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DIAGNOSTIC AGREEMENT BETWEEN A COMPREHENSIVE, FAST-TRACK COMMUNITY HOSPITAL EMERGENCY DEPARTMENT We studied the group of patients attended at our ED and then transferred to the referral hospital in the year 2009, in order to determine the degree of agreement between our ED diagnosis and the definitive discharge diagnosis, and analyzed: a) the rate of misdiagnosis, b) possible relationship between misdiagnosis and epidemiological variables, c) the primary reasons for error, and d) possible mortality associated with these errors. Method We performed a prospective, observational, cohort study. The study population consisted of patients referred from our ED to the reference hospital during the year 2009. From the emergency medical history we gathered data on age, sex, origin of transfer and ED diagnosis. We then compared this diagnosis with that in the report from the referral hospital concerned. The diagnoses were coded according to International Classification of Diseases, 9th Edition, Clinical Modification. We considered diagnostic agreement as being the same diagnosis or, if not exactly the same, the syndrome was correctly identified, requiring action and/or tests not available at our hospital. Otherwise, the diagnosis was considered erroneous. In cases of misdiagnosis, we reviewed in detail the medical history and laboratory tests to determine if the reason for the error lay primarily in: a) inadequate clinical assessment (background, symptoms or signs, physical examination), b) radiological interpretation, c) laboratory analytical interpretation) electrocardiographic interpretation (in this group we analyzed cases to assess the impact of such interpretation on the treatment administered). We compared the variables analyzed for the group with and without diagnostic agreement. Descriptive analysis was performed using univariate and multivariate binary logistic regression. Results During the study period, a total of 50,461 emergency patients were attended; 1,598 (3.2%) were transferred, of whom 1,494 (93%) were transferred. The remaining 104 patients were mainly those who used their own means and subsequently consulted a specialist (ophthalmology, otolaryngology and pediatrics), but also those erroneously identified (mainly foreigners) and patients who ultimately decided not to attend the referral hospital. The reasons for transfer were to undergo specialized assessment and/or other diagnostic tests (imaging tests, invasive procedures or specific analytical microbiology). The mean age was 41.6 ± 30.0 years, 56% were male. As for the origin of transfer, the ED transferred 1,359 (91%) and the multi-purpose area 135 (9%). Diagnostic groups were distributed as follows: trauma 403 (27%), internal medicine 386 (25.8%), surgery 302 (20.2%), pediatrics 145 (9.7%), gynecology 118 (7 9%), ophthalmology 104 (7%) and otolaryngology 36 (2.4%). There was diagnostic agreement in 1,372 (91.8%) of the cases (87.2% coincided and 12.8% had correct identification of the syndrome), and 122 (8.2%) discordant diagnoses. The reasons for diagnostic error were inadequate clinical assessment in 85 cases (69.7%), radiological interpretation in 26 (21.3%), analytical interpretation in 7 (5.7%) and electrocardiographic interpretation in 4 (3.3%) cases. Table 1 lists the most common discordant diagnoses, grouped according to type of error. There were no deaths in this group of patients without diagnostic agreement. Univariate analysis of the groups with and without diagnostic agreement is shown in Table 2. The group without diagnostic agreement was younger, most commonly referred from the ED, and belonging to the pediatric diagnostic group. Table 1. Most frequent suspected diagnoses categorized according to reasons for error in the 122 patients without final diagnostic agreementwith the referral hospital Error in clinical assessment Radiological error Analytical error ECG error N = 85 (69,7%) N = 26 (21,3%) N = 7 (5,7%) N = 4 (3,3%) Soft tissue injury (11) Limb fracture (19) Respiratory infection (2) Arrhythmias (4) Infection in children (7) Vertebral fracture (3) Miscellaneous (5) Acute abdomen (6) Upper gastrointestinal bleeding (4) Acute coronary syndrome (4) Gastrointestinal disorders in children (4) Stroke (3) Ear disease (3) Miscellaneous * (43) Miscellaneous (4) *By specialties: surgery (12), internal medicine (8), pediatrics (7), ophthalmology (7), trauma (3), gynecology (3) otolaryngology (3). ECG: electrocardiography. Emergencias 2010; 22: 282-285 283
F. J. Mellado Vergel et al. Table 2. Univariate analysis in patient groups with and without diagnostic agreement Variables DA (N = 1.372) No DA (N = 122) p OR (IC95%) Age, mean ± SD 42.2 ± 24.7 35.2 ± 26.8 < 0.05 Sex, n (%) 0.24 Male 761 (55.5) 75 (61) 1 (reference) Female 609 (44.5) 48 (39) 0.8 (0.548-1.167) Origin of transfer, n (%) < 0.05 ED 1.241 (90.5) 118 (95.9) 1 (reference) Multipurpose area Diagnostic groups, n (%) 130 (9.5) 5 (4.1) 0.404 (0.162-1.008) Traumatology 367 (26.8) 36 (29.3) 0.55 1.132 (0.754-1.700)* Internal Medicine 357 (26) 29 (23.6) 0.55 0.876 (0.568-1.352)* Surgery 280 (20.4) 22 (17.9) 0.50 0.849 (0.525-1.371)* Pediatrics 124 (9) 21 (17.1) < 0.05 2.070 (1.250-3.429)* Gynecology 114 (8.3) 4 (3.3) 0.46 0.371 (0.134-1.022)* Ophthalmology 97 (7.1) 7 (5.7) 0.56 0.793 (0.360-1.747)* Otolaryngology 32 (2.3) 4 (3.3) 0.52 1.407 (0.489-4.04)* DA: diagnostic agreement. OR: odds ratio. CI: confidence interval. *The reference category is constituted by other patients. Binary logistic regression with these three variables was performed, and only age remained a significant variable, so the group of patients without diagnostic agreement were younger. Discussion With nearly 1,500 patients, the cohort analyzed is the largest published to date in Spain. It also has the peculiarity of including a wide range of diagnostic categories, covering many different specialties, and an age range from childhood to old age. A comparison of the diagnoses between our ED and the referral hospital showed a misdiagnosis rate of 8.2%. There is no established value against which to measure the quality of diagnosis of our center. The only reference values available are from previous studies that used different samples and methods of analysis, with a rate of misdiagnosis that varies widely, from a low 0.6% 11 4.6% 7 , 10.7% 5 , 14.6% 12 , and up to 19.7% 4 . A very important finding was that there were no deaths among any of the patients with no diagnostic agreement, a key factor in assessing health outcomes after medical errors. According to our results, sex, origin of transfer and diagnostic groups are not related to erroneous diagnoses, only age remained associated with no diagnostic agreement, a fact not found in other studies, where age was unrelated 7 , or increased age was associated with misdiagnosis, as in the work of Miret et al. 4 , but in this study the population studied presented advanced middle age (73 years). As for the different diagnostic groups, several studies have linked error with a wide variety of diagnoses 11-16 . As regards the reasons for error in our series, the main cause (69.7%) was inadequate clinical assessment, as found in other similar studies 4,7,11 with percentages between 40 and 55%. However, as indicated by Tudela et al. 7 , to interpret these results we must also consider the possibility that the initial clinical assessment was not incorrect, but in some cases the evolution of the disease involved increasing expressiveness and the final diagnosis only became evident after admission to the referral hospital. Errors of radiographic interpretation 17 were the second most common cause of error, and in our series they occurred predominantly when the diagnosis was trauma. As for errors in electrocardiographic interpretation, the four errors in our study were merely in classifying the type of arrhythmia, with no impact on the treatment administered. With these results it seems reasonable to suggest that a systematic clinical and radiological assessment and careful diagnosis could improve accuracy. The combination of experienced clinical professionals with more time for patient care and less ED workload could help to improve diagnostic agreement 7 . Certain limitations of our study should be noted; first, 7% of patients transferred to the referral hospital were lost to follow up, but on review it was found that these were cases of low morbidity and attended the referral hospital or other specialists using their own means. Second, the gold standard was the final diagnosis of the referral hospital, supported by the main criteria for referral, but this could occasionally be incorrect. Third, the limited number of cases in the group with no diagnostic agreement could have influenced some of our results. Finally, further studies on diagnostic agreement are required to establish acceptable limits, taking into account the peculiarities of each centre. Such 284 Emergencias 2010; 22: 282-285
Page 1: BRIEF REPORTS Diagnostic agreement

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