Factors Associated With Potentially Missed Diagnosis of Appendicitis in the Emergency Department

Abstract

IMPORTANCE Appendicitis may be missed during initial emergency department (ED) presentation.OBJECTIVE To compare patients with a potentially missed diagnosis of appendicitis (ie, patients with symptoms associated with appendicitis, including abdominal pain, constipation, nausea and/or vomiting, fever, and diarrhea diagnosed within 1-30 days after initial ED presentation) with patients diagnosed with appendicitis on the same day of ED presentation to identify factors associated with potentially missed appendicitis. DESIGN, SETTING, AND PARTICIPANTSIn this cohort study, a retrospective analysis of commercially insured claims data was conducted from January 1 to December 15, 2019. Patients who presented to the ED with undifferentiated symptoms associated with appendicitis between January 1, 2010, and December 31, 2017, were identified using the Clinformatics Data Mart administrative database (Optum Insights). The study sample comprised eligible adults (aged Ն18 years) and children (aged <18 years) who had previous ED visits within 30 days of an appendicitis diagnosis. MAIN OUTCOMES AND MEASURESPotentially missed diagnosis of appendicitis. Adjusted odds ratios (AORs) for abdominal pain and its combinations with other symptoms associated with appendicitis were compared between patients with a same-day diagnosis of appendicitis and patients with a potentially missed diagnosis of appendicitis. RESULTSOf 187 461 patients with a diagnosis of appendicitis, a total of 123 711 (66%; 101 375 adults [81.9%] and 22 336 children [18.1%]) were eligible for analysis. Among adults, 51 923 (51.2%) were women, with a mean (SD) age of 44.3 (18.2) years; among children, 9631 (43.1%) were girls, with a mean (SD) age of 12.2 (18.2) years. The frequency of potentially missed appendicitis was 6060 of 101 375 adults (6.0%) and 973 of 22 336 children (4.4%). Patients with isolated abdominal pain (adults, AOR, 0.65; 95% CI, 0.62-0.69; P < .001; children, AOR, 0.79; 95% CI, 0.69-0.90; P < .001) or with abdominal pain and nausea and/or vomiting (adults, AOR, 0.90; 95% CI, 0.84-0.97; P = .003; children, AOR, 0.84; 95% CI, 0.71-0.98; P = .03) were less likely to have missed appendicitis. Patients with abdominal pain and constipation (adults, AOR, 1.51; 95% CI, 1.31-1.75; P < .001; children, AOR, 2.43; 95% CI, 1.86-3.17; P < .001) were more likely to have missed appendicitis. Stratified by the presence of undifferentiated symptoms, women (abdominal pain, AOR, 1.68; 95% CI, 1.58-1.78; nausea and/or vomiting, AOR, 1.68; 95% CI, 1.52-1.85; fever, AOR, 1.32; 95% CI, 1.10-1.59; diarrhea, AOR, 1.19; 95% CI, 1.01-1.40; and constipation, AOR, 1.50; 95% CI, 1.24-1.82) and girls (abdominal pain, AOR, 1.64; 95% CI, 1.43-1.88; nausea and/or vomiting, AOR, 1.74; 95% CI, 1.42-2.13; fever, AOR, 1.55; 95% CI, 1.14-2.11; diarrhea, AOR, 1.80; 95% CI, 1.19-2.74; and constipation, AOR, 1.25; 95% CI, 0.88-1.78) as well as patients with a comorbidity index of 2 or greater (adults, abdominal pain, AOR, 3.33; 95% CI, 3.09-3.60; nausea and/or vomiting, AOR, 3.66; 95% CI, ...

Monitoring Diagnostic Safety Risks in Emergency Departments: Protocol for a Machine Learning Study

“…Trigger 5: nonadmitted returns New diagnosis or symptom-disease dyads (eg dizziness-stroke [33] and abdominal pain-appendicitis [34]). Trigger 6: high-risk conditions a ED: emergency department.…”

Operational measurement of diagnostic safety: state of the science

“…Whereas direct reports from patients and clinicians may offer unique insights, HCOs may also be ready to use large datasets to uncover trends in diagnostic performance and events that are not otherwise easily identified. Administrative and billing data are widely available in most modern HCOs and have been proposed as one source of data for detecting missed opportunities for accurate and timely diagnosis [64][65][66]. For example, diagnosis codes assigned at successive clinical encounters may be used as a proxy for the evolution of a clinical diagnosis; if significant discrepancies are found, it may lead to a search for reasons [44].…”

“…For example, diagnosis codes assigned at successive clinical encounters may be used as a proxy for the evolution of a clinical diagnosis; if significant discrepancies are found, it may lead to a search for reasons [44]. Using symptom-disease-based dyads, such as abdominal pain followed by appendicitis a few days later or dizziness followed by stroke, are examples of this approach [66,67].…”

Value of laboratory investigation data for the diagnostic of acute appendicitis in children

“…У типових випадках діагностика ГА не складає труднощів. Проте, клінічні прояви можуть бути не чіткими, а симптоми частково співпадати з іншою патологією, зокрема у дівчат-підлітків, дітей до трьох років, пацієнтів з надмірною вагою тощо [7,17]. Окрім того, труднощі у діагностиці ГА виникають у випадках наявності в дитини дізурії, закрепів або діареї, симптомів інфекційних захворювань верхніх дихальних шляхів, нечітко вираженого напруження м'язів у правій клубовій ділянці або симптомів подразнення очеревини, що підтверджують й інші дослідники [9].…”