Are Mental Health and Substance Use Disorders Risk Factors for Missed Acute Myocardial Infarction Diagnoses Among Chest Pain or Dyspnea Encounters in the Emergency Department?

Adam L Sharp; Rani Pallegadda; Aileen Baecker; Stacy Park; Najlla Nassery; Ahmed Hassoon; Susan Peterson; Samantha I Pitts; Zheyu Wang; Yuxin Zhu; David E Newman-Toker

doi:10.1016/j.annemergmed.2021.08.016

Are Mental Health and Substance Use Disorders Risk Factors for Missed Acute Myocardial Infarction Diagnoses Among Chest Pain or Dyspnea Encounters in the Emergency Department?

Ann Emerg Med. 2022 Feb;79(2):93-101. doi: 10.1016/j.annemergmed.2021.08.016. Epub 2021 Oct 2.

Authors

Affiliations

¹ Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA; Department of Health System Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA; Department of Emergency Medicine, Kaiser Permanente Southern California, Los Angeles Medical Center, Los Angeles, CA; Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA. Electronic address: adam.l.sharp@kp.org.
² Department of Emergency Medicine, Kaiser Permanente Southern California, Los Angeles Medical Center, Los Angeles, CA; Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA.
³ Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA.
⁴ Department of Internal Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
⁵ Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
⁶ Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
⁷ Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Biostatistics, Johns Hopkins University, Baltimore, MD.
⁸ Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD.

PMID: 34607739
DOI: 10.1016/j.annemergmed.2021.08.016

Abstract

Study objective: To assess if having a mental health and/or substance use disorder is associated with a missed acute myocardial infarction diagnosis in the emergency department (ED).

Methods: This was a retrospective cohort analysis (2009 to 2017) of adult ED encounters at Kaiser Permanente Southern California. We used the validated symptom-disease pair analysis of diagnostic error methodological approach to "look back" and "look forward" and identify missed acute myocardial infarctions within 30 days of a treat-and-release ED visit. We use adjusted logistic regression to report the odds of missed acute myocardial infarction among patients with a history of mental health and/or substance use disorders.

Results: The look-back analysis identified 44,473 acute myocardial infarction hospital encounters; 574 (1.3%) diagnoses were missed. The odds of missed diagnoses were higher in patients with mental health disorders (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.23 to 1.77) but not in those with substance abuse disorders (OR 1.22, 95% CI 0.91 to 1.62). The highest risk was observed in those with co-occurring disorders (OR 1.90, 95% CI 1.30 to 2.76). The look-forward analysis identified 325,088 chest pain/dyspnea ED encounters; 508 (0.2%) were missed acute myocardial infarctions. No significant associations of missed acute myocardial infarction were revealed in either group (mental health disorder: OR 0.92, 95% CI 0.71 to 1.18; substance use disorder: OR 1.22, 95% CI 0.80 to 1.85).

Conclusion: The look-back analysis identified patients with mental illness at increased risk of missed acute myocardial infarction diagnosis, with the highest risk observed in those with a history of comorbid substance abuse. Having substance use disorders alone did not increase this risk in either cohort. The look-forward analysis revealed challenges in prospectively identifying high-risk patients to target for improvement.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Adolescent
Adult
Aged
Aged, 80 and over
Chest Pain / etiology*
Dyspnea / etiology*
Emergency Service, Hospital*
Female
Humans
Logistic Models
Male
Mental Disorders / complications*
Mental Disorders / diagnosis
Middle Aged
Missed Diagnosis / psychology*
Missed Diagnosis / statistics & numerical data
Myocardial Infarction / complications
Myocardial Infarction / diagnosis*
Odds Ratio
Retrospective Studies
Risk Assessment
Risk Factors
Substance-Related Disorders / complications
Young Adult