Diagnostic Overshadowing: Delayed Management in Substance Use Disorder Patients With Splenic Injury

Diagnostic overshadowing, a type of cognitive bias, happens when a pre-existing medical condition overshadows the evaluation of other potential diagnoses. This study aimed to explore diagnostic overshadowing in trauma due to the impact of substance and alcohol use disorder (SUD) on time to diagnosis and management in patients with blunt splenic injury.

The 2017-2020 American College of Surgeons Trauma Quality Improvement Project database was used to identify patients ≥18 y with blunt splenic injury who underwent splenectomy. Patients were stratified into those with and without SUD. Delayed diagnosis (time to abdominal computed tomography scan >1 h) and delayed splenectomy (>2 h) were defined using median-based thresholds to measure distributional shifts in care timeliness between groups. Multivariable logistic regression examined the impact of SUD on delayed diagnosis, delayed splenectomy, and outcomes (e.g., mortality, postoperative complications). A sensitivity analysis was conducted by excluding patients with a positive alcohol screen on admission.

Nine thousand two hundred thirty-seven patients were included: 1739 (19%) SUD and 7498 (81%) non-SUD. The median time to splenectomy was 2.4 h (interquartile range = 1.2-7.1) in SUD patients compared with 2 h (interquartile range = 1.1-4.9) in non-SUD patients (P < 0.001). On multivariable analyses, SUD patients were more likely to experience delayed diagnosis (adjusted odds ratio [aOR] = 1.13, 95% confidence interval [CI] = 1.04-1.23), delayed splenectomy (aOR = 1.25, 95% CI = 1.09-1.42), and composite complications (aOR = 1.14, 95% CI = 1.01-1.31) compared with non-SUD patients. After excluding intoxicated patients, those with SUD were still more likely to have delayed diagnosis and management, with a greater risk of delayed splenectomy compared with the overall cohort.

Diagnostic overshadowing, exemplified in blunt splenic injury patients with SUD, can be measured and can negatively impact patient care. Further studies are needed to explore the prevalence and impact of diagnostic overshadowing in trauma patients.