Recognizing Emergency Department Patients Prone to Diagnostic Discrepancies

Overview

This study examined the independent association between frailty and diagnostic discordance between the presumptive emergency department (ED) diagnosis and the adjudicated discharge diagnosis among adults presenting with suspected infection. Frailty was independently associated with a higher likelihood of diagnostic discordance.

Background

Establishing an accurate presumptive diagnosis in the ED can be difficult in patients with suspected infection, particularly when distinguishing infectious from noninfectious conditions or identifying the infection focus. Prior studies have reported diagnostic discordance in 8% to 43% of patients with suspected infection. Such discordance may contribute to both overtreatment and undertreatment.

Data Highlights

• The analysis included 646 unique adults presenting to the ED with suspected infection.

• Diagnostic discordance occurred in 163 of 646 patients (25%).

• Discordance occurred more frequently in frail than nonfrail patients (31.3% vs 21.8%; P = 0.007).

• Frailty was independently associated with diagnostic discordance (adjusted odds ratio [aOR], 1.622; 95% CI, 1.094-2.405; P = 0.016).

• A higher age-adjusted Charlson Comorbidity Index was also independently associated with discordance (aOR, 1.105; 95% CI, 1.013-1.204; P = 0.024).

Key Findings

• Frailty, assessed using the Clinical Frailty Scale, was independently associated with diagnostic discordance after adjustment for age, comorbidity, and other factors.

• Age alone was not independently associated with diagnostic discordance after adjustment, suggesting that diagnostic complexity attributed to older age may be more closely related to frailty and multimorbidity than chronological age alone.

• Diagnostic discordance should not automatically be interpreted as diagnostic error, because differences between ED and discharge diagnoses may reflect the natural evolution of diagnostic assessment as additional information becomes available.

• Diagnostic discordance may contribute to overtreatment, including unnecessary antibiotic exposure, as well as undertreatment associated with complications, sepsis, and in-hospital mortality.

• Exploratory analyses suggested that the association between frailty and discordance may be more pronounced for infection focus than for infection presence, although these findings require cautious interpretation.

Clinical Implications

Recognition of frailty may help identify ED patients with suspected infection in whom diagnostic assessment is more challenging. The authors emphasize careful diagnostic evaluation, consideration of alternative diagnoses, and repeated reassessment as additional clinical information becomes available rather than recommending a specific frailty-based diagnostic intervention.

Conclusion

Frailty and comorbidity were independently associated with diagnostic discordance among ED patients with suspected infection. Although the findings do not establish causality, frailty may serve as a marker of greater diagnostic complexity and may help identify patients who warrant particularly careful evaluation and repeated reassessment.

Related Resources & Content

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