Missed Serious Neurologic Conditions in Emergency Department Patients Discharged With Nonspecific Diagnoses of Headache or Back Pain

Abstract

Serious neurologic conditions can be missed on initial emergency department (ED) visit and discharge diagnosis oftentimes remains a nonspecific symptom. We aim to examine the incidence of potential harm from serious neurologic conditions in ED patients discharged with a nonspecific diagnosis of headache or back pain, identify specific missed conditions, and determine risk factors for potential misdiagnosis-related harm. This was a retrospective analysis using the population-based data of 6 US states from the State Emergency Department Databases and State Inpatient Databases from 2006 through 2012. We identified adults (≥18 years) discharged from the ED with a diagnosis of atraumatic headache or back pain. The primary outcome was a composite of return ED visit and hospitalization for primary diagnosis of a serious neurologic condition or inhospital death within 30 days of ED discharge. There were 2,101,081 ED discharges with a nonspecific diagnosis of headache and 1,381,614 discharges with a nonspecific diagnosis of back pain. Overall, 0.5% of the headache patients and 0.2% of back pain patients had a primary outcome. The most common missed condition for headache was ischemic stroke (18.1%). The most common missed condition for back pain was intraspinal abscess (41%). In both populations, advanced age, male sex, non-Hispanic white, and comorbidities (eg, neurologic disorders, HIV/AIDS, malignancy) were associated with higher odds of outcome. A small proportion of ED patients discharged with nonspecific diagnoses of headache or back pain returned with a serious neurologic condition or inhospital death within 30 days.