Department of Pediatrics, Section of Pediatric Cardiology, Baylor College of Medicine, Houston, TX.
Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX.
J Pediatr. 2019 May;208:258-264.e3. doi: 10.1016/j.jpeds.2018.12.029. Epub 2019 Jan 21.
To determine frequency of missed heart failure diagnosis at first presentation among children with no known heart disease admitted with new-onset heart failure.
Using a retrospective design, we reviewed electronic medical records of all patients aged <21 years with no known heart disease, hospitalized with new-onset heart failure during 2003-2015 at a tertiary-quaternary care institution. We assessed records for missed diagnosis of heart failure (primary outcome), associated process breakdowns, and clinical outcomes using a structured data collection instrument.
Of 191 patients meeting inclusion criteria, 49% (94/191) were missed on first presentation. Most common incorrect diagnostic labels given to "missed" patients were bacterial infection (29%; 27/94), followed by viral illness (22%; 21/94) and gastroenteritis/hepatitis (21%; 20/94). On multivariable analysis, presentation to primary care provider (PCP), longer duration of symptoms (median 7 days), more than 2 symptoms of heart failure, and nausea/emesis were associated with missed diagnosis. On examining process breakdowns, 49% had errors in history-taking and 50% had no documentation of differential diagnoses. There was no difference in hospital mortality, length of stay, or mechanical circulatory support in missed vs not-missed cohorts. Unnecessary noninvasive and invasive tests were performed in 18% and 4% of patients, respectively.
Nearly one-half of children with no known heart disease hospitalized with systolic heart failure were missed at first presentation and underwent significant nonrelevant treatment and testing. Initial presentation to the PCP, longer duration of symptoms before presentation, and nausea/emesis were associated with missed diagnosis.
确定首诊时无已知心脏病的新发心力衰竭患儿中心力衰竭漏诊的频率。
我们采用回顾性设计，回顾了 2003 年至 2015 年期间在一家三级/四级医疗机构因新发心力衰竭住院的所有年龄<21 岁且无已知心脏病的患者的电子病历。我们使用结构化数据采集工具评估记录以确定心力衰竭漏诊（主要结局）、相关的流程失败和临床结局。
符合纳入标准的 191 例患者中，49%（94/191）在首诊时漏诊。给予“漏诊”患者的最常见错误诊断标签是细菌感染（29%；27/94），其次是病毒感染（22%；21/94）和胃肠炎/肝炎（21%；20/94）。多变量分析显示，首诊于初级保健提供者（PCP）、症状持续时间较长（中位数 7 天）、心力衰竭症状超过 2 个以及恶心/呕吐与漏诊相关。在检查流程失败时，49%的患者在采集病史时存在错误，50%的患者没有记录鉴别诊断。漏诊组和未漏诊组在住院死亡率、住院时间或机械循环支持方面无差异。分别有 18%和 4%的患者进行了不必要的非侵入性和侵入性检查。
近一半因收缩性心力衰竭住院的无已知心脏病的儿童在首诊时被漏诊，并接受了大量不必要的治疗和检查。最初就诊于 PCP、就诊前症状持续时间较长以及恶心/呕吐与漏诊相关。
