Abstract Details

Title Patient Harm From Diagnostic Error of Neuro-Ophthalmologic Conditions

Topic Neuro-ophthalmology/Neuro-otology

Presentation(s) Neuro-ophthalmology/Neuro-otology Posters (7:00 AM-5:00 PM)

Poster/Presentation
Number 005

Background

Neuro-ophthalmic conditions are frequently misdiagnosed.

Objective To prospectively examine diagnostic error of neuro-ophthalmic conditions and resultant patient harm.

Design/Methods Prospective study of 496 consecutive adult new patients seen in consultation at three university-based tertiary neuro-ophthalmology centers in the United States. Collected data included demographics, prior care, referral diagnosis, final diagnosis, diagnostic testing, treatment, patient disposition, and impact of the neuro-ophthalmologic encounter. The causes of error were identified using the Diagnosis Error Evaluation and Research (DEER) taxonomy tool, and patient harm from misdiagnoses was assessed.

Results

242 (49%) patients were misdiagnosed (incorrect or absent referral diagnosis). 62/242 (26%) misdiagnosed patients suffered harm, and in 60/62 (97%), the harm could have been prevented by earlier referral to neuro-ophthalmology. 116/496 (23%) experienced inappropriate laboratory testing, diagnostic imaging, or treatment prior to referral, with higher rates for patients misdiagnosed prior to referral (34%) vs those with a correct diagnosis (13%) (p<0.0001).

The most common reasons for referral were optic neuropathy (102/496, 21%), papilledema (94/496, 19%), diplopia or cranial nerve palsies (79/496, 16%), and unspecified vision loss (55/496, 11%). 434/496 (88%) were appropriate referrals. 47/62 (76%) inappropriate referrals were misdiagnosed vs 195/434 (45%) appropriate referrals (p<0.0001). The most common sources of diagnostic error were the physical examination (36%) (inaccurate funduscopic or motility examinations, underweighing normal examination findings); generation of a differential diagnosis (24%); history taking (24%); and utilization or interpretation of diagnostic testing (13%) (failure to obtain appropriate neuroimaging, poor interpretation of or failure to obtain visual fields).

In 489/496 (99%) patients, neuro-ophthalmologic consultation impacted patient care. Misdiagnosis and inappropriate referrals correlated with increased impact (p<0.0001). Avoiding harmful treatment and providing urgent referral were more common in patients misdiagnosed (17%) vs those correctly diagnosed (4%).

Conclusions Misdiagnosis of neuro-ophthalmic conditions, mismanagement prior to referral, and preventable harm are common. Early appropriate referral to neuro-ophthalmology should prevent patient harm.

Authors/Disclosures
Leanne Stunkel, MD (Washington University in St. Louis) PRESENTER	Dr. Stunkel has nothing to disclose.
	No disclosure on file
Devin D. Mackay, MD (Indiana University)	Dr. Mackay has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Optum. Dr. Mackay has received personal compensation in the range of $50,000-$99,999 for serving as an Expert Witness for various law firms.
	No disclosure on file
Gregory P. Van Stavern, MD, FAAN (Washington University Ophthalmology)	Dr. Van Stavern has received personal compensation in the range of $500-$4,999 for serving as an Expert Witness for Wise, Child, Caraway. Dr. Van Stavern has received publishing royalties from a publication relating to health care.
Nancy J. Newman, MD, FAAN (Emory University School of Medicine)	Dr. Newman has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for GenSight. Dr. Newman has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Chiesi. Dr. Newman has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Stoke. Dr. Newman has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Neurophth. The institution of Dr. Newman has received research support from GenSight. The institution of Dr. Newman has received research support from Chiesi/Santhera. The institution of Dr. Newman has received research support from NINDS/NIH. Dr. Newman has received publishing royalties from a publication relating to health care. Dr. Newman has received publishing royalties from a publication relating to health care. Dr. Newman has received publishing royalties from a publication relating to health care.
Valerie Biousse, MD	Dr. Biousse has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Gensights Biologic. Dr. Biousse has received personal compensation in the range of $0-$499 for serving as a Consultant for Neurophoenix. Dr. Biousse has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Topcon. Dr. Biousse has received publishing royalties from a publication relating to health care. Dr. Biousse has received publishing royalties from a publication relating to health care.