Missed acute myocardial infarction in the emergency department-standardizing measurement of misdiagnosis-related harms using the SPADE method

Adam L Sharp; Aileen Baecker; Najlla Nassery; Stacy Park; Ahmed Hassoon; Ming-Sum Lee; Susan Peterson; Samantha Pitts; Zheyu Wang; Yuxin Zhu; David E Newman-Toker

doi:10.1515/dx-2020-0049

Missed acute myocardial infarction in the emergency department-standardizing measurement of misdiagnosis-related harms using the SPADE method

Diagnosis (Berl). 2020 Jul 24;8(2):177-186. doi: 10.1515/dx-2020-0049. Print 2021 May 26.

Authors

Adam L Sharp^{1

2}, Aileen Baecker¹, Najlla Nassery³, Stacy Park¹, Ahmed Hassoon⁴, Ming-Sum Lee⁵, Susan Peterson⁶, Samantha Pitts³, Zheyu Wang⁷, Yuxin Zhu⁷, David E Newman-Toker^{4

6

8}

Affiliations

¹ Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States.
² Department of Health System Science, Kaiser Permanente School of Medicine, Pasadena, CA, United States.
³ Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
⁴ Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States.
⁵ Kaiser Permanente Southern California, Los Angeles Medical Center, Division of Cardiology, Los Angeles, CA, United States.
⁶ Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
⁷ Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States.
⁸ Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.

PMID: 32701479
DOI: 10.1515/dx-2020-0049

Abstract

Objectives: Diagnostic error is a serious public health problem. Measuring diagnostic performance remains elusive. We sought to measure misdiagnosis-related harms following missed acute myocardial infarctions (AMI) in the emergency department (ED) using the symptom-disease pair analysis of diagnostic error (SPADE) method.

Methods: Retrospective administrative data analysis (2009-2017) from a single, integrated health system using International Classification of Diseases (ICD) coded discharge diagnoses. We looked back 30 days from AMI hospitalizations for antecedent ED treat-and-release visits to identify symptoms linked to probable missed AMI (observed > expected). We then looked forward from these ED discharge diagnoses to identify symptom-disease pair misdiagnosis-related harms (AMI hospitalizations within 30-days, representing diagnostic adverse events).

Results: A total of 44,473 AMI hospitalizations were associated with 2,874 treat-and-release ED visits in the prior 30 days. The top plausibly-related ED discharge diagnoses were "chest pain" and "dyspnea" with excess treat-and-release visit rates of 9.8% (95% CI 8.5-11.2%) and 3.4% (95% CI 2.7-4.2%), respectively. These represented 574 probable missed AMIs resulting in hospitalization (adverse event rate per AMI 1.3%, 95% CI 1.2-1.4%). Looking forward, 325,088 chest pain or dyspnea ED discharges were followed by 508 AMI hospitalizations (adverse event rate per symptom discharge 0.2%, 95% CI 0.1-0.2%).

Conclusions: The SPADE method precisely quantifies misdiagnosis-related harms from missed AMIs using administrative data. This approach could facilitate future assessment of diagnostic performance across health systems. These results correspond to ∼10,000 potentially-preventable harms annually in the US. However, relatively low error and adverse event rates may pose challenges to reducing harms for this ED symptom-disease pair.

Keywords: chest pain; diagnostic errors; dyspnea; emergency medical services; health services research; healthcare disparities; myocardial infarction.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Chest Pain / diagnosis
Chest Pain / epidemiology
Chest Pain / etiology
Diagnostic Errors
Emergency Service, Hospital
Humans
Myocardial Infarction* / diagnosis
Retrospective Studies