AHRQ Study: Administrative Data Can Help Emergency Departments Avoid Missed Heart Attacks
A new AHRQ-funded study found that hospital administrative data contain information that may help emergency department (ED) staff identify populations at risk of experiencing a missed diagnosis of acute myocardial infarction (AMI). Researchers used 2007 data from AHRQ’s Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases to evaluate missed diagnoses in 111,973 admitted adult patients. They found 993 missed diagnoses, or nearly 1 percent of all patients who were admitted with AMI. The patients with a missed diagnosis had visited an ED with chest pain or cardiac conditions, were released and were subsequently admitted for AMI within a week. Patients who were African American or younger had higher odds of having a missed AMI diagnosis. AHRQ’s Ernest Moy, M.D., is a coauthor of the article, “Missed Diagnoses of Acute Myocardial Infarction in the E.D.: Variation by Patient and Facility Characteristics,” published in the February issue of the journal Diagnosis.
Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and facility characteristics
1Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850, USA
2ML Barrett, Inc, 13943 Boquita Drive, Del Mar, CA 92014, USA
3Truven Health Analytics, Inc., 7700 Old Georgetown Road, Suite 650, Bethesda, MD 20814, USA
4Truven Health Analytics and ML Barrett, Inc, 7700 Old Georgetown Road, Suite 650, Bethesda, MD 20814
5Department of Neurology, The Johns Hopkins University School of Medicine, Meyer Building 8-154, 600 North Wolfe Street, Baltimore, MD 21287, USA
©2014, Anika L. Hines et al., published by De Gruyter. This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License. (CC BY-NC-ND 3.0)
Background: An estimated 1.2 million people in the US have an acute myocardial infarction (AMI) each year. An estimated 7% of AMI hospitalizations result in death. Most patients experiencing acute coronary symptoms, such as unstable angina, visit an emergency department (ED). Some patients hospitalized with AMI after a treat-and-release ED visit likely represent missed opportunities for correct diagnosis and treatment. The purpose of the present study is to estimate the frequency of missed AMI or its precursors in the ED by examining use of EDs prior to hospitalization for AMI.
Methods: We estimated the rate of probable missed diagnoses in EDs in the week before hospitalization for AMI and examined associated factors. We used Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases for 2007 to evaluate missed diagnoses in 111,973 admitted patients aged 18 years and older.
Results: We identified missed diagnoses in the ED for 993 of 112,000 patients (0.9% of all AMI admissions). These patients had visited an ED with chest pain or cardiac conditions, were released, and were subsequently admitted for AMI within 7 days. Higher odds of having missed diagnoses were associated with being younger and of Black race. Hospital teaching status, availability of cardiac catheterization, high ED admission rates, high inpatient occupancy rates, and urban location were associated with lower odds of missed diagnoses.
Conclusions: Administrative data provide robust information that may help EDs identify populations at risk of experiencing a missed diagnosis, address disparities, and reduce diagnostic errors.
An estimated 1.2 million people in the US have an acute myocardial infarction (AMI) each year . In 2009, inpatient hospital costs for AMI were nearly 12 billion dollars . Although overall AMI mortality rates are declining , about 7% of all AMI hospitalizations in 2007 resulted in death [1, 4].
Most patients experiencing an acute coronary syndrome (ACS) (i.e., AMI or a precursor such as unstable angina) come through an emergency department (ED). EDs commonly evaluate patients presenting with chest pain and other symptoms suggestive of ACS with electrocardiograms and biochemical diagnostic tests. After evaluation, patients considered at high risk of AMI are hospitalized or held for observation until an AMI can be diagnosed or excluded, and patients considered at low risk are released with outpatient follow-up.
The decision to hospitalize or release is not always clear. Previous studies have estimated that 2% to 8% of patients with AMI are not diagnosed in the ED and are inadvertently released home [5–9]. These studies have been small – usually including fewer than a dozen hospitals. They have also focused on the characteristics of patients who are more likely to have missed diagnoses of AMI: women younger than 55 years, patients who are not White, and those who present with atypical features of cardiac ischemia [7, 10, 11]. Additional research with a larger number of patients would yield more generalizable estimates.
Some patients hospitalized with AMI after a treat-and-release ED visit likely represent missed opportunities for correct diagnosis and treatment . Although the effects of missed AMI diagnoses are not completely understood, some studies have found a nearly two-fold increase in the risk of death . Tracking rates of these missed diagnoses might allow providers to target specific patients and policy makers to target specific facilities for improvement. Furthermore, the ability to track missed diagnoses across a range of symptoms and problems would facilitate public health prioritization efforts to reduce misdiagnosis and mitigate harms .
The purpose of the present study is to estimate the frequency of missed AMI or its precursors (e.g., unstable angina) in the ED by examining use of EDs prior to hospitalization for AMI. We focus on patients evaluated for chest pain or cardiac conditions within 1 week of hospitalization; these patients were the most likely to have missed opportunities for diagnosis and intervention that might have reduced their risk for AMI. We use administrative data from the Healthcare Cost and Utilization Project (HCUP) – a family of databases that encompasses inpatient discharge data for over 95% of visits to hospitals in the US . We estimate the overall rate of missed diagnoses and examine the association between missed diagnoses and patient, ED, and hospital characteristics.