 37 674 for SAH. The mean (SD) age was 77.9 (10.3) years; 8.9% were younger than 65 years, and 54.1% were female. The proportions of diagnostic opportunities missed in the ED were as follows: ruptured AAA (3.4%; 95% CI, 2.9%-4.0%), AMI (2.3%; 95% CI, 2.1%-2.4%), stroke (4.1%; 95% CI, 4.0%-4.2%), aortic dissection (4.5%; 95% CI, 3.9%-5.1%), and SAH (3.5%; 95% CI, 3.1%-3.9%). Longitudinal trends were either nonsignificant (AMI and aortic dissection) or increasing (ruptured AAA, stroke, and SAH). Patient characteristics associated with unrecognized emergencies included age younger than 65 years, dual eligibility for Medicare and Medicaid coverage, female sex, and each of the following chronic conditions: end-stage renal disease, dementia, depression, diabetes, cerebrovascular disease, hypertension, coronary artery disease, and chronic obstructive pulmonary disease.CONCLUSIONS AND RELEVANCE Among Medicare patients, opportunities to diagnose ruptured AAA, AMI, stroke, aortic dissection, and SAH are missed in less than 1 in 20 ED presentations. Further improvement may prove difficult.

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

“…5 In the emergency department (ED), the likelihood varies widely by diagnosis and ranges from 0.6% to 35%. [6][7][8][9][10][11][12] Many diagnostic errors are associated with the potential for moderate to severe harm. 13 Previous studies on closed ED malpractice claims have demonstrated that most errors are the result of a failure to make a diagnosis.…”

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

“…Diagnostic delays are increasingly being recognized as an important threat to patient safety [ 21 ]. To date, little is known about the incidence of and risk factors for diagnostic delays, and most prior work has focused on myocardial infarction and stroke [ 19 ]. Beyond diseases affecting the cardiovascular system, diagnostic delays associated with infectious diseases may be especially important to consider, given that delays in the treatment of infectious diseases are associated with worse clinical outcomes [ 22–27 ], herpes simplex encephalitis is one such disease.…”

“…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.…”

Understanding diagnostic processes in emergency departments: a mixed methods case study protocol

“…Sampling, eligibility, recruitment, informed consent and data collection Part 1: individual patient case as the unit of observation Sampling We will use purposive sampling of patients presenting to the ED who are at higher risk for diagnostic mishaps such as those with undifferentiated symptoms of abdominal pain, fever, chest pain or shortness of breath. [22][23][24][25][26][27] While data has linked chest pain symptoms with a wide range of never-miss conditions, 23 27 limited research has explored shortness of breath and never-miss conditions. Both symptoms will be included as they represent undifferentiated symptoms commonly seen in the ED that have been associated with missed diagnosis.…”