Studies suggest that there are missed opportunities to diagnose cerebrovascular causes for stroke symptoms. “While traditional stroke symptoms are rarely missed,” says David E. Newman-Toker, MD, PhD, “clinicians can sometimes overlook or discount non-specific symptoms, such as dizziness or headache.”

Quantifying Misdiagnoses

In the journal Diagnosis, Dr. Newman-Toker and colleagues recently published a study estimating the likelihood of missed stroke in the ED. The study also looked at associations with patient, hospital, and ED visit characteristics and calculated the odds of missed stroke within those domains. Using federal healthcare data, the researchers identified adults admitted for stroke with a treat-and-release ED visit in the prior 30 days.

Diagnosing-Stroke-Callout

Up to 12.7% of patients who were later admitted for stroke had been potentially misdiagnosed and erroneously sent home from the ED in the 30 days before being hospitalized for stroke. “Patients who were misdiagnosed for stroke disproportionately presented with dizziness or headaches,” says Dr. Newman-Toker. About half of the unexpected returns for stroke occurred within 7 days, and more than half occurred in the first 48 hours. Women and minorities were more likely to be misdiagnosed. People younger than 45 were about seven times more likely to be given an incorrect diagnosis and sent home without treatment.

“Based on our data, the estimated number of missed strokes resulting in harm to patients in the U.S. could be anywhere between 15,000 and 165,000 annually,” says Dr. Newman-Toker. “That’s a wide range, but the number is likely between 50,000 and 100,000 per year when all of the variables are taken into consideration.” He notes that it is challenging to ascertain more specific estimates because of shortcomings in health data reporting.

Important Implications

“Independent of patient age and cerebrovascular risk factors, ED physicians need to be more vigilant when assessing possible stroke symptoms,” Dr. Newman-Toker says. “When symptoms like dizziness and headache appear, we should be aware of the possibility of stroke, especially for younger patients, women, and racial and ethnic minorities. Many younger individuals may be misdiagnosed because stroke was probably not given much consideration during diagnostic assessments due to their age.”

Rather than focusing solely on traditional stroke risk factors, Dr. Newman-Toker recommends that physicians instead use proven bedside methods for identifying patients with stroke that do not rely only on demographics or baseline risk. These techniques identify specific features in a patient’s history or exam that point to stroke, enabling clinicians to accurately identify patients who are safe to go home without extensive testing and those who need rapid evaluation and treatment.

References

Newman-Toker DE, Moy E, Valente E, Coffey R, Hines AL. Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample. Diagnosis. 2014 Apr 3 [Epub ahead of print]. Available at: http://www.degruyter.com/view/j/dx.ahead-of-print/dx-2013-0038/dx-2013-0038.xml?format=INT.

Newman-Toker DE, Pronovost PJ. Diagnostic errors–the next frontier for patient safety. J Am Med Assoc. 2009;301:1060-1062.

Perry JJ, Stiell IG, Sivilotti ML, et al. Clinical decision rules to rule out subarachnoid hemorrhage for acute headache. J Am Med Assoc. 2013;310:1248-55

Newman-Toker DE, Edlow JA. High-stakes diagnostic decision rules for serious disorders: the Ottawa subarachnoid hemorrhage rule. J Am Med Assoc. 2013;310:1237-1239.

Newman-Toker DE, McDonald KM, Meltzer DO. How much diagnostic safety can we afford, and how should we decide? A health economics perspective. BMJ Qual Saf. 2013;22(Suppl):ii11-ii20.

Newman-Toker DE, Kerber KA, Hsieh YH, et al. HINTS Outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Acad Emerg Med. 2013;20:986-996.