Missed stroke in acute vertigo and dizziness: It is time for action, not debate

Newman‐Toker, David E.

doi:10.1002/ana.24532

Cited by 103 publications

(73 citation statements)

References 36 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…The answer to the latter question might be to "obtain neurologic consultation and neuroimaging in all patients with dizziness". However, this is not likely to be the correct answer to the former question, given that 97% of patients with dizziness do not have stroke as a cause [7]. The first question deals with a symptom-defined cohort, whereas the latter deals with a disease-defined cohort.…”

Section: Symptom-specific Approaches To Studying Diagnostic Strategiementioning

confidence: 99%

Identifying and analyzing diagnostic paths: a new approach for studying diagnostic practices

Rao

Epner²,

Bauer

et al. 2017

Diagnosis

Self Cite

View full text Add to dashboard Cite

Diagnostic error is a serious public health problem to which knowledge gaps and associated cognitive error contribute significantly. Identifying diagnostic approaches to common problems in ambulatory care associated with more timely and accurate diagnosis and lower cost and harm associated with diagnostic evaluation is an important priority for health care systems, clinicians, and of course patients. Unfortunately, guidance on how best to approach diagnosis in patients with common presenting complaints such as abdominal pain, dizziness, and fatigue is lacking. Exploring diagnostic practice variation and patterns of diagnostic evaluation is a potentially valuable approach to identifying best current diagnostic practices. A "diagnostic path" is the sequence of actions taken to evaluate a new complaint from first presentation until a diagnosis is established, or the evaluation ends for other reasons. A "big data" approach to identifying diagnostic paths from electronic health records can be used to identify practice variation and best practices from a large number of patients. Limitations of this approach include incompleteness and inaccuracy of electronic medical record data, the fact that diagnostic paths may not represent clinician thinking, and the fact that diagnostic paths may be used to identify best current practices, rather than optimal practices.

show abstract

Section: Symptom-specific Approaches To Studying Diagnostic Strategiementioning

confidence: 99%

Identifying and analyzing diagnostic paths: a new approach for studying diagnostic practices

Rao

Epner²,

Bauer

et al. 2017

Diagnosis

Self Cite

View full text Add to dashboard Cite

show abstract

“…2627 Imagine we are unsure of whether this symptom-disease pair (dizziness-stroke) is a real dyad 2628 or merely coincidental. We would note that, biologically speaking, dizziness/vertigo can be a manifestation of minor stroke or transient ischaemic attack (TIA).…”

Section: The Spade Approachmentioning

confidence: 99%

Symptom-Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological approach for unearthing misdiagnosis-related harms using big data

Liberman

Newman‐Toker

2018

BMJ Qual Saf

View full text Add to dashboard Cite

Background The public health burden associated with diagnostic errors is likely enormous, with some estimates suggesting millions of individuals are harmed each year in the USA, and presumably many more worldwide. According to the US National Academy of Medicine, improving diagnosis in healthcare is now considered ‘a moral, professional, and public health imperative.’ Unfortunately, well-established, valid and readily available operational measures of diagnostic performance and misdiagnosis-related harms are lacking, hampering progress. Existing methods often rely on judging errors through labour-intensive human reviews of medical records that are constrained by poor clinical documentation, low reliability and hindsight bias. Methods Key gaps in operational measurement might be filled via thoughtful statistical analysis of existing large clinical, billing, administrative claims or similar data sets. In this manuscript, we describe a method to guantify and monitor diagnostic errors using an approach we call ‘Symptom-Disease Pair Analysis of Diagnostic Error’ (SPADE). Results We first offer a conceptual framework for establishing valid symptom-disease pairs illustrated using the well-known diagnostic error dyad of dizziness-stroke. We then describe analytical methods for both look-back (casecontrol) and look-forward (cohort) measures of diagnostic error and misdiagnosis-related harms using ‘big data’. After discussing the strengths and limitations of the SPADE approach by comparing it to other strategies for detecting diagnostic errors, we identify the sources of validity and reliability that undergird our approach. Conclusion SPADE-derived metrics could eventually be used for operational diagnostic performance dashboards and national benchmarking. This approach has the potential to transform diagnostic quality and safety across a broad range of clinical problems and settings.

show abstract

“…Compared to those without dizziness, dizzy patients undergo more testing, more imaging, have longer ED lengths of stay, and are more likely to be admitted (1). In 2013, total health care–related costs for patients with dizziness in the United States was estimated to exceed ≥10 billion (3,4). Additional “costs” included adverse events, such as patient anxiety, injuries from falls, and preventable major strokes following misdiagnosed minor cerebrovascular events (5).…”

Section: Introductionmentioning

confidence: 99%

A New Diagnostic Approach to the Adult Patient with Acute Dizziness

Edlow

Gurley

Newman‐Toker

2018

The Journal of Emergency Medicine

Self Cite

View full text Add to dashboard Cite

Background Dizziness, a common chief complaint, has an extensive differential diagnosis that includes both benign and serious conditions. Emergency physicians must distinguish the majority of patients with self-limiting conditions from those with serious illnesses that require acute treatment. Objective of the Review This article presents a new approach to diagnosis of the acutely dizzy patient that emphasizes different aspects of the history to guide a focused physical examination with the goal of differentiating benign peripheral vestibular conditions from dangerous posterior circulation strokes in the emergency department. Discussion Currently, misdiagnoses are frequent and diagnostic testing costs are high. This relates in part to use of an outdated, prevalent, diagnostic paradigm. The traditional approach, which relies on dizziness symptom quality or type (i.e., vertigo, presyncope, or disequilibrium) to guide inquiry, does not distinguish benign from dangerous causes, and is inconsistent with current best evidence. A new approach divides patients into three key categories using timing and triggers, guiding a differential diagnosis and targeted bedside examination protocol: 1) acute vestibular syndrome, where bedside physical examination differentiates vestibular neuritis from stroke; 2) spontaneous episodic vestibular syndrome, where associated symptoms help differentiate vestibular migraine from transient ischemic attack; and 3) triggered episodic vestibular syndrome, where the Dix-Hallpike and supine roll test help differentiate benign paroxysmal positional vertigo from posterior fossa structural lesions. Conclusions The timing and triggers diagnostic approach for the acutely dizzy patient derives from current best evidence and offers the potential to reduce misdiagnosis while simultaneously decreases diagnostic test overuse, unnecessary hospitalization, and incorrect treatments.

show abstract

Missed stroke in acute vertigo and dizziness: It is time for action, not debate

Cited by 103 publications

References 36 publications

Identifying and analyzing diagnostic paths: a new approach for studying diagnostic practices

Identifying and analyzing diagnostic paths: a new approach for studying diagnostic practices

Symptom-Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological approach for unearthing misdiagnosis-related harms using big data

A New Diagnostic Approach to the Adult Patient with Acute Dizziness

Contact Info

Product

Resources

About