stroke misdiagnosis disproportionate in the young says Washington Post

Kohn, Michael Michael.Kohn at UCSF.EDU
Thu Jun 19 07:18:40 UTC 2014


Dear colleagues,

I am not surprised that our sensitivity for identifying stroke is worse in younger patients.   We adjust our threshold for further testing or hospitalization based on the patient's pretest probability of disease.   For example, a patient with a very low pretest probability of pulmonary embolism needs a  D-dimer greater than 800 ug/L before we order a CTA,  while a patient with a high pretest probability  gets a CTA for a D-dimer > 350. If you look only at patients who ultimately  turned out to have a PE, there will be more false negatives (initial failure to order the CTA) among the low pre-test probability patients.

The decision to continue the work-up after doing a test depends on the post-test probability of disease, which in turn depends on both the pre-test probability and the test result.  Young patients have a much lower baseline probability of stroke than older patients, so we require a highly suggestive history and exam  before engaging in an extensive workup (e.g. ordering an MRI),  whereas for older patients,  even a mildly suggestive history and exam will prompt us to do further work up.   When you look only at  those patients who ultimately turned out to have a stroke, we will have more false negatives among the young stroke patients than among the older stroke patients.   We should be comparing the diagnostic yield of MRI in younger and older patients.  If you believe that it is more important to  diagnose stroke in a young person than in an old person, the diagnostic yield of MRI should be lower in young  patients than in old  patients.   If you believe that it is equally important to diagnose stroke in a young person  as in an old person, then the diagnostic yield of MRI should be similar in both groups.

Respectfully,

Michael Kohn

Michael A. Kohn, MD, MPP
Associate Professor
Epidemiology and Biostatistics
UCSF
Attending Emergency Physician
Mills-Peninsula Medical Center
Burlingame, CA



From: David Gordon, M.D. [mailto:davidc.gordon at DUKE.EDU]
Sent: Wednesday, June 18, 2014 6:40 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] stroke misdiagnosis disproportionate in the young says Washington Post
Importance: Low

David,

A real challenge here is trying to separate the signal from the noise, and when it comes to neurologic complaints, there is unfortunately a lot of noise in emergency departments. Overcrowding and financial pressures further compound the difficulty of who requires the full work-up.

I think risk stratification is key to this issue. We have imperfect but overall good processes and tools in place for the risk stratification of ACS and pulmonary embolism. As an emergency physician, I don't feel I have the same cognitive tools available for independently risk stratifying TIA/stroke. I am fortunate to work in a clinical environment where I have ready access to neurology consultation to assist in the process and an observation protocol for equivocal/intermediate cases, but I gather to say this is far from the norm.

As far as the treatment of neurologic complaints in the emergency setting, we need more evidence. It is going to take prospective analysis of all-comers to the ED with stroke-like symptoms to better understand who needs immediate work-up and who can be safely discharged. Perhaps we will end up with 2 different stratification tools- one for the young and one for the old.

As far as whether diagnostic aids will be utilized or ignored due to CDRs, I think it depends. If the rule has good performance, easy to use, and is bought into by both emergency physicians and neurologists, I do think it would be readily employed - especially if the evidence becomes increasingly convincing that the epidemiology of stroke is changing (or becoming better understood) and young patient's are being misdiagnosed.

-David

David Gordon, MD
Associate Professor
Undergraduate Education Director
Division of Emergency Medicine
Duke University

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________________________________
From: David Newman-Toker [toker at JHU.EDU]
Sent: Tuesday, June 17, 2014 2:56 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [IMPROVEDX] stroke misdiagnosis disproportionate in the young says Washington Post
Stroke is a major public health problem, and recent work suggests young patients are having more strokes, with rates rising alarmingly in recent years, according to an article in today's Washington Post...

http://www.washingtonpost.com/national/health-science/strokes-long-on-the-decline-among-the-elderly-are-rising-among-younger-adults/2014/06/16/f1f54538-e5d9-11e3-a86b-362fd5443d19_story.html

They are also much more likely to be misdiagnosed (7-fold greater risk in those 18-45 relative to those >75)...

http://www.degruyter.com/view/j/dx.2014.1.issue-2/dx-2013-0038/dx-2013-0038.xml

Thoughts?

David


David E. Newman-Toker, MD, PhD
Associate Professor, Department of Neurology
Johns Hopkins Hospital, Meyer 8-154; 600 North Wolfe Street, Baltimore, MD 21287
Email: toker at jhu.edu<mailto:toker at jhu.edu>; 410-502-6270 (phone); 410-502-6265 (fax)
Web address: Johns Hopkins Neurology (David Newman-Toker)<http://www.hopkinsmedicine.org/neurology_neurosurgery/specialty_areas/vestibular/profiles/team_member_profile/516F40C024FCA3D4B4B633D0E080FE1B/David_Newman-Toker>


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