Misdiagnosis of Acute Appendicitis in the Emergency Department: Prevalence, Associated Factors, and Outcomes According to the Patients' Disposition

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Figure 1.
Symptom onset time was noted twice for patients discharged from the emergency department (ED): time before their first encounter in the ED and total time before their eventual hospitalization.
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Figure 2.
Patient identification and inclusion in the study analysis.
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Figure 3.
Late referral vs missed diagnosis in patients with periappendicular abscess. ED, emergency department.

Table.

Characteristics and Outcomes of the Study Population

	Study Population				Missed Diagnosis Subgroups^b
Variable	Missed Diagnosis Group, n=90	Identified Diagnosis Group, n=1,178	Relative Risk (95% CI)	P Value	Discharged From ED, n=44	Hospitalized With Wrong Diagnosis, n=47	Relative Risk (95% CI)	P Value
Age, years, median [IQR]^a	29 [18, 43]	23 [14, 39]		0.023	32 [21, 44]	23 [16,42]		0.24
Sex
Female	38 (42.2)	436 (37.0)	1.22 (0.82, 1.83)	0.37	13 (29.5)	26 (55.3)	0.56 (0.34, 0.92)	0.019
Male	52 (57.8)	742 (63.0)			31 (70.5)	21 (44.7)
Symptom onset before first ED encounter^a
>24 hours	35 (44.3)	584 (51.3)	0.77 (0.50, 1.18)	0.25	11 (31.4)	25 (55.6)	0.56 (0.32, 0.98)	0.042
≤24 hours	44 (55.7)	554 (48.7)			24 (68.6)	20 (44.4)
Symptom onset before eventual hospitalization^a
>24 hours	55 (64.7)	584 (51.3)	1.68 (1.09, 2.58)	0.018	31 (75.6)	25 (55.6)	1.66 (0.95, 2.90)	0.07
≤24 hours	30 (35.3)	554 (48.7)			10 (24.4)	20 (44.4)
Time between ED first encounter and surgery, hours, median [IQR]^b^,^c	29.5 [21.6, 45.4]	9.3 [6.7, 14.1]		<0.001	29.6 [21.4, 60.5]	29.6 [21.6, 40.7]		0.29
Surgical finding
Complicated appendicitis	49 (54.4)	324 (27.5)	2.87 (1.93, 4.27)	<0.001	19 (43.2)	30 (63.8)	0.65 (0.42, 1.00)	0.06
Not complicated	41 (45.6)	854 (72.5)			25 (56.8)	17 (36.2)

↵^aMissing data: Age in 2 patients; symptom onset before first ED encounter in 51 patients (40/1,178 in identified group; 11/90 in missed group [9/44 in ED discharged subgroup and 2/47 in hospitalized in the wrong department subgroup; in 90 missed patients there were 91 events, see comment ^b below]); symptom onset before eventual hospitalization in 45 patients (40/1,178 in identified group; 5/90 in missed group [3/44 in ED discharged subgroup and 2/47 in hospitalized in the wrong department subgroup]); time between ED first encounter and surgery in 1 patient who refused surgery and following interval appendectomy had evidence of uncomplicated appendicitis.
↵^bOne patient who was discharged from the ED and upon return was hospitalized with the wrong diagnosis in the wrong department was counted twice for a total of 91 events in 90 patients.
↵^cPatients with diagnosis of periappendicular abscess are excluded.
Note: Data are presented as n (%) unless otherwise indicated.
ED, emergency department.