Stroke hospitalization after misdiagnosis of “benign dizziness” is lower in specialty care than general practice: a population-based cohort analysis of missed stroke using SPADE methods

Abstract

Objectives Isolated dizziness is a challenging stroke presentation in the emergency department, but little is known about this problem in other clinical settings. We sought to compare stroke hospitalizations after treat-and-release clinic visits for purportedly “benign dizziness” between general and specialty care settings. Methods This was a population-based retrospective cohort study from a national database. We included clinic patients with a first incident treat-and-release visit diagnosis of non-specific dizziness/vertigo or a peripheral vestibular disorder (ICD-9-CM 780.4 or 386.x [not 386.2]). We compared general care (internal medicine, family medicine) vs. specialty care (neurology, otolaryngology) providers. We used propensity scores to control for baseline stroke risk differences unrelated to dizziness diagnosis. We measured excess (observed>expected) stroke hospitalizations in the first 30 d (i.e., missed strokes associated with an adverse event). Results We analyzed 144,355 patients discharged with “benign dizziness” (n=117,117 diagnosed in general care; n=27,238 in specialty care). After propensity score matching, patients in both groups were at higher risk of stroke in the first 30 d (rate difference per 10,000 treat-and-release visits for “benign dizziness” 24.9 [95% CI 18.6–31.2] in general care and 10.6 [95% CI 6.3–14.9] in specialty care). Short-term stroke risk was higher in general care than specialty care (relative risk, RR 2.2, 95% CI 1.5–3.2) while the long-term risk was not significantly different (RR 1.3, 95% CI 0.9–1.9), indicating higher misdiagnosis-related harms among dizzy patients who initially presented to generalists after adequate propensity matching. Conclusions Missed stroke-related harms in general care were roughly twice that in specialty care. Solutions are needed to address this care gap.

Use of Neuroimaging for Patients With Dizziness Who Present to Outpatient Clinics vs Emergency Departments in the US

“…Although outpatient clinicians may also less frequently encounter opportunities to use the HINTS examination, targeted clinical education may be warranted because missed stroke-related harms after primary care presentations for dizziness are twice that of specialty care presentations. 49 For episodic and chronic presentations, imaging case selection and appropriate use could be informed by novel decision support tools built into the electronic ordering systems based on contemporary diagnostic criteria [54][55][56] and practice guidelines. 57,58 Clinicians may also benefit from education on the use of asynchronous virtual examinations of patients via cell phone video recordings of paroxysmal attacks because the findings (eg, central vs peripheral) may inform decisions on the timing, setting, and need for neuroimaging during an in-person evaluation.…”

“…In a National Ambulatory Medical Care Survey analysis, 5.5% of adult outpatient visits for dizziness resulted in imaging orders . Although impending strokes may be missed, several studies indicate that neuroimaging has a lower yield and therapeutic efficacy in ambulatory clinics where central lesion prevalence is lower and presentations are more often episodic or chronic than acute . For example, less than 3% of brain MRI scans or CT angiography scans yielded new findings among outpatients with isolated dizziness, just over half of which altered management .…”

“…Outpatient clinic clinicians may feel pressured to order imaging tests defensively to rule out diagnoses rather than wait for the complex evolution of symptoms prior to initiating treatment. Although outpatient clinicians may also less frequently encounter opportunities to use the HINTS examination, targeted clinical education may be warranted because missed stroke-related harms after primary care presentations for dizziness are twice that of specialty care presentations . For episodic and chronic presentations, imaging case selection and appropriate use could be informed by novel decision support tools built into the electronic ordering systems based on contemporary diagnostic criteria and practice guidelines .…”

Short‐term stroke risk after emergency department treat‐and‐release headache visit

“…In the current study, our direction of analysis is from index ED visit to subsequent stroke hospitalization for all patient groups constituting a look‐forward SPADE study design 9 . We consider a probable missed ED diagnosis of cerebrovascular disease as one in which a patient has a subsequent stroke hospitalization within 30 days of their index ED visit 14,17 . Using ED visits that result in a discharge to home (treat‐and‐release) in a look‐forward SPADE analysis is a popular strategy that relies on the presumption that patients who are sent home from the ED are those who are thought, at the time of their initial ED evaluation, to have low‐risk conditions that can be managed in the outpatient setting.…”

Early Start of Anti-Dementia Medication Delays Transition to 24-Hour Care in Alzheimer’s Disease Patients: A Finnish Nationwide Cohort Study

“…Also the patient might have taken a wrong medicine, or not have followed a drug prescription given by doctor (Col, Fanale and Kronholm, 1990). Secondly, the "fault" may lie at the doctor: they might have misdiagnosed the patient's health problem (Chang et al, 2021;Horberg et al, 2021), or overlooked some comorbidity, and issued a drug prescription which is not fit for the patient, resulting in the sudden admittance to hospital (Lau et al, 2005). All these are realistic and prevalent risk factors for hospital admittance.…”