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  • Mortality and risk factors associated with misdiagnosis of acute aortic syndrome in Ontario, Canada: a population-based study

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Original research
Mortality and risk factors associated with misdiagnosis of acute aortic syndrome in Ontario, Canada: a population-based study
  1. Robert Ohle1,
  2. David W Savage2,
  3. Joseph Caswell3,
  4. Sarah McIsaac4,
  5. Krishan Yadav5,
  6. Michael Conlon3
  1. 1 Department of Emergency Medicine, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
  2. 2 Emergency Medicine, Northern Ontario School of Medicine University, Thunder Bay, Ontario, Canada
  3. 3 Health Sciences North Research Institute, Sudbury, Ontario, Canada
  4. 4 Northern Ontario School of Medicine University, Sudbury, Ontario, Canada
  5. 5 Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
  1. Correspondence to Dr Robert Ohle, Department of Emergency Medicine, Northern Ontario School of Medicine, Sudbury, ON P3E 2C6, Canada; robert.ohle{at}gmail.com

Abstract

Introduction Acute aortic syndrome (AAS) is a life-threatening aortic emergency. It describes three diagnoses: acute aortic dissection, acute intramural haematoma and penetrating atherosclerotic ulcer. Unfortunately, there are no accurate estimates of the miss rate for AAS, risk factors for missed diagnosis or its effect on outcomes.

Methods A population-based retrospective cohort study of anonymously linked data for residents of Ontario, Canada, was carried out. Incident cases of AAS were identified between 2003 and 2018 using a validated algorithm based on ICD codes and death. Before multivariate modelling, all categorical variables were analysed for an association with missed AAS diagnosis using χ2 tests. These preliminary analyses were unadjusted for clustering or any covariates. Finally, we performed multilevel logistic regression analysis using a generalised linear mixed model approach to model the probability of a missed case occurring.

Results There were 1299 cases of AAS (age mean (SD) 68.03±14.70, woman 500 (38.5%), rural areas (n=111, 8.55%)) over the study period. Missed cases accounted for 163 (12.5%) of the cohort. Mortality (non-missed AAS 59.7% vs missed AAS 54.6%) and surgical intervention (non-missed AAS 31% vs missed AAS 30.7%) were similar in missed and non-missed cases. However, lower acuity (Canadian triage acuity scale >2 (OR 2.45 95% CI 1.71 to 3.52) (the scale is from 1 to 5, with 1 indicating high acuity) had a higher odds of being a missed case and non-ambulatory presentation (OR 0.47 95% CI 0.33 to 0.67) and presenting to a teaching (OR 0.60 95% CI 0.40 to 0.90)) or cardiac centre (OR 0.41 95% CI 0.27 to 0.62) were associated with a lower odds of being a missed case.

Conclusions The high rate of misdiagnosis has remained stable for over a decade. Non-teaching and non-cardiac hospitals had a higher incidence of missed cases. Mortality and rates of surgery were not associated with a missed diagnosis of AAS. Educational interventions should be prioritised in non-teaching hospitals and non-cardiac centres.

  • cardiac care

Data availability statement

Data may be obtained from a third party and are not publicly available. Data are available through request to the Institute of Clinical Evaluative Sciences.

https://doi.org/10.1136/emermed-2023-213331

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    Data availability statement

    Data may be obtained from a third party and are not publicly available. Data are available through request to the Institute of Clinical Evaluative Sciences.

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    Footnotes

    • Handling editor Edward Carlton

    • Contributors JC performed the analysis, and provided methodology input, and manuscript contributions. RO was responsible for study design, and manuscript preparation. KY provided methodology input in addition to manuscript preparation. MC and DWS provided methodology input in addition to being content experts in administrative data. SM provided methodology input and oversight in addition to manuscript editing. RO acts as guarantor for the accuracy and integrity of the manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer-reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.