ImportanceDiagnostic delays are common in the emergency department (ED) and may predispose to worse outcomes.ObjectiveTo evaluate the association of annual pediatric volume in the ED with delayed diagnosis.Design, Setting, and ParticipantsThis retrospective cohort study included all children younger than 18 years treated at 954 EDs in 8 states with a first-time diagnosis of any of 23 acute, serious conditions: bacterial meningitis, compartment syndrome, complicated pneumonia, craniospinal abscess, deep neck infection, ectopic pregnancy, encephalitis, intussusception, Kawasaki disease, mastoiditis, myocarditis, necrotizing fasciitis, nontraumatic intracranial hemorrhage, orbital cellulitis, osteomyelitis, ovarian torsion, pulmonary embolism, pyloric stenosis, septic arthritis, sinus venous thrombosis, slipped capital femoral epiphysis, stroke, or testicular torsion. Patients were identified using the Healthcare Cost and Utilization Project State ED and Inpatient Databases. Data were collected from January 2015 to December 2019, and data were analyzed from July to December 2023.ExposureAnnual volume of children at the first ED visited.Main Outcomes and MeasuresPossible delayed diagnosis, defined as a patient with an ED discharge within 7 days prior to diagnosis. A secondary outcome was condition-specific complications. Rates of possible delayed diagnosis and complications were determined. The association of volume with delayed diagnosis across conditions was evaluated using conditional logistic regression matching on condition, age, and medical complexity. Condition-specific volume-delay associations were tested using hierarchical logistic models with log volume as the exposure, adjusting for age, sex, payer, medical complexity, and hospital urbanicity. The association of delayed diagnosis with complications by condition was then examined using logistic regressions.ResultsOf 58 998 included children, 37 211 (63.1%) were male, and the mean (SD) age was 7.1 (5.8) years. A total of 6709 (11.4%) had a complex chronic condition. Delayed diagnosis occurred in 9296 (15.8%; 95% CI, 15.5-16.1). Each 2-fold increase in annual pediatric volume was associated with a 26.7% (95% CI, 22.5-30.7) decrease in possible delayed diagnosis. For 21 of 23 conditions (all except ectopic pregnancy and sinus venous thrombosis), there were decreased rates of possible delayed diagnosis with increasing ED volume. Condition-specific complications were 11.2% (95% CI, 3.1-20.0) more likely among patients with a possible delayed diagnosis compared with those without.Conclusions and RelevanceEDs with fewer pediatric encounters had more possible delayed diagnoses across 23 serious conditions. Tools to support timely diagnosis in low-volume EDs are needed.

中文翻译：

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急诊室数量和严重儿科疾病的延迟诊断

重要性诊断延迟在急诊科 (ED) 中很常见，可能会导致更糟糕的结果。目的评估 ED 中每年儿科病例数与延迟诊断的关系。设计、设置和参与者这项回顾性队列研究包括所有接受治疗的 18 岁以下儿童8 个州的 954 个急诊室首次诊断出 23 种急性严重疾病中的任何一种：细菌性脑膜炎、筋膜室综合征、复杂性肺炎、颅脊髓脓肿、深颈感染、宫外孕、脑炎、肠套叠、川崎病、乳突炎、心肌炎、坏死性筋膜炎、非外伤性颅内出血、眼眶蜂窝组织炎、骨髓炎、卵巢扭转、肺栓塞、幽门狭窄、化脓性关节炎、静脉窦血栓形成、股骨头骨骺滑脱、中风或睾丸扭转。使用医疗保健成本和利用项目州急诊室和住院患者数据库来识别患者。收集2015年1月至2019年12月的数据，并分析2023年7月至2023年12月的数据。暴露量首次急诊就诊的儿童年人数。主要结果和措施可能的延迟诊断，定义为患者在就诊前7天内急诊出院诊断。次要结果是特定情况的并发症。确定了可能的延迟诊断和并发症的发生率。使用条件逻辑回归匹配条件、年龄和医疗复杂性来评估容量与跨条件延迟诊断的关联。使用分层逻辑模型以日志量作为暴露，并根据年龄、性别、付款人、医疗复杂性和医院城市化程度进行调整，测试了特定条件的流量与延迟关联。然后使用逻辑回归分析延迟诊断与病情并发症的关联。结果 58 998 名儿童中，37 211 名 (63.1%) 为男性，平均 (SD) 年龄为 7.1 (5.8) 岁。共有 6709 人（11.4%）患有复杂的慢性病。9296 例发生延迟诊断（15.8%；95% CI，15.5-16.1）。年儿科病例数每增加 2 倍，可能的延迟诊断就会减少 26.7%（95% CI，22.5-30.7）。对于 23 种情况中的 21 种（除异位妊娠和窦静脉血栓形成外），随着 ED 体积的增加，可能的延迟诊断率降低。与没有延迟诊断的患者相比，可能延迟诊断的患者发生特定病情并发症的可能性高出 11.2%（95% CI，3.1-20.0）。 结论和相关性 儿科就诊次数较少的急诊科在 23 种严重疾病中更可能出现延迟诊断。需要有工具来支持小批量急诊室的及时诊断。