Multicenter evaluation of a method to identify delayed diagnosis of diabetic ketoacidosis and sepsis in administrative data

Kenneth A. Michelson; Richard G. Bachur; Andrea T. Cruz; Joseph A. Grubenhoff; Scott D. Reeves; Pradip P. Chaudhari; Michael C. Monuteaux; Arianna H. Dart; Jonathan A. Finkelstein

doi:10.1515/dx-2023-0019

Article

Multicenter evaluation of a method to identify delayed diagnosis of diabetic ketoacidosis and sepsis in administrative data

Kenneth A. Michelson , Richard G. Bachur , Andrea T. Cruz , Joseph A. Grubenhoff , Scott D. Reeves , Pradip P. Chaudhari , Michael C. Monuteaux , Arianna H. Dart and Jonathan A. Finkelstein

Published/Copyright: June 22, 2023

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From the journal Diagnosis Volume 10 Issue 4

Abstract

Objectives

To derive a method of automated identification of delayed diagnosis of two serious pediatric conditions seen in the emergency department (ED): new-onset diabetic ketoacidosis (DKA) and sepsis.

Methods

Patients under 21 years old from five pediatric EDs were included if they had two encounters within 7 days, the second resulting in a diagnosis of DKA or sepsis. The main outcome was delayed diagnosis based on detailed health record review using a validated rubric. Using logistic regression, we derived a decision rule evaluating the likelihood of delayed diagnosis using only characteristics available in administrative data. Test characteristics at a maximal accuracy threshold were determined.

Results

Delayed diagnosis was present in 41/46 (89 %) of DKA patients seen twice within 7 days. Because of the high rate of delayed diagnosis, no characteristic we tested added predictive power beyond the presence of a revisit. For sepsis, 109/646 (17 %) of patients were deemed to have a delay in diagnosis. Fewer days between ED encounters was the most important characteristic associated with delayed diagnosis. In sepsis, our final model had a sensitivity for delayed diagnosis of 83.5 % (95 % confidence interval 75.2–89.9) and specificity of 61.3 % (95 % confidence interval 56.0–65.4).

Conclusions

Children with delayed diagnosis of DKA can be identified by having a revisit within 7 days. Many children with delayed diagnosis of sepsis may be identified using this approach with low specificity, indicating the need for manual case review.

Keywords: administrative data; diabetes; diagnostic error; emergency medicine; healthcare system; pediatrics

Corresponding author: Kenneth A. Michelson, MD, MPH, Division of Emergency Medicine, Boston Children’s Hospital, 300 Longwood Ave, BCH 3066, Boston, MA 02115, USA, E-mail: kenneth.michelson@childrens.harvard.edu

Funding source: Agency for Healthcare Research and Quality

Award Identifier / Grant number: K08HS026503

Funding source: Boston Children’s Hospital

Award Identifier / Grant number: N/A

Research funding: Dr. Michelson received funding through award K08HS026503 from the Agency for Healthcare Research and Quality, and from the Boston Children’s Hospital Office of Faculty Development.
Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
Competing interests: Authors state no conflict of interest.
Informed consent: Not applicable.
Ethical approval: This study was approved by each site’s Institutional Review Board and complied with the World Medical Association Declaration of Helsinki regarding ethical conduct of research involving human subjects.

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Supplementary Material

This article contains supplementary material (https://doi.org/10.1515/dx-2023-0019).

Received: 2023-02-16

Accepted: 2023-06-07

Published Online: 2023-06-22

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Supplementary Material

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Keywords for this article

administrative data; diabetes; diagnostic error; emergency medicine; healthcare system; pediatrics