Do emergency department patients receive a pathological diagnosis? A nationally-representative sample

Abstract

Introduction: Understanding the cause of patients' symptoms often requires identifying a pathological diagnosis. A single-center study found that many patients discharged from the emergency department (ED) do not receive a pathological diagnosis. We analyzed 17 years of data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) to identify the proportion of patients who received a pathological diagnosis at ED discharge. We hypothesized that many patients do not receive a pathological diagnosis, and that the proportion of pathological diagnoses increased between 1993 and 2009.

Methods: Using the NHAMCS data from 1993-2009, we analyzed visits of patients age ≥18 years, discharged from the ED, who had presented with the three most common chief complaints: chest pain, abdominal pain, and headache. Discharge diagnoses were coded as symptomatic versus pathological based on a pre-defined coding system. We compared weighted annual proportions of pathological discharge diagnoses with 95% CIs and used logistic regression to test for trend.

Results: Among 299,919 sampled visits, 44,742 met inclusion criteria, allowing us to estimate that there were 164 million adult ED visits presenting with the three chief complaints and then discharged home. Among these visits, the proportions with pathological discharge diagnosis were 55%, 71%, and 70% for chest pain, abdominal pain, and headache, respectively. The total proportion of those with a pathological discharge diagnosis decreased between 1993 and 2009, from 72% (95% CI, 69-75%) to 63% (95% CI, 59-66%). In the multivariable logistic regression model, those more likely to receive pathological diagnoses were females, African-American as compared to Caucasian, and self-pay patients. Those more likely to receive a symptomatic diagnosis were patients aged 30-79 years, with visits to EDs in the South or West regions, and seen by a physician in the ED.

Conclusion: In this analysis of a nationally-representative database of ED visits, many patients were discharged from the ED without a pathological diagnosis that explained the likely cause of their symptoms. Despite advances in diagnostic testing, the proportion of pathological discharge diagnoses decreased. Future studies should investigate reasons for not providing a pathological diagnosis and how this may affect clinical outcomes.

Figure

Proportion of emergency department patients discharged with pathological discharge diagnosis for three most common chief complaints, 1993–2009.