Are Mental Health and Substance Use Disorders Risk Factors for Missed Acute Myocardial Infarction Diagnoses Among Chest Pain or Dyspnea Encounters in the Emergency Department?,Annals of Emergency Medicine

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Are Mental Health and Substance Use Disorders Risk Factors for Missed Acute Myocardial Infarction Diagnoses Among Chest Pain or Dyspnea Encounters in the Emergency Department?
Annals of Emergency Medicine ( IF 5.0 ) Pub Date : 2021-10-02 , DOI: 10.1016/j.annemergmed.2021.08.016
Adam L Sharp ₁ , Rani Pallegadda ₂ , Aileen Baecker ₃ , Stacy Park ₃ , Najlla Nassery ₄ , Ahmed Hassoon ₅ , Susan Peterson ₆ , Samantha I Pitts ₄ , Zheyu Wang ₇ , Yuxin Zhu ₇ , David E Newman-Toker ₈

Affiliation

Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA; Department of Health System Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA; Department of Emergency Medicine, Kaiser Permanente Southern California, Los Angeles Medical Center, Los Angeles, CA; Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA.
Department of Emergency Medicine, Kaiser Permanente Southern California, Los Angeles Medical Center, Los Angeles, CA; Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA.
Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA.
Department of Internal Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Biostatistics, Johns Hopkins University, Baltimore, MD.
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD.

Study objective

To assess if having a mental health and/or substance use disorder is associated with a missed acute myocardial infarction diagnosis in the emergency department (ED).

Methods

This was a retrospective cohort analysis (2009 to 2017) of adult ED encounters at Kaiser Permanente Southern California. We used the validated symptom-disease pair analysis of diagnostic error methodological approach to “look back” and “look forward” and identify missed acute myocardial infarctions within 30 days of a treat-and-release ED visit. We use adjusted logistic regression to report the odds of missed acute myocardial infarction among patients with a history of mental health and/or substance use disorders.

Results

The look-back analysis identified 44,473 acute myocardial infarction hospital encounters; 574 (1.3%) diagnoses were missed. The odds of missed diagnoses were higher in patients with mental health disorders (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.23 to 1.77) but not in those with substance abuse disorders (OR 1.22, 95% CI 0.91 to 1.62). The highest risk was observed in those with co-occurring disorders (OR 1.90, 95% CI 1.30 to 2.76). The look-forward analysis identified 325,088 chest pain/dyspnea ED encounters; 508 (0.2%) were missed acute myocardial infarctions. No significant associations of missed acute myocardial infarction were revealed in either group (mental health disorder: OR 0.92, 95% CI 0.71 to 1.18; substance use disorder: OR 1.22, 95% CI 0.80 to 1.85).

Conclusion

The look-back analysis identified patients with mental illness at increased risk of missed acute myocardial infarction diagnosis, with the highest risk observed in those with a history of comorbid substance abuse. Having substance use disorders alone did not increase this risk in either cohort. The look-forward analysis revealed challenges in prospectively identifying high-risk patients to target for improvement.

中文翻译：

在急诊科遇到胸痛或呼吸困难时，心理健康和物质使用障碍是否是漏诊急性心肌梗塞的危险因素？

学习目标

评估心理健康和/或物质使用障碍是否与急诊科 (ED) 漏诊的急性心肌梗塞有关。

方法

这是一项回顾性队列分析（2009 年至 2017 年）在 Kaiser Permanente 南加州遇到的成人 ED。我们使用经过验证的症状-疾病配对分析诊断错误方法学方法来“回顾”和“展望”，并在治疗和释放 ED 就诊后 30 天内识别漏诊的急性心肌梗死。我们使用调整后的逻辑回归来报告有精神健康和/或物质使用障碍病史的患者错过急性心肌梗死的几率。

结果

回顾分析确定了 44,473 次急性心肌梗死住院病例；574 (1.3%) 次诊断被遗漏。精神疾病患者漏诊的几率较高（比值比 [OR] 1.48，95% 置信区间 [CI] 1.23 至 1.77），但在药物滥用障碍患者中则不然（OR 1.22，95% CI 0.91 至 1.62））。在同时发生疾病的患者中观察到的风险最高（OR 1.90，95% CI 1.30 至 2.76）。前瞻性分析确定了 325,088 例胸痛/呼吸困难 ED 遭遇；508 (0.2%) 人错过了急性心肌梗死。两组均未发现漏诊急性心肌梗死的显着相关性（精神健康障碍：OR 0.92，95% CI 0.71 至 1.18；物质使用障碍：OR 1.22，95% CI 0.80 至 1.85）。