Abstract
Objectives
Isolated dizziness is a challenging stroke presentation in the emergency department, but little is known about this problem in other clinical settings. We sought to compare stroke hospitalizations after treat-and-release clinic visits for purportedly “benign dizziness” between general and specialty care settings.
Methods
This was a population-based retrospective cohort study from a national database. We included clinic patients with a first incident treat-and-release visit diagnosis of non-specific dizziness/vertigo or a peripheral vestibular disorder (ICD-9-CM 780.4 or 386.x [not 386.2]). We compared general care (internal medicine, family medicine) vs. specialty care (neurology, otolaryngology) providers. We used propensity scores to control for baseline stroke risk differences unrelated to dizziness diagnosis. We measured excess (observed>expected) stroke hospitalizations in the first 30 d (i.e., missed strokes associated with an adverse event).
Results
We analyzed 144,355 patients discharged with “benign dizziness” (n=117,117 diagnosed in general care; n=27,238 in specialty care). After propensity score matching, patients in both groups were at higher risk of stroke in the first 30 d (rate difference per 10,000 treat-and-release visits for “benign dizziness” 24.9 [95% CI 18.6–31.2] in general care and 10.6 [95% CI 6.3–14.9] in specialty care). Short-term stroke risk was higher in general care than specialty care (relative risk, RR 2.2, 95% CI 1.5–3.2) while the long-term risk was not significantly different (RR 1.3, 95% CI 0.9–1.9), indicating higher misdiagnosis-related harms among dizzy patients who initially presented to generalists after adequate propensity matching.
Conclusions
Missed stroke-related harms in general care were roughly twice that in specialty care. Solutions are needed to address this care gap.
Funding source: Armstrong Institute Center for Diagnostic Excellence (Dr. Newman-Toker)
Acknowledgments
The authors would like to thank Hsun-Yang Chuang for his help in collecting the data used in this study.
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Research funding: Dr. Newman-Toker’s effort was supported by the Armstrong Institute Center for Diagnostic Excellence and the Gordon and Betty Moore Foundation (#5756). Dr. Liberman is supported by NIH grant K23NS107643 from NINDS.
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Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission. Tzu-Pu Chang: I declare that I designed the study, collected the data, analyzed the data, designed the figures and drafted the manuscript. I have seen and approved the final version of the manuscript. I have no conflicts of interest. Anand K. Bery: I declare that I assisted in the study design, analyzed the data, and drafted the manuscript. I have seen and approved the final version. I have no conflicts of interest Zheyu Wang: I declare that I led all statistical analyses; edited the manuscript for scientific content; and that I have seen and approved the final version. I have no conflicts of interest. Krisztian Sebestyen: I declare that I participated in data analysis. I have seen and approved the final version. I have no conflicts of interest. Yu-Hung Ko: I declare that I participated in data collection. I have seen and approved the final version. I have no conflicts of interest. Ava L. Liberman: I declare that I reviewed and edited the manuscript for scientific content. I have seen and approved the final version. I have no conflicts of interest. David Newman-Toker: I declare that I conceived the manuscript concept, helped draft the manuscript, and reviewed and critically edited the manuscript. I serve as an unpaid member of the Board of Directors of the Society to Improve Diagnosis in Medicine, and as its President. I periodically serve as a medico-legal consultant for both plaintiff and defense in cases related to diagnostic error. I have no other relevant conflicts of interest.
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Competing interests: DNT serves as a paid consultant, reviewing medicolegal cases for both plaintiff and defense firms related to misdiagnosis of neurologic conditions, including dizziness and stroke. He has conducted government and foundation funded research related to diagnostic error, dizziness, and stroke. He has been loaned research equipment related to diagnosis of dizziness and stroke by two commercial companies (GN Otometrics and Interacoustics) and Johns Hopkins has licensed related diagnostic decision-support technology to GN Otometrics for which DNT has received royalties. The other co-authors have no disclosures.
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Informed consent: This national health insurance database study was exempt from informed consent because human subjects were not directly involved in the study, and patient-level information was anonymized.
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Ethical approval: This study was exempt from Institutional Review Board review because human subjects were not directly involved in the study, and patient-level information was anonymized.
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Supplementary Material
The online version of this article offers supplementary material (https://doi.org/10.1515/dx-2020-0124).
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