Feasibility of Pediatric Diagnostic Quality Measurement in All United States Hospitals

To evaluate the proportion of emergency departments (EDs) with sufficient volumes to measure pediatric misdiagnosis reliably.

We conducted a cross-sectional study of a nationally representative 20% sample of US EDs within the 2022 Nationwide Emergency Department Sample. We counted the number of child visits (less than 18 years old) at each ED for each of 24 serious pediatric emergency conditions and each ED's total across all conditions. We calculated the proportion of EDs that could reliably measure misdiagnosis rates at least 10% worse than condition-specific national reference standards. We also calculated the proportion of children visiting measurable EDs.

Reliable misdiagnosis measurement across all serious conditions was possible in 614 out of 4,515 EDs (13.6%, 95% confidence interval [CI] 11.5 to 15.9). Appendicitis was the most reliably measurable condition (n=530 EDs, 11.7%, 95% CI 9.8 to 14.0), whereas complicated pneumonia (n=33, 0.7%, 95% CI 0.3 to 1.5), testicular torsion (n=29, 0.6%, 95% CI 0.2-1.4), and intussusception (n=25, 0.6%, 95% CI 0.2 to 1.2) were less frequently measurable. The 20 other included conditions were not reliably measurable in any ED (0.0%, 95% CI 0.0 to 0.4). Midwest, nonmetropolitan, and EDs evaluating less than 1,800 children per year were least likely to be able to support reliable measurement. Among 185,490 children with a serious condition, 130,894 (70.6%) visited an ED in which misdiagnosis was measurable.

Few EDs have sufficient pediatric volumes to reliably measure diagnostic accuracy generally, and even fewer can do so for individual conditions. Aggregation of EDs could improve power to measure misdiagnosis.