A third attendance: a question two people have already answered

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• Mahajan P, Basu T, Pai CW, Singh H, Petersen N, Bellolio MF, Gadepalli SK, Kamdar NS. Factors Associated With Potentially Missed Diagnosis of Appendicitis in the Emergency Department. JAMA Netw Open. 2020;3(3):e200612. Retrospective cohort of commercially insured claims (Clinformatics Data Mart) for patients presenting to an emergency department with undifferentiated symptoms associated with appendicitis between January 2010 and December 2017. Of 187,461 patients with a diagnosis of appendicitis, 123,711 were eligible (101,375 adults, 22,336 children). The frequency of potentially missed appendicitis — diagnosis 1 to 30 days after an initial emergency department presentation with associated symptoms — was 6.0% in adults and 4.4% in children. Women had higher adjusted odds of missed diagnosis across symptom strata, including abdominal pain (AOR 1.68; 95% CI 1.58-1.78), nausea and/or vomiting (AOR 1.68; 95% CI 1.52-1.85) and fever (AOR 1.32; 95% CI 1.10-1.59), as did patients with a comorbidity index of 2 or greater. Patients with abdominal pain and constipation were more likely to be missed (adults AOR 1.51; 95% CI 1.31-1.75); those with isolated abdominal pain were less likely (adults AOR 0.65; 95% CI 0.62-0.69).
• Drapkin Z, Dunnick J, Madsen TE, Bryce M, Schunk JE. Pediatric Appendicitis: Association of Chief Complaint With Missed Appendicitis. Pediatr Emerg Care. 2020;36(4):e204-e207. Retrospective chart review of 1,680 patients diagnosed with appendicitis in a paediatric emergency department over five years, reviewing the record for additional emergency department visits in the seven preceding days. In 67 cases (4%) there had been at least one additional visit in the preceding week. Patients diagnosed at the initial visit and after multiple visits did not differ in age (9.9 vs 10.1 years), sex, white cell count (14.4 vs 12.3 x 10^3/L) or presence of fever. Of patients whose triage chief complaint was suggestive of appendicitis, 3.8% were missed at the initial visit, against 8.8% of those with a nonspecific triage complaint (odds ratio 2.46; 95% CI 1.1-5.6). The authors describe this as confirming the potential impact of anchoring bias by triage chief complaint. This is a study of children in a single paediatric department and is quoted for its mechanism rather than its rate.
• Sabbatini AK, Kocher KE, Basu A, Hsia RY. In-Hospital Outcomes and Costs Among Patients Hospitalized During a Return Visit to the Emergency Department. JAMA. 2016;315(7):663-71. Retrospective analysis of 9,036,483 index adult emergency department visits to 424 acute care hospitals in Florida and New York in 2013, using Healthcare Cost and Utilization Project data. Among the 7,278,124 patients discharged at the index visit, 598,404 (8.2%) returned within 7 days and 86,012 (14.4% of returners) were then admitted. Those 86,012 patients had significantly lower in-hospital mortality than the 1,609,145 admitted at the index visit without a return (1.85% vs 2.48%; odds ratio 0.73, 95% CI 0.69-0.78), lower intensive care admission (23.3% vs 29.0%; odds ratio 0.73, 95% CI 0.71-0.76), lower mean costs ($10,169 vs $10,799) and longer lengths of stay. The authors conclude that hospital admissions associated with return visits may not adequately capture deficits in the quality of care delivered during an emergency department visit.