Costs and Consequences of Misdiagnosed Cellulitis

Rick Hessler, Mercer University College of Pharmacy

It has been suggested that lower extremity inflammatory dermatoses are misdiagnosed as cellulitis at a rate between 30% to 90%. [1] Although hospital admissions for cellulitis have been shown to account for 10% of all infectious disease-related hospitalizations in the United States, data regarding costs and complications from misdiagnosed cellulitis were stated to be lacking. [2]

Costs and Consequences Associated with Misdiagnosed Lower Extremity Cellulitis [3]
Design Cross-sectional, retrospective; N= 259
Objective To determine health care burden of misdiagnosed lower extremity cellulitis
Study Groups Cellulitis (n= 180); pseudocellulitis (n= 79)
Methods The study included all patients admitted to the emergency department with a diagnosis of lower extremity cellulitis.  Patients discharged with cellulitis diagnosis were categorized into the cellulitis study arm.  Patients given a different diagnosis during hospital stay, on discharge, or within 30 days of discharge were placed into pseudocellulitis study arm.  Hospital admission was deemed necessary if the final diagnoses were morbid or required inpatient treatment.  Antibiotics were considered necessary for final diagnoses with a bacterial etiology.  National, annual cost figures were obtained from the Medical Expenditure Panel Survey (MEPS).  Patients with abscess were excluded from the pseudocellulitis group and in the final cost analysis.  Baseline characteristics and results focused strictly on the pseudocellulitis treatment arm.
Duration June 2010 to December 2012
Primary Outcome Measure Complications during hospitalization and cost estimates of hospital admission for misdiagnosed cellulitis
Baseline Characteristics   Pseudocellulitis
Mean age, years (SD) 60.4 (18)
Female, n (%) 26 (5)
White, n (%) 37 (71)
Black, n (%) 7 (13)
Hispanic, n (%) 4 (8)
Other, n (%) 4 (8)
Mean days hospitalized, n (SD) 4.8 (4)
Antibiotics at discharge, n (%) 30 (58)
Antibiotics in hospital, n (%) 52 (100)
Results Unnecessary admission, n (%) 44 (85)
Unnecessary antibiotics in hospital, n (%) 48 (92)
Unnecessary antibiotics on discharge, n (%) 26 (50)
Complications within 30 days, n (%) 14 (32)
  Misdiagnosis
National rate Study rate
15% 30% 30.5% 45%
12.9% abscess rate, cost in millions 253 506 515 760
35% abscess rate, cost in millions 189 378 384 567
67% abscess rate, cost in millions 96 192 195 288
Adverse Events Common Adverse Events: not disclosed
Serious Adverse Events: not disclosed
Percentage that Discontinued due to Adverse Events: not disclosed
Study Author Conclusions Nearly a third of pseudocellulitis patients in the study experienced a complication due to unnecessary treatment for cellulitis.  These complications carry the potential for considerable morbidity and mortality and should be a component of judicious evaluation of appropriate antibiotic use.

As seen in the case of misdiagnosed lower extremity cellulitis, appropriate diagnosis and antimicrobial stewardship stand to improve patient outcomes as well as reduce financial and antimicrobial burden.  It may be beneficial to implement new strategies such as utilization of dermatology consultation in the case of suspected cellulitis.  The study’s small sample size may have increased the risk for type two error.  The authors did not take into account all possible reasons for admission while deeming admission as necessary or unnecessary, thus opening the door for subjective inclusion bias.  Future studies may benefit from using a prospective study design to allow the investigators to obtain more study specific information from each patient.

References

  1. David CV, Chira S, Eells  SJ,  et al.  Diagnostic accuracy in patients admitted to hospitals with cellulitis. Dermatol Online J. 2011;17(3):1.
  2. The DRG Handbook.Comparative Clinical and Financial Benchmarks. Evanston, IL: Solucient; 2006.
  3. Weng QY, Raff AB, Cohen JM, Gunasekera N, Okhovat J, Vedak P, Joyce C, Kroshinsky D, Mostaghimi A. Costs and Consequences Associated With Misdiagnosed Lower Extremity Cellulitis. JAMA Dermatol. Published online November 02, 2016. doi:10.1001/jamadermatol.2016.3816
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