Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology

Najlla Nassery; Michael A Horberg; Kevin B Rubenstein; Julia M Certa; Eric Watson; Brinda Somasundaram; Ejaz Shamim; Jennifer L Townsend; Panagis Galiatsatos; Samantha I Pitts; Ahmed Hassoon; David E Newman-Toker

doi:10.1515/dx-2020-0140

Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology

Diagnosis (Berl). 2021 Feb 25;8(4):469-478. doi: 10.1515/dx-2020-0140. Print 2021 Nov 25.

Authors

Najlla Nassery^{1

2}, Michael A Horberg^{3

4}, Kevin B Rubenstein³, Julia M Certa³, Eric Watson³, Brinda Somasundaram³, Ejaz Shamim^{3

5}, Jennifer L Townsend⁶, Panagis Galiatsatos⁷, Samantha I Pitts¹, Ahmed Hassoon^{2

8

9}, David E Newman-Toker^{2

8

9

10}

Affiliations

¹ Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
² Center for Diagnostic Excellence, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, USA.
³ Mid-Atlantic Permanente Medical Group, Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA.
⁴ Mid-Atlantic Permanente Medical Group, Department of Infectious Diseases, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA.
⁵ Mid-Atlantic Permanente Medical Group, Department of Neurology, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA.
⁶ Division of Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁷ Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁸ Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁹ Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
¹⁰ Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

PMID: 33650389
DOI: 10.1515/dx-2020-0140

Abstract

Objectives: The aim of this study was to identify delays in early pre-sepsis diagnosis in emergency departments (ED) using the Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) approach.

Methods: SPADE methodology was employed using electronic health record and claims data from Kaiser Permanente Mid-Atlantic States (KPMAS). Study cohort included KPMAS members ≥18 years with ≥1 sepsis hospitalization 1/1/2013-12/31/2018. A look-back analysis identified treat-and-release ED visits in the month prior to sepsis hospitalizations. Top 20 diagnoses associated with these ED visits were identified; two diagnosis categories were distinguished as being linked to downstream sepsis hospitalizations. Observed-to-expected (O:E) and temporal analyses were performed to validate the symptom selection; results were contrasted to a comparison group. Demographics of patients that did and did not experience sepsis misdiagnosis were compared.

Results: There were 3,468 sepsis hospitalizations during the study period and 766 treat-and-release ED visits in the month prior to hospitalization. Patients discharged from the ED with fluid and electrolyte disorders (FED) and altered mental status (AMS) were most likely to have downstream sepsis hospitalizations (O:E ratios of 2.66 and 2.82, respectively). Temporal analyses revealed that these symptoms were overrepresented and temporally clustered close to the hospitalization date. Approximately 2% of sepsis hospitalizations were associated with prior FED or AMS ED visits.

Conclusions: Treat-and-release ED encounters for FED and AMS may represent harbingers for downstream sepsis hospitalizations. The SPADE approach can be used to develop performance measures that identify pre-sepsis.

Keywords: delirium; diagnostic error; emergency medical services; health services research; sepsis; water-electrolyte balance.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Adult
Diagnostic Errors
Emergency Service, Hospital
Hospitalization
Humans
Insurance*
Retrospective Studies
Sepsis* / diagnosis
Sepsis* / epidemiology