Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology in an integrated health system

doi:10.1515/dx-2020-0145

. 2021 Apr 26;8(4):479-488.

doi: 10.1515/dx-2020-0145. Print 2021 Nov 25.

Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology in an integrated health system

Michael A Horberg^{1

2}, Najlla Nassery^{3

4}, Kevin B Rubenstein¹, Julia M Certa¹, Ejaz A Shamim^{1

5}, Richard Rothman⁶, Zheyu Wang⁷, Ahmed Hassoon^{4

8

9}, Jennifer L Townsend¹⁰, Panagis Galiatsatos¹¹, Samantha I Pitts³, David E Newman-Toker^{4

6

8

9}

Affiliations

¹ Mid-Atlantic Permanente Medical Group, Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA.
² Mid-Atlantic Permanente Medical Group, Department of Infectious Diseases, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA.
³ Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁴ Center for Diagnostic Excellence, Johns Hopkins Medicine, Armstrong Institute for Patient Safety and Quality, Baltimore, MD, USA.
⁵ Mid-Atlantic Permanente Medical Group, Department of Neurology, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA.
⁶ Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁷ Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
⁸ Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
⁹ Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
¹⁰ Division of Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
¹¹ Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

PMID: 33894108
DOI: 10.1515/dx-2020-0145

Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology in an integrated health system

Michael A Horberg et al. Diagnosis (Berl). 2021.

. 2021 Apr 26;8(4):479-488.

doi: 10.1515/dx-2020-0145. Print 2021 Nov 25.

Authors

Affiliations

¹ Mid-Atlantic Permanente Medical Group, Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA.
² Mid-Atlantic Permanente Medical Group, Department of Infectious Diseases, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA.
³ Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁴ Center for Diagnostic Excellence, Johns Hopkins Medicine, Armstrong Institute for Patient Safety and Quality, Baltimore, MD, USA.
⁵ Mid-Atlantic Permanente Medical Group, Department of Neurology, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA.
⁶ Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁷ Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
⁸ Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
⁹ Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
¹⁰ Division of Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
¹¹ Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

PMID: 33894108
DOI: 10.1515/dx-2020-0145

Abstract

Objectives: Delays in sepsis diagnosis can increase morbidity and mortality. Previously, we performed a Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) "look-back" analysis to identify symptoms at risk for delayed sepsis diagnosis. We found treat-and-release emergency department (ED) encounters for fluid and electrolyte disorders (FED) and altered mental status (AMS) were associated with downstream sepsis hospitalizations. In this "look-forward" analysis, we measure the potential misdiagnosis-related harm rate for sepsis among patients with these symptoms.

Methods: Retrospective cohort study using electronic health record and claims data from Kaiser Permanente Mid-Atlantic States (2013-2018). Patients ≥18 years with ≥1 treat-and-release ED encounter for FED or AMS were included. Observed greater than expected sepsis hospitalizations within 30 days of ED treat-and-release encounters were considered potential misdiagnosis-related harms. Temporal analyses were employed to differentiate case and comparison (superficial injury/contusion ED encounters) cohorts.

Results: There were 4,549 treat-and-release ED encounters for FED or AMS, 26 associated with a sepsis hospitalization in the next 30 days. The observed (0.57%) minus expected (0.13%) harm rate was 0.44% (absolute) and 4.5-fold increased over expected (relative). There was a spike in sepsis hospitalizations in the week following FED/AMS ED visits. There were fewer sepsis hospitalizations and no spike in admissions in the week following superficial injury/contusion ED visits. Potentially misdiagnosed patients were older and more medically complex.

Conclusions: Potential misdiagnosis-related harms from sepsis are infrequent but measurable using SPADE. This look-forward analysis validated our previous look-back study, demonstrating the SPADE approach can be used to study infectious disease syndromes.

Keywords: delirium; diagnostic error; emergency medical services; health services research; sepsis; water-electrolyte balance.

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References

1. Newman-Toker, DE, Schaffer, AC, Yu-Moe, CW, Nassery, N, Saber Tehrani, AS, Clemens, GD, et al.. Serious misdiagnosis-related harms in malpractice claims: the “Big Three” – vascular events, infections, and cancers. Diagnosis (Berl) 2019;6:227–40. https://doi.org/10.1515/dx-2019-0019.
1. National Academies of Sciences Engineering and Medicine. Improving diagnosis in health care. Balogh, EP, Miller, BT, Ball, JR, editors. Washington DC: The National Academies Press; 2015.
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1. Thomas, EJ, Studdert, DM, Burstin, HR, Orav, EJ, Zeena, T, Williams, EJ, et al.. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000;38:261–71. https://doi.org/10.1097/00005650-200003000-00003.
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[1] Newman-Toker, DE, Schaffer, AC, Yu-Moe, CW, Nassery, N, Saber Tehrani, AS, Clemens, GD, et al.. Serious misdiagnosis-related harms in malpractice claims: the “Big Three” – vascular events, infections, and cancers. Diagnosis (Berl) 2019;6:227–40. https://doi.org/10.1515/dx-2019-0019.

[2] Newman-Toker, DE, Schaffer, AC, Yu-Moe, CW, Nassery, N, Saber Tehrani, AS, Clemens, GD, et al.. Serious misdiagnosis-related harms in malpractice claims: the “Big Three” – vascular events, infections, and cancers. Diagnosis (Berl) 2019;6:227–40. https://doi.org/10.1515/dx-2019-0019.

[3] National Academies of Sciences Engineering and Medicine. Improving diagnosis in health care. Balogh, EP, Miller, BT, Ball, JR, editors. Washington DC: The National Academies Press; 2015.

[4] National Academies of Sciences Engineering and Medicine. Improving diagnosis in health care. Balogh, EP, Miller, BT, Ball, JR, editors. Washington DC: The National Academies Press; 2015.

[5] Leape, LL, Brennan, TA, Laird, N, Lawthers, AG, Localio, AR, Barnes, BA, et al.. The nature of adverse events in hospitalized patients. N Engl J Med 1991;324:377–84. https://doi.org/10.1056/nejm199102073240605.

[6] Leape, LL, Brennan, TA, Laird, N, Lawthers, AG, Localio, AR, Barnes, BA, et al.. The nature of adverse events in hospitalized patients. N Engl J Med 1991;324:377–84. https://doi.org/10.1056/nejm199102073240605.

[7] Thomas, EJ, Studdert, DM, Burstin, HR, Orav, EJ, Zeena, T, Williams, EJ, et al.. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000;38:261–71. https://doi.org/10.1097/00005650-200003000-00003.

[8] Thomas, EJ, Studdert, DM, Burstin, HR, Orav, EJ, Zeena, T, Williams, EJ, et al.. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000;38:261–71. https://doi.org/10.1097/00005650-200003000-00003.

[9] Zwaan, L, De Bruijne, M, Wagner, C, Thijs, A, Smits, M, Van Der Wal, G, et al.. Patient record review of the incidence, consequences, and causes of diagnostic adverse events. Arch Intern Med 2010;170:1015–21. https://doi.org/10.1001/archinternmed.2010.146.

[10] Zwaan, L, De Bruijne, M, Wagner, C, Thijs, A, Smits, M, Van Der Wal, G, et al.. Patient record review of the incidence, consequences, and causes of diagnostic adverse events. Arch Intern Med 2010;170:1015–21. https://doi.org/10.1001/archinternmed.2010.146.

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Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology in an integrated health system

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Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology in an integrated health system

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