Hopkins chastises stroke patient misdiagnoses

Over the past few years it has become increasingly evident that emergency physicians overlook tens of thousands of strokes each year. These missed diagnoses are not equally distributed among the population, but ER doctors disproportionately miss strokes of women, minorities and younger patients.

Researchers at Hopkins conducted a retrospective analysis on the inpatient discharge and emergency department records of nine states. David Newman-Toker, an associate professor of neurology at the Hopkins School of Medicine, led the team. In an interview with The News-Letter, Newman-Toker explained that studying this data may help identify trends in public health. “Studying errors at the local level allows us to identify institution-specific problems, but federal data sets allow us to identify national public health problems and priorities,” Newman-Toker said.

By combining data from nine states, the research team was able to generate a large sample. “Because there are many more cases in these large datasets, we can identify patterns that would not be evident using smaller datasets. For example, considering stroke misdiagnosis at a single hospital, there might only be a dozen cases each year too small a number to assess whether racial, gender, or age disparities exist,” Newman-Toker said.

From the collected data, the Hopkins research team found that one in 10 Emergency Department visits resulted in a discharge diagnosis of headache or dizziness. These events, which were interpreted as possible missed strokes, were more likely to occur with patients who identified with minority groups, female patients or those under the age of 45.

“Reducing misdiagnosis is difficult, and doing so will likely require a combination of computer-based tools (e.g., diagnostic decision support, data visualization techniques, improved electronic health record results tracking/reporting, etc.), human solutions (e.g., improved training in diagnosis, more effective teamwork/communication, better feedback to doctors on their diagnostic accuracy), and new scientific discoveries (e.g., improved diagnostic technologies).” This issue will not be easy to fix. “There are no ‘magic bullets,’ and many solutions will probably need to be symptom (e.g., dizziness) or disease (e.g., stroke) specific,” Newman-Toker said in his interview.

Despite these challenges, the Hopkins research team already has an idea of how to decrease the number of missed strokes in the future: “The primary way we approach stroke diagnosis now is to focus on age and vascular risk factors to guess at the odds of a stroke diagnosis; instead, we need to emphasize clinical features that reliably identify strokes, independent of patient demographics (e.g., assessing eye movements in patients presenting dizziness),” Newman-Toker said in his interview.

This Hopkins study estimates that with 1.3 million strokes in the Unites States each year, there could be about 15,000 to 165,000 misdiagnosed cerebrovascular events annually. When asked by the News-Letter how to raise awareness of this issue, Newman-Toker said “Each year, the Society to Improve Diagnosis in Medicine’s ‘Diagnostic Error in Medicine’ conference seeks to raise awareness among healthcare professionals and policy-makers. The Institute of Medicine is developing a report on Diagnostic Errors scheduled to be published in 2015, which will likely draw significant attention to this major public health and safety problem.”

While this will help raise awareness, Newman-Toker knows that the issue can only be solved through patient advocacy: “Ultimately, it is patients who need to advocate for this issue with their Congressional representatives and as part of grassroots campaigns we can’t reduce diagnostic errors without more research into solutions, and right now, almost no money is being allocated to develop solutions. Until patients force politicians to place more emphasis on diagnostic error, the pace of progress will remain very slow,” Newman-Toker said in his interview with the News-Letter.