The Misdiagnosis of Cerebrovascular Disease in Emergent Headache Evaluations

几乎每个美国人一生中都会经历一次诊断错误。当错过与显著发病率和死亡率相关的可治疗疾病时，诊断错误尤其具有破坏性。在紧急情况下对脑血管事件的误诊可能导致失去或延迟获得挽救生命的治疗的机会。在美国每年估计的70万例中风中，高达9%最初是在急诊室被误诊的。在被误诊的脑卒中患者中，头痛是最常见的症状之一。尽管血管性头痛在中风患者中很常见，但在美国急诊科评估的大多数头痛都是良性的。在主诉头痛的患者中，特别是那些无雷击符号的患者中，很少有基于证据的临床决策规则来检测急性脑血管疾病。因此，我们建议使用大型区域信息交换来量化头痛患者中脑血管疾病的可能误诊率，该信息交换包含来自多个机构的数据，该数据基于出院后以新的原发性头痛诊断的短期卒中入院率。我们将使用来自约翰霍普金斯卫生系统急诊科的信息来识别与脑血管疾病误诊相关的患者和医生层面的因素。基于先前的研究，我们预计误诊将与年轻和少数民族以及有缺陷的医生临床推理和头痛医学知识差距有关。为了确定诊断错误的其他来源，我们将对Montefiore医疗中心急诊科评估的头痛患者进行一项混合方法的前瞻性观察研究。这项工作将通过在同一中心的医生访谈来增强，旨在描述急诊系统诊断过程中的缺点。这种多管齐下的研究方法使用不同的数据来源来解决一个新的主题，这肯定会为如何改善脑血管疾病的诊断和治疗提供所需的见解。我们希望这项工作将为开发有针对性的筛查工具、教育干预、床边测试或其他低成本干预铺平道路，通过提高诊断准确性来降低患者的发病率和死亡率。此外，我们确定头痛患者脑血管误诊率的方法可以作为未来脑血管疾病诊断错误症状特异性研究的模型。

Nearly every American will experience a diagnostic error in his or her lifetime. Diagnostic errors are particularly damaging when treatable diseases associated with significant morbidity and mortality are missed. Misdiagnosis of cerebrovascular events in the emergency setting can result in lost or delayed opportunities for life-saving treatments. Up to 9% of the estimated 700,000 strokes seen annually in the US are initially misdiagnosed in emergency departments. Among stroke patients who are misdiagnosed, headache is one of the most common presenting symptoms. Though vascular headaches are common among stroke patients, the clear majority of headaches evaluated in US emergency departments are benign. There are few evidence based clinical decision rules to detect acute cerebrovascular disease among patients who complain of headache, particularly for those with non-thunderclap semiology. We therefore propose to quantify the rate of probable misdiagnosis of cerebrovascular disease among headache patients using a large regional information exchange that contains data from multiple institutions based on rates of short-term stroke admission after discharge with a new primary headache diagnosis. We will use information from the Emergency Department of John Hopkins Health System to identify patient and physician-level factors associated with cerebrovascular disease misdiagnosis. Based on prior research, we anticipate that misdiagnosis will be associated with young age and minority race as well as flawed physician clinical reasoning and knowledge gaps in headache medicine. To identify additional sources of diagnostic error, we will conduct a mixed-methods prospective observational study of headache patients evaluated in the Montefiore Medical Center Emergency Department. This work will be augmented by physician interviews at the same center designed to characterize shortcomings in emergency system diagnostic processes. This multi-pronged research approach uses different data sources to address a novel topic that is sure to provide needed insight as to how to improve the diagnosis and treatment of cerebrovascular diseases. We hope this work will pave the way for the development of targeted screening tools, educational interventions, bedside testing, or other low-cost interventions to reduce patient morbidity and mortality by improving diagnostic accuracy. Additionally, our methods of determining rates of cerebrovascular misdiagnosis among headache patients may serve as a model for future symptom-specific studies of diagnostic error in cerebrovascular disease.