Diagnostic agreement between prehospital and in-hospital diagnoses for dyspnea: a retrospective study in a French prehospital emergency medical service.

Abstract

Background: Dyspnea is a common, high-acuity presentation in emergency medicine and is associated with substantial short-term mortality. Early etiological diagnosis remains challenging in the prehospital setting, particularly in physician-staffed mobile intensive care unit (MICU) systems.

Methods: We conducted a retrospective, single-center study of adults managed by a physician-staffed MICU for dyspnea in Orléans, France, between 2023 and 2024. Agreement between the prehospital MICU working diagnosis and the first in-hospital coded diagnosis was assessed among patients with paired diagnostic data using percent agreement and Cohen's kappa with bootstrap 95% confidence intervals. Prehospital management was retrospectively assessed against key principles of acute dyspnea management. Modified Poisson regression with robust variance was used to explore 28-day mortality.

Results: Among 318 patients, 313 had paired diagnostic data. Overall agreement was 83.4% (261/313) with a Cohen's kappa of 0.79 (95% bootstrap CI 0.74-0.84). The most frequent prehospital diagnostic categories were acute heart failure, acute COPD exacerbation, pneumonia, and asthma exacerbation. Among patients with paired diagnoses, 45 died within 28 days (14.4%). Mortality was higher in discordant than concordant cases (23.1% [12/52] vs. 12.6% [33/261]; crude RR: 1.83, 95% CI 1.01-3.29). In adjusted complete cases analysis (n = 269; 41 deaths), the association was attenuated aRR: 1.59 (95% CI 0.83-3.05). Prehospital management was judged consistent in 75.0% of discordant cases.

Conclusions: In this selected MICU population, agreement between prehospital working diagnoses and first in-hospital coded diagnoses was substantial. Most discordant cases still received consistent prehospital management. The association between discordance and 28-day mortality was attenuated after adjustment.