Welcome to the fifty-seventh episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to a recent AEM Article or Article in Press, with an author interview podcast.

Find this podcast series on iTunes here.

DISCUSSING (OPEN ACCESS THROUGH january 31, 2022; CLICK ON TITLE TO ACCESS)

Cerebrovascular disease hospitalizations following emergency department headache visits: A nested case–control study

Ava L. Liberman MD,Ahmed Hassoon MD, MPH,Mehdi Fanai MD,Shervin Badihian MD,Hetal Rupani MHA,Susan M. Peterson MD,Krisztian Sebestyen MS,Zheyu Wang PhD,Yuxin Zhu PhD,Richard B. Lipton MD,David E. Newman-Toker MD, PhD

LISTEN NOW: INTERVIEW WITH AUTHOR

Abstract

Background

Delayed diagnosis of cerebrovascular disease (CVD) among patients can result in substantial harm. If diagnostic process failures can be identified at emergency department (ED) visits that precede CVD hospitalization, interventions to improve diagnostic accuracy can be developed.

Methods

We conducted a nested case–control study using a cohort of adult ED patients discharged from a single medical center with a benign headache diagnosis from October 1, 2015 to March 31, 2018. Hospitalizations for CVD within 1 year of index ED visit were identified using a regional health information exchange. Patients with subsequent CVD hospitalization (cases) were individually matched to patients without subsequent hospitalization (controls) using patient age and visit date. Demographic, clinical, and ED process characteristics were assessed via detailed chart review. McNemar's test for categorical and paired t-test for continuous variables were used with statistical significance set at ≤0.05.

Results

Of the 9157 patients with ED headache visits, 57 (0.6%, 95% confidence interval [CI] = 0.5–0.8) had a subsequent CVD hospitalization. Median time from ED visit to hospitalization was 107 days. In 25 patients (43.9%, 25/57) the CVD hospitalization and the index ED visit were at different hospitals. Fifty-three cases and 53 matched controls were included in the final study analysis. Cases and controls had similar baseline demographic and headache characteristics. Cases more often had a history of stroke (32.1% vs. 13.2%, p = 0.02) and neurosurgery (13.2% vs. 1.9%, p = 0.03) prior to the index ED visit. Cases more often had less than two components of the neurologic examination documented (30.2% vs. 11.3%, p = 0.03).

Conclusion

We found that 0.6% of patients with an ED headache visit had subsequent CVD hospitalization, often at another medical center. ED visits for headache complaints among patients with prior stroke or neurosurgical procedures may be important opportunities for CVD prevention. Documented neurologic examinations were poorer among cases, which may represent an opportunity for ED process improvement.