Published: Apr 7, 2014 | Updated: Apr 8, 2014
By Todd Neale, Senior Staff Writer, MedPage Today
Action Points
- Many strokes are potentially missed in emergency departments (EDs) in the days before the problems become obvious, a retrospective study found.
- Note that about one in every 10 of those potential misses were ED visits that ended with a discharge diagnosis of headache or dizziness, and those were considered probable missed strokes.
Many strokes may be missed in emergency departments (EDs) in the days before the problems become obvious, a retrospective study suggested.
Of 187,188 admissions for stroke, 12.7% were associated with an ED visit in the preceding 30-day period that ended with any non-cerebrovascular diagnosis, indicating a potentially missed stroke, according to David Newman-Toker, MD, of Johns Hopkins University in Baltimore, and colleagues.
About one in every 10 of those potential misses were ED visits that ended with a discharge diagnosis of headache or dizziness, and those were considered probable missed strokes, the researchers reported online in Diagnosis.
Several types of patients, including those younger than 45, women, and those from minority groups, had an increased likelihood of experiencing a missed stroke.
“This study provides some immediate suggestions to ED physicians who are evaluating patients with these symptoms — be more attuned to the possibility of stroke in younger, female, and non-white patients,” Newman-Toker and colleagues wrote.
“Though ‘simple’, indiscriminate use of neuroimaging will not prove an effective strategy to detect stroke in these patients,” they added. “Instead, clinicians should leverage well-studied bedside methods to identify dizziness and headache patients at high risk for stroke.”
Stroke is commonly missed diagnosis, with one study showing that “preventable deaths from stroke are attributed to diagnostic error over 30 times more often than deaths from myocardial infarction,” according to the authors.
Non-traditional stroke symptoms have been associated with a greater likelihood of missed diagnosis, but less information is available on demographic or healthcare system factors that might predispose to a missed stroke.
To explore the issue, Newman-Toker and colleagues performed a retrospective analysis of inpatient discharge and ED records from the 2009 Healthcare Cost and Utilization Project State Inpatient Databases, and from the 2008-2009 State ED Databases from nine states.
Of all stroke admissions identified, there were 23,809 potentially missed strokes in the prior 30 days, which included 2,243 probable missed strokes (ED visits with a discharge diagnosis of benign headache or dizziness).
Extrapolating those figures to the 1.3 million new or recurrent strokes or transient ischemic attacks in the U.S. each year, the researchers estimated that there could be 15,000 to 165,000 misdiagnosed cerebrovascular events annually.
Men were less likely than women to have a probable missed diagnosis (OR 0.75), and the odds of having a probable missed diagnosis declined with age compared with younger adults younger than 45.
“It is probably not surprising that stroke, generally considered a disease of the elderly, would be misdiagnosed in the young,” the authors noted.
Compared with privately insured patients, those covered by Medicare, Medicaid, or “other” payers had lower odds of probable missed diagnoses (ORs 0.63 to 0.70).
Patients from racial/ethnic minorities — including blacks (OR 1.18), Asian/Pacific Islanders (OR 1.29), and Hispanics (OR 1.30) — were more likely to have a missed diagnosis, as were those who left the ED against medical advice (OR 2.94).
In terms of hospital characteristics, non-teaching status (OR 1.45) and low volume (OR 1.57) were associated with a greater likelihood of missed diagnoses, whereas centers in small metropolitan areas had lower odds compared with those from large metropolitan areas.
The authors acknowledged some limitations of their study, including the lack of information on whether there were any errors in the diagnostic process or whether the misdiagnosis was preventable or caused harm, the lack of chart review to confirm missed diagnoses, and the inability to capture strokes that didn’t result in readmission.
They said that further research is needed to confirm the findings and that it “should seek to identify targeted error-reduction interventions to reduce stroke misdiagnosis and improve patient outcomes at reasonable cost.”
The analysis and preparation of the study manuscript were funded by the Agency for Healthcare Research and Quality.
The authors disclosed no relevant relationships with industry. However, authors from Truven Health Analytics were under contract to the Agency for Healthcare Research and Quality, and Newman-Toker was under contract to Truven Health Analytics.
From the American Heart Association:
- An Updated Definition of Stroke for the 21st Century
- Guidelines for the Early Management of Patients with Acute Ischemic Stroke
- Guidelines for the Primary Prevention of Stroke
- Guidelines for the Prevention of Stroke in Women
- Interactions within Stroke Systems of Care
Primary source: Diagnosis