Emergency Physicians Take Issue With AHRQ Errors Report

Nine top professional emergency medicine organizations in the United States jointly issued a letter expressing concerns about the misleading and incomplete nature of a systematic review issued by the Agency for Healthcare Research and Quality (AHRQ) on diagnostic errors in the emergency department.

The AHRQ review, issued on December 15, 2022, stated that the findings of their study translate “to about 1 in 18 emergency department (ED) patients receiving an incorrect diagnosis, 1 in 50 suffering an adverse event, and 1 in 350 suffering permanent disability or death.” The authors describe these rates as similar to those seen in primary care and inpatient hospital settings.

The review was conducted through an Evidence-Based Practice Center as part of AHRQ’s Effective Health Care Program. The authors included data from 279 studies in the review. They identified the five most frequently misdiagnosed conditions in the ED as stroke, myocardial infarction, aortic aneurysm and dissection, spinal cord compression and injury, and venous thromboembolism.

The authors note that, given an estimated 130 million ED visits in the United States each year, the overall rate of incorrect diagnoses in the ED is approximately 5.7% and that 2.0% of the patients whose conditions were misdiagnosed suffer an adverse event as a result. On a local level, the authors estimate that an average ED with approximately 25,000 visits per year could experience 1400 diagnostic errors, 500 diagnostic adverse events, and 75 serious harms, including 50 deaths. However, the authors note that the overall error and harm rates were based on three studies from outside the United States (Canada, Spain, and Switzerland) and that only two of these were used to estimate harms.

“It’s imperative that we, as emergency physicians, inform the public that the AHRQ report used flawed methodology and statistics that extrapolated — and therefore overstated — the potential for harm when receiving care in US emergency departments,” said Robert Glatter, MD, an emergency medicine physician at Lenox Hill Hospital at Northwell Health and an assistant professor at the Zucker School of Medicine at Hofstra/Northwell, New York, in an interview.

Emergency Medicine Organizations Express Concerns for Accuracy

The American College of Emergency Physicians (ACEP) and eight other medical organizations representing emergency medicine in the United States sent a letter to the AHRQ on December 14, 2022, spelling out their concerns. The review was conducted as part of the AHRQ’s ongoing Effective Health Care Program, and the organizations had the opportunity to review a draft before it was published. On reading the review, they asked that the publication of the review be delayed. “After reviewing the executive summary and initial draft, we believe that the report makes misleading, incomplete, and erroneous conclusions from the literature reviewed and conveys a tone that inaccurately characterizes and unnecessarily disparages the practice of emergency medicine in the United States,” the organizations wrote in their letter.

The concerns of the emergency medicine organizations fell into four categories: misrepresentation of the practice and nature of emergency medicine; applicability of references cited; inaccurate interpretation of malpractice data; and the reporting of a single overall diagnostic error rate of 5.7% in EDs.

The practice of emergency medicine is variable and unique among specialties in that the focus is less about the final diagnosis and more about immediate identification and treatment of life-threatening conditions, according to the letter.

Notably, many of the studies cited did not mention whether the patient’s final diagnosis was apparent on admission to the ED. “Without this knowledge, it is completely inappropriate to label such discrepancies as ‘ED diagnostic error,’ ” the organizations wrote.

All medical specialties have room for improvement, but the current AHRQ review appears not to identify these opportunities, and instead of contributing to a discussion of improving patient care in the ED, it may cause harm by presenting misinformation, they said.

Misleading and Inadequate Evidence

“I strongly agree with the concerns mentioned from ACEP and other key organizations about the problems and conclusions reached in the AHRQ report,” Glatter told Medscape.

“The methodology used to arrive at the conclusions [in the review] was flawed and does not provide an accurate estimate of diagnostic error and, consequently, misdiagnosis and deaths occurring in emergency departments in the US,” he said. “The startling headline that 250,000 people die annually in US EDs was extrapolated from a single study based on one death that occurred in a Canadian ED in 2004,” Glatter noted. “Clearly, this is not only poor methodology but flawed science.”

The AHRQ report misused one death from this single study to estimate the death rate across the United States, Glatter explained, and this overestimate improperly inflated and magnified the number of potential patients that may have been harmed by physician error.

“This flawed evidence would actually place ED misdiagnoses in the top five causes of death in the United States, with 1 in every 500 ED patients dying as a result of an error by a physician. Simply put, there is just no evidence to support such a claim,” said Glatter.

The repercussions of the AHRQ review could be harmful to patients by instilling fear and doubt about the ability of emergency physicians to diagnose those who present with life-threatening conditions, Glatter said.

“This more balanced and accurate picture of the role of emergency physicians in diagnosing and managing such emergencies needs to be communicated to the public in order to reassure and instill confidence in our role in the sequence of emergency care in relation to continuity of care in patients presenting to the ED,” he said.

“While our primary role as emergency medicine physicians is to stabilize and evaluate patients, arriving at a particular diagnosis is not always possible for some conditions,” and additional diagnostic testing is often needed to identify more specific causes of symptoms, Glatter added.

Additional research is needed for a more accurate representation of diagnostic errors in the ED, said Glatter. New prospective studies are needed to address outcomes in US EDs that account for the latest advances and diagnostic modalities in emergency medicine, “particularly advances in bedside ultrasound that can expedite critical decision-making, which can be lifesaving,” he said.

“The AHRQ report is simply not an accurate reflection of the technology and skill set that current emergency medicine practice offers our patients in 2023.”

Glatter has disclosed no relevant financial relationships.

AHRQ. Diagnostic Errors in the Emergency Department: A Systematic Review. Published online December 15, 2022. Full text

Heidi Splete is a freelance medical journalist with 20 years of experience.For more news, follow Medscape on Facebook, Twitter, Instagram, and YouTube.

For more news, follow Medscape on Facebook, Twitter, Instagram, and YouTube.

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