By Greg Freeman
EXECUTIVE SUMMARY
Researchers claim an alarming number of patients are misdiagnosed in EDs. About 370,000 patients suffer serious harm each year from these errors.
- Emergency physicians say the conclusions are unfounded.
- Critics say the rate of harm is extrapolated from one death in Canada.
- Some of the data may not reflect recent advances in emergency medicine.
Investigators from the Agency for Healthcare Research and Quality (AHRQ) estimated more than 7 million people may be inaccurately diagnosed in hospital EDs every year, prompting concerns about patient safety and the potential for liability.1
However, emergency physicians (EPs) are sharply critical of the report. They say some of the conclusions are based on faulty interpretations of data.
The data suggest about 370,000 patients suffer serious harm from ED misdiagnoses every year. Researchers from Johns Hopkins University conducted the study under contract with AHRQ, analyzing data from 279 previous studies regarding the prevalence and effect of diagnostic errors in the ED. They found 7.4 million patients (5.7%) are misdiagnosed during 130 million ED visits every year, with 2.6 million (2%) suffering an adverse event. About 370,000 suffer serious harm, and 250,000 (0.2%) die, they reported. The top five diseases associated with serious misdiagnosis-related harms in the ED were stroke, myocardial infarction, aortic aneurysm or dissection, spinal cord compression or injury, and venous thromboembolism.
The risk of misdiagnosis was increased by the presence of nonspecific or atypical symptoms, researchers noted. Women and people of color reported a 20% to 30% higher risk of misdiagnosis.
The researchers concluded the estimated rate of misdiagnoses in the ED is relatively low, but the errors remain a “critically important patient safety concern.”
ACEP Pushes Back
The results of the AHRQ study were widely reported in the media. The emergency medicine community soon responded with criticism. The American College of Emergency Physicians (ACEP) and nine other emergency medicine organizations issued a letter questioning some of the methodology the researchers used to reach their conclusions.2
The letter authors noted while emergency medicine, like all other specialties, can improve, multiple findings in the report are “misleading, incorrectly interpreted, and, in several cases, incorrect. The initial request ... was to investigate opportunities to improve care in the ED. We see little in this report to identify such opportunities. Instead, we see a diagnostic error rate (derived from non-applicable European sources with training very different than that of the U.S.) and an analysis of malpractice data interpreted to be cognitive error.”
The authors of the letter expressed concern the report will “irresponsibly and falsely alarm the public and potentially lead them to delay or even forgo treatment for time-sensitive emergencies, while also undermining the relationship between patient and emergency physician. The intended effect of improving patient care and increasing patient safety may, in fact, paradoxically result in greater harm.”
Data Sources Questioned
The reaction to the report by Owais Durrani, DO, an emergency physician in Houston, was typical of many in the field.
“I was very dismayed and upset, if I’m being frank. When I saw that headline initially, I wondered where they got this data from,” Durrani says. “When I did some more digging, I realized it was a misrepresentation of what the practice of emergency medicine is in the United States. The numbers they came up with didn’t really hold water. A lot of that was extrapolated from foreign data, and some assumptions were made. It was not a true representation of reality.”
The criticism of emergency care was especially frustrating at a time when most ED physicians are overworked and EDs are understaffed, still trying to bounce back from the stress of the pandemic. Many of the report’s findings — and the most sensational statement that made headlines — were extrapolated from one study in Canada and another in Spain, Durrani says. That is problematic because their emergency medicine programs and training are different than those in the United States.
“On top of that, it was old data. We’ve made huge gains in diagnosing sepsis early and reducing substance-related mortality over the last five years,” Durrani notes. “We’re making assumptions off of data that’s not even U.S. data, and then it’s old data. If what they are saying is true, then doctors in the emergency system in the United States would be one of the top five causes of death, which would be a huge issue and a national emergency, but that’s not the case.”
Although EPs always seek an accurate diagnosis, it is not their primary goal. Ignoring this fact makes any rate of misdiagnosis seem worse. “The function of the ED is to not get the exact answer. It is to rule out life-threatening diagnoses,” Durrani says. “We as a society do not really know the role of the ED, and it leads to a lot of daily frustration. A lot of patients kind of expect that we should give them that exact answer, whereas we are really good at diagnosing life-threatening illnesses and treating you for those things.”
One Canadian Death
Kristen Panthagani, MD, PhD, a resident physician and Yale Emergency Scholar at Yale New Haven Hospital, also was critical of the AHRQ report. Panthagani notes the researchers’ literature review revealed one high-quality study and others that she says were much weaker.
The authors of the high-quality study assessed 503 patients discharged from two Canadian EDs in the late 2000s. One patient suffered an unexpected death that was related to a delay in diagnosis.
The Canadian study was legitimate, but the Johns Hopkins researchers drew faulty conclusions from it, Panthagani says. The sample size was not large enough to estimate how often misdiagnosis leads to death.
The authors of the AHRQ report did not respond to a request for comment, but they wrote a letter to the Wall Street Journal in response to Panthagani’s criticism in the newspaper.3 They noted her criticism of using the single Canadian death to estimate a death rate in the United States, saying it was a misrepresentation of their work.
“We triangulated data from multiple sources to validate the 0.2% death rate before extrapolating nationally. We analyzed two independent, high-quality studies that corroborate a 0.2% to 0.3% death rate,” the AHRQ authors wrote. “We showed that the 0.2% rate corresponds to 6.7% of ER-associated deaths being due to diagnostic error, which matches findings from autopsy studies on the percentage of deaths that are due to misdiagnosis (5.2% to 13%).”
Panthagani stands by her criticism. “Their response suggests I failed to acknowledge or address the other studies they cited in attempt to corroborate the 0.2% death rate. This is false,” she says. “I addressed the other studies briefly in my Wall Street Journal article4 and linked to a detailed explanation that goes through each study.”
REFERENCES
- Newman-Toker DE, Peterson SM, Badihian S, et al. Diagnostic errors in the emergency department: A systematic review. Dec. 15, 2022.
- Multi-organizational letter regarding AHRQ report on diagnostic errors in the emergency department. Dec. 14, 2022.
- Newman-Toker D, Robinson K. Misdiagnosis meets overdiagnosis in the ER. Jan. 4, 2023.
- Panthagani K. A study sounds a false alarm about America’s emergency rooms. Dec. 29, 2022.
SOURCES
- Owais Durrani, DO, Houston. Email: [email protected].
- Kristen Panthagani, MD, PhD, Yale New Haven Hospital, Connecticut. Email: [email protected].
Investigators from AHRQ estimated more than 7 million people may be inaccurately diagnosed in hospital EDs every year, prompting concerns about patient safety and the potential for liability. However, emergency physicians are sharply critical of the report. They say some of the conclusions are based on faulty interpretations of data.
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