…if we extrapolate the results from this single-center study to the entire United States.
In Annals this month, a chart review of the “discordance” between the final neurologist “gold standard” diagnosis and the provisional Emergency Department diagnosis. Apparently, in Cleveland, 36% of the patients receiving an initial diagnosis of transient ischemic attack in the Emergency Department are subsequently evaluated by a neurologist and given an alternative diagnosis. As the authors note in their introduction, the diagnosis of TIA is made 300,000 yearly – and if 36% of those cases are made incorrectly, then we’re theoretically admitting 100,000 patients for extensive and expensive evaluation.
So, are they right? Well, if the three neurologists responsible for 93% of their 427 evaluations are representative of the entire country, perhaps. Or, if their chart review methods are adequate – as the authors note, one of their chart audits changed an abstracted diagnosis of TIA to “right hip pain” – then, perhaps. If you ignore that ED physicians have a few minutes of history, examination, and limited imaging available at their disposal – compared with the neurologists that can subsequently perform any manner of inpatient studies that might uncover an alternative diagnosis mimicking a TIA – then, perhaps.
If neurologists are walking into the ED and evaluating patients under the same constraints as we are and producing this level of discordance, then we have a problem. But, I don’t think this study tells us anything we can use to evaluate ED physicians’ ability to appropriately include or exclude TIA in the differential for neurologic complaints of a transient nature.
Somewhat disappointing that a small, retrospective chart review with results that might not be internally or externally valid are in the premier, #1 Impact Factor journal of our profession.
“Variables Associated With Discordance Between Emergency Physician and Neurologist Diagnoses of Transient Ischemic Attacks in the Emergency Department”
http://www.ncbi.nlm.nih.gov/pubmed/21624703