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Unrecognized Cardiovascular Emergencies Among Medicare Patients

Educational Objective
To estimate the proportions of emergency department visits attributable to symptoms of imminent ruptured abdominal aortic aneurysm, acute myocardial infarction, stroke, aortic dissection, and subarachnoid hemorrhage that end in discharge home without diagnosis.
1 Credit CME
Key Points

Question  Of emergency department visits attributable to imminent ruptured abdominal aortic aneurysm, acute myocardial infarction, stroke, aortic dissection, and subarachnoid hemorrhage, what proportions end in discharge home without diagnosis?

Findings  In this cohort study of Medicare claims, the proportion of missed opportunities to diagnose these conditions in the emergency department ranged from 2.3% (ruptured abdominal aortic aneurysm) to 4.5% (aortic dissection). We found no evidence for improvement across the 2007 to 2014 study time frame.

Meaning  Among Medicare patients, opportunities to diagnose these conditions in the emergency department are missed infrequently, but further improvement may prove difficult.

Abstract

Importance  The Institute of Medicine described diagnostic error as the next frontier in patient safety and highlighted a critical need for better measurement tools.

Objectives  To estimate the proportions of emergency department (ED) visits attributable to symptoms of imminent ruptured abdominal aortic aneurysm (AAA), acute myocardial infarction (AMI), stroke, aortic dissection, and subarachnoid hemorrhage (SAH) that end in discharge without diagnosis; to evaluate longitudinal trends; and to identify patient characteristics independently associated with missed diagnostic opportunities.

Design, Setting, and Participants  This was a retrospective cohort study of all Medicare claims for 2006 to 2014. The setting was hospital EDs in the United States. Participants included all fee-for-service Medicare patients admitted to the hospital during 2007 to 2014 for the conditions of interest. Hospice enrollees and patients with recent skilled nursing facility stays were excluded.

Main Outcomes and Measures  The proportion of potential diagnostic opportunities missed in the ED was estimated using the difference between observed and expected ED discharges within 45 days of the index hospital admissions as the numerator, basing expected discharges on ED use by the same patients in earlier months. The denominator was estimated as the number of recognized emergencies (index hospital admissions) plus unrecognized emergencies (excess discharges).

Results  There were 1 561 940 patients, including 17 963 hospitalized for ruptured AAA, 304 980 for AMI, 1 181 648 for stroke, 19 675 for aortic dissection, and 37 674 for SAH. The mean (SD) age was 77.9 (10.3) years; 8.9% were younger than 65 years, and 54.1% were female. The proportions of diagnostic opportunities missed in the ED were as follows: ruptured AAA (3.4%; 95% CI, 2.9%-4.0%), AMI (2.3%; 95% CI, 2.1%-2.4%), stroke (4.1%; 95% CI, 4.0%-4.2%), aortic dissection (4.5%; 95% CI, 3.9%-5.1%), and SAH (3.5%; 95% CI, 3.1%-3.9%). Longitudinal trends were either nonsignificant (AMI and aortic dissection) or increasing (ruptured AAA, stroke, and SAH). Patient characteristics associated with unrecognized emergencies included age younger than 65 years, dual eligibility for Medicare and Medicaid coverage, female sex, and each of the following chronic conditions: end-stage renal disease, dementia, depression, diabetes, cerebrovascular disease, hypertension, coronary artery disease, and chronic obstructive pulmonary disease.

Conclusions and Relevance  Among Medicare patients, opportunities to diagnose ruptured AAA, AMI, stroke, aortic dissection, and SAH are missed in less than 1 in 20 ED presentations. Further improvement may prove difficult.

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Article Information

Accepted for Publication: December 18, 2017.

Corresponding Author: Daniel A. Waxman, MD, PhD, RAND, 1776 Main St, Santa Monica, CA 90407 (dwaxman@rand.org).

Published Online: February 26, 2018. doi:10.1001/jamainternmed.2017.8628

Author Contributions: Dr Waxman had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Waxman, Schriger.

Obtained funding: Waxman.

Administrative, technical, or material support: Kanzaria.

Study supervision: Waxman.

Conflict of Interest Disclosures: Dr Schriger received salary support through an unrestricted grant from the Korein Foundation. No other conflicts are reported.

Funding/Support: RAND provided programming support for this project. Data access for Dr Waxman was supported through an interagency agreement between the Office of the Assistant Secretary for Planning and Evaluation (ASPE) (US Department of Health & Human Services) and the Centers for Medicare & Medicaid Services for the research and analysis.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: Asa Wilks, MPA, provided programming assistance, and Carolyn Rutter, PhD, helped develop the methods at an early phase in the project. Both are affiliated with RAND. No compensation was received.

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