Government Study of Emergency Department Errors Riddled With Errors

In December, the Agency for Healthcare Research and Quality (AHRQ) published a report claiming that up to 250,000 people die each year from misdiagnosis in emergency department (ED). National media outlets quickly picked story, breathless headlines ensured. Emergency care was named leading cause of death United States, behind heart disease, cancer, COVID-19. A swift backlash promptly erupted. The American College Physicians (ACEP) 9 other professional medical organizations penned letter saying they were “deeply concerned” about 744-page report, which found incorrect, misleading, unnecessarily disparaging. Chief among their concerns use faulty data, including malpractice lawsuits overextrapolation. Reviewers study, Dr. Jesse Pines, MD, MBA, Director Clinical Innovation at US Acute Care Solutions, who also technical expert on complained comments fell deaf ears. Leaders ACEP urged1ACEP's Concern with AHRQ Report Diagnostic ErrorsAmerican Physicians.https://www.acep.org/federal-advocacy/ahrqreport/Date: 2023Google Scholar delay publication, writing “we are deeply concerned publishing this document would have negative implications both our current workforce future pipeline physicians, as well millions seek US.” According Gabe Kelen, professor chair medicine Johns Hopkins, didn’t review until late October asked re-open public comment period so could detail concerns. He says retract paper outright. delayed publication couple weeks make some edits soften claims, according but end, stood by original conclusions. It landed like gut punch field that—in wake COVID-19 pandemic—was still grappling staffing shortages record amounts physician burnout. “It has been pretty brutal all us,” said Kelen an Frontline podcast.2When Errors is Error: Review EM Errors.https://soundcloud.com/acep-frontline/when-a-report-on-errors-is-all-in-error-review-of-the-ahrq-report-on-em-diagnostic-errorsGoogle They felt claims sensational, wildly overstated, damaging. Many egregious will distract addressing issues ways improving them. Annals Medicine spoke prominent physicians understand what went wrong. Along way, offered perspective valid exist making diagnoses EDs how improve future. experts say authors used inappropriate data Any statistician knows extrapolation tricky business must rely large high quality data. rate diagnostic error harm calculated only 3 studies: “Spanish study,” which, closer inspection, Canary Islands, archipelago off coast Morocco, Swiss Canadian study looking specifically severity patients. These locales widely divergent systems do not necessarily resemble system. studies small, containing 1,758 patients, outdated, based information collected 15 20 years prior. From these small studies, leaped conclusion 5.7 percent ED patients receive wrong diagnosis 2 harmed result. “I think fully inadequate almost every way,” Lewis Nelson, Professor Chair Rutgers University. “To generalize few papers, different era geographical location doesn't sound methodological approach me,” he says. 5.7% Islands Switzerland, critics point out problems using generalizable conclusions health systems. For one, island community million people. Testing less common there—doctors order computed tomography scans mere 2% (compared 14% States), half undergo routine laboratory tests. Laboratory imaging tests ordered more frequently often verging overuse. definition errors problematic. Island counted returns “diagnostic errors,” roughly one-fourth result received after being discharged. measured discrepancy, error, 12% once admitted hospital. Richard Hamilton, President Society Academic Medicine, “the goal single time.” On average, gets 4 hours evaluate patient limited tools, tests, access patient’s history, “working diagnosis,” acts placeholder exams can be done. thinks lost sight important medicine, where stabilizing saving lives top priority rushed, chaotic environment. “If we implies rash minor complaint walks through door precisely defined, then going waiting room seen,” Christopher Carpenter, MSc, Washington University School Medicine. Carpenter there no scheduling ED, doctors need mindful time beds because get slammed anytime. you send home abdominal pain unclear etiology scan did show appendicitis, four later, see gastroenterologist finds irritable bowel syndrome, I don't consider myself having made mistake,” Hamilton Another issue way extrapolated. To calculate this, 2004 500 concluded one died error. came chest pain, referred cardiology elevated troponin levels, subsequently aortic dissection. determine serious applied it population. “This most my mind,” Ryan Snitowsky, Florida State “They never gave details death, entire States population excess deaths year…it’s absurd,” Even basic rudimentary knowledge statistics points underscore extrapolation. true 95 confidence interval give wide range annual rates ranging 6,500 1.4 million—a meaningless estimate. quick uses lawsuit tort law cases. Nelson known “numerator data” denominator know many treated had problem. call database draw very questionable approach,” adds Hamilton. represents adversarial system.” rife uncertainty. Worried arrive unannounced troubling symptoms. Without any history patient, best available tools pick subtle clues whether or safe go home. Chris enough research-backed decisionmaking tools; wants change that. want message complaints methods took,” Snitowsky agrees. defending itself ripping shreds,” “But something work on.” paucity evidence-based research medicine. overly focused accuracy, sensitivity, specificity, beyond compare high-tech approaches traditional explore cost-effectiveness, long-term outcomes, life. At present, clinical practice guidelines recurrent example. Patients may repeatedly over months, difficult risks benefits ordering repeated subsequent visits. systematic review3Venkatesh A.K. Savage D. Sandefur B. et al.Systematic guidelines: policy.PLoS One. 2017; 12e0178456Crossref Scopus (26) Google 2017 91 included randomized controlled trials. momentum—such is—generated fund techniques. same given cancer screening evaluated cost, benefit, unintended harm. “We those higher levels evidence everything department,” working develop around difficult-to-diagnose symptoms dizziness. guidelines—called Guidelines Reasonable Appropriate Department GRACE Guidelines—highlight approaches. example, come feeling dizzy. Vertigo symptom benign, atypical stroke. creating protocols assess its threat life-threatening condition help avoid mistakes. Pines “Avoiding needs central medicine,” conditions when comes benign complaint. address standardized approaches, example back causes rare Spinal compression due abscess such misdiagnosed. standard picking clues. addition, should hesitate consult specialists. Just pilots safety checklist before takeoff, too physicians. cost-effective impactful issue, funding,” Carpenter. “Without it, problem talking again years.”