The cost of misdiagnosing cellulitis


Clinical question: What are the national health care costs of misdiagnosing cellulitis?

Background: Lower extremity cellulitis is primarily a clinical diagnosis but many mimickers such as venous stasis, lymphedema, gout, deep venous thrombosis, and contact dermatitis can lead to a misdiagnosis rate of 30%-90%. Between 14% and 17% of emergency department patients with cellulitis are admitted, accounting for 10% of all infectious disease-related hospitalizations. Overdiagnosis leads to antibiotic misuse and increased hospital utilization.

Study design: Retrospective cross-sectional study.
Setting: Emergency department of Massachusetts General Hospital.

Synopsis: Among 259 ED patients identified from all screened (840 patients total) from June 2010 to December 2012, 79 (30.5%) were incorrectly diagnosed with lower extremity cellulitis and 52 of these misdiagnosed patients were admitted primarily for their cellulitis, resulting in 92.3% of this group receiving unnecessary antibiotics and 84.6% unnecessarily hospitalized.

The authors used cost estimates and previously published data from the Medical Expenditure Panel Survey (MEPS) provided by the Agency for Healthcare Research and Quality (AHRQ) 2010 to project that cellulitis misdiagnosis leads to 50,000-130,000 unnecessary hospitalizations and $195-$515 million in avoidable health care expense annually. The estimates include over 44,000 pseudocellulitis patients being exposed to antibiotics annually with an associated 13% readmission rate and medication complications such as rash and gastrointestinal side effects and implications for resistance selection and antimicrobial stewardship efforts. Nationally, the unnecessary antibiotics and hospitalization associated with misdiagnosis were estimated to cause more than 9,000 nosocomial infections, 1,000 to 5,000 Clostridium difficile infections, and two to six cases of anaphylaxis annually.

Bottom line: Misdiagnosis of lower extremity cellulitis is common and leads to unnecessary patient exposures (antibiotics, hospitalization) and excessive health care spending.

Citations: Weng QY, Raff AB, Cohen JM, et al. Costs and consequences associated with misdiagnosed lower extremity cellulitis. JAMA Dermatol. 2016; doi: 10.1001/jamadermatol.2016.3816.

Dr. Cerceo is an assistant professor in the Division of Hospital Medicine, and associate director of the internal medicine residency program at Cooper Medical School of Rowan University, Camden, N.J.

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