The Misdiagnosis of Cerebrovascular Disease in Emergent Headache Evaluations

几乎每个美国人都会在有生之年经历一次诊断错误。当漏掉与重大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。在紧急情况下误诊脑血管事件可能会导致失去或延误救生治疗的机会。据估计，美国每年约有70万中风，其中高达9%的中风最初是在急诊科被误诊的。在被误诊的中风患者中，头痛是最常见的症状之一。尽管血管头痛在中风患者中很常见，但美国急诊科评估的明显大多数头痛是良性的。在主诉头痛的患者中，几乎没有基于证据的临床决策规则来检测急性脑血管疾病，特别是对于那些没有闪电症状的患者。因此，我们建议使用大型地区性信息交换来量化头痛患者中可能的脑血管疾病误诊率，该信息交换包含来自多个机构的基于新的原发头痛诊断的出院后短期中风入院率的数据。我们将使用约翰·霍普金斯卫生系统急诊部的信息来确定与脑血管疾病误诊相关的患者和医生级别的因素。根据先前的研究，我们预计误诊将与年龄较小、少数民族以及有缺陷的医生临床推理和头痛医学方面的知识差距有关。为了确定诊断错误的其他来源，我们将对蒙蒂菲奥里医学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进行的医生访谈来加强，旨在描述急救系统诊断过程中的缺陷。这种多管齐下的研究方法使用不同的数据来源来处理一个新的主题，该主题肯定会为如何改进脑血管疾病的诊断和治疗提供必要的见解。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措施铺平道路，以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的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.