Acute patients discharged without an established diagnosis: risk of mortality and readmission of nonspecific diagnoses compared to disease-specific diagnoses

Rasmus Gregersen, Marie Villumsen, Katarina Høgh Mottlau, Cathrine Fox Maule, Hanne Nygaard, Jens Henning Rasmussen, Mikkel Bring Christensen, Janne Petersen
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Abstract

Nonspecific discharge diagnoses after acute hospital courses represent patients discharged without an established cause of their complaints. These patients should have a low risk of adverse outcomes as serious conditions should have been ruled out. We aimed to investigate the mortality and readmissions following nonspecific discharge diagnoses compared to disease-specific diagnoses and assessed different nonspecific subgroups. Register-based cohort study including hospital courses beginning in emergency departments across 3 regions of Denmark during March 2019–February 2020. We identified nonspecific diagnoses from the R- and Z03-chapter in the ICD-10 classification and excluded injuries, among others—remaining diagnoses were considered disease-specific. Outcomes were 30-day mortality and readmission, the groups were compared by Cox regression hazard ratios (HR), unadjusted and adjusted for socioeconomics, comorbidity, administrative information and laboratory results. We stratified into short (3–<12 h) or lengthier (12–168 h) hospital courses. We included 192,185 hospital courses where nonspecific discharge diagnoses accounted for 50.7% of short and 25.9% of lengthier discharges. The cumulative risk of mortality for nonspecific vs. disease-specific discharge diagnoses was 0.6% (0.6–0.7%) vs. 0.8% (0.7–0.9%) after short and 1.6% (1.5–1.7%) vs. 2.6% (2.5–2.7%) after lengthier courses with adjusted HRs of 0.97 (0.83–1.13) and 0.94 (0.85–1.05), respectively. The cumulative risk of readmission for nonspecific vs. disease-specific discharge diagnoses was 7.3% (7.1–7.5%) vs. 8.4% (8.2–8.6%) after short and 11.1% (10.8–11.5%) vs. 13.7% (13.4–13.9%) after lengthier courses with adjusted HRs of 0.94 (0.90–0.98) and 0.95 (0.91–0.99), respectively. We identified 50 clinical subgroups of nonspecific diagnoses, of which Abdominal pain (n = 12,462; 17.1%) and Chest pain (n = 9,599; 13.1%) were the most frequent. The subgroups described differences in characteristics with mean age 41.9 to 80.8 years and mean length of stay 7.1 to 59.5 h, and outcomes with < 0.2–8.1% risk of 30-day mortality and 3.5–22.6% risk of 30-day readmission. In unadjusted analyses, nonspecific diagnoses had a lower risk of mortality and readmission than disease-specific diagnoses but had a similar risk after adjustments. We identified 509 clinical subgroups of nonspecific diagnoses with vastly different characteristics and prognosis.
未经确诊出院的急症患者:非特异性诊断与疾病特异性诊断的死亡率和再入院风险比较
急性住院治疗后的非特异性出院诊断是指患者出院时没有明确的主诉原因。这些患者的不良后果风险应该很低,因为严重的疾病应该已经被排除。我们旨在调查非特异性出院诊断与疾病特异性诊断相比的死亡率和再入院率,并评估不同的非特异性亚组。基于登记的队列研究包括2019年3月至2020年2月期间丹麦3个地区急诊科开始的住院治疗。我们从 ICD-10 分类的 R 章和 Z03 章中确定了非特异性诊断,并排除了受伤等诊断--剩余的诊断被视为疾病特异性诊断。结果为 30 天死亡率和再入院率,通过 Cox 回归危险比(HR)对各组进行比较,未经调整或根据社会经济、合并症、管理信息和实验室结果进行调整。我们将住院时间分为短(3-<12 小时)和长(12-168 小时)两类。我们纳入了 192,185 个住院病程,其中非特异性出院诊断占短期出院病程的 50.7%,占长期出院病程的 25.9%。非特异性出院诊断与疾病特异性出院诊断的累积死亡率风险分别为:短病程为 0.6% (0.6-0.7%) vs. 0.8% (0.7-0.9%),长病程为 1.6% (1.5-1.7%) vs. 2.6% (2.5-2.7%),调整后 HR 分别为 0.97 (0.83-1.13) 和 0.94 (0.85-1.05)。非特异性出院诊断与疾病特异性出院诊断的累积再入院风险分别为:短期疗程为 7.3% (7.1-7.5%) vs. 8.4% (8.2-8.6%),长期疗程为 11.1% (10.8-11.5%) vs. 13.7% (13.4-13.9%),调整后的 HR 分别为 0.94 (0.90-0.98) 和 0.95 (0.91-0.99)。我们确定了 50 个非特异性诊断的临床亚组,其中腹痛(n = 12,462; 17.1%)和胸痛(n = 9,599; 13.1%)最为常见。亚组的特征存在差异,平均年龄为 41.9 岁至 80.8 岁,平均住院时间为 7.1 小时至 59.5 小时,30 天死亡风险< 0.2%至 2.8%,30 天再入院风险为 3.5%至 22.6%。在未调整分析中,非特异性诊断的死亡率和再入院风险低于疾病特异性诊断,但调整后风险相似。我们确定了 509 个非特异性诊断临床亚组,这些亚组的特征和预后大不相同。
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