Study: Fewer Kids in the ED Means More Missed Diagnoses

Emergency departments (EDs) that saw fewer kids were more likely to have potentially delayed diagnoses for serious acute conditions in that population, a large retrospective cohort study showed.

For pediatric patients, the overall risk of possible delayed diagnosis — having an ED discharge within the 7 days prior to diagnosis — dropped by 26.7% (95% CI 22.5-30.7) for every two-fold increase in annual pediatric volume at the ED where they were seen, reported Kenneth Michelson, MD, MPH, of Lurie Children’s Hospital in Chicago, and colleagues.

Across 23 specific diagnoses, all except sinus venous thrombosis and ectopic pregnancy had a significantly lower risk of delayed diagnosis with higher pediatric ED volume, when adjusted for covariates, they noted in JAMA Pediatrics.

Stroke, which fell in the middle of the range of effect sizes, had a 26.5% (95% CI 11.1-39.3) decreased odds of possible delayed diagnosis per two-fold increase in volume. The strongest association was seen in pyloric stenosis, which had a 50.5% (95% CI 42.0-57.7) decreased odds of possible delayed diagnosis per two-fold increase in volume.

Michelson and colleagues noted that, in addition to factors like serious illness having the potential to be more subtle in children and young patients being less able to communicate specific symptoms, structural differences between EDs may contribute to diagnostic delays and complications.

“Understanding the types of conditions for which ED pediatric experience plays a role in delayed diagnosis would illuminate the potential impact of interventions that support high-quality diagnosis in such EDs,” they added.

The consistency of the findings across most conditions came as a surprise, Michelson told MedPage Today in an email. “It suggests lower volume EDs would benefit from supports to improve diagnosis.”

Overall, possible delayed diagnosis occurred in 9,296 of the 58,998 patients studied (15.8%, 95% CI 15.5-16.1), and 75.9% of those with possible delayed diagnosis had their index encounter within the 3 days preceding diagnosis, Michelson and colleagues reported.

Condition-specific complications were 11.2% (95% CI 3.1-20.0) more likely for patients with a possible delayed diagnosis than for those who did not experience a delay, Michelson and colleagues reported.

Specifically, complications were significantly more likely after a possible delayed diagnosis for patients with craniospinal abscess, deep neck infection, intussusception, myocarditis, orbital cellulitis, pyloric stenosis, septic arthritis, stroke, and testicular torsion.

Patients were identified using the Healthcare Cost and Utilization Project State ED and Inpatient Databases. The study included all individuals younger than age 18 who were treated at 954 EDs in eight states for a first-time diagnosis of any of the 23 conditions specified. Data were collected from January 2015 to December 2019.

Slightly more than 63% of children were male, and the mean age was 7.1 years. More than 11% of kids had a complex chronic condition.

Limitations included that some patients with possible delayed diagnosis had disease progression rather than a true delay, Michelson and colleagues noted. Also, certain conditions like sinus venous thrombosis were rare, which limited power, they added. Finally, several important conditions, such as those that are chronic or those without accurate diagnosis coding, were not included.