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Diagnostic Overshadowing: Delayed Intervention in Substance Use Disorder Patients with Traumatic Brain Injury
*Yasmin Arda, *Vahe S. Panossian, *Ikemsinachi C. Nzenwa, *Matthew Bartek, *Casey M. Luckhurst, *Charudutt N. Paranjape, *Joshua S. Ng-Kamstra, *Jonathan Parks, *Katherine Albutt, *John O. Hwabejire, *Michael P. DeWane, George Velmahos, Haytham Kaafarani
Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA.
Background: Diagnostic overshadowing, a type of cognitive bias, happens when a pre-existing medical condition overshadows the evaluation of other potential diagnoses. This risk is arguably higher in trauma patients as surgeons must quickly make accurate decisions under stress. We aimed to explore the prevalence of diagnostic overshadowing in trauma, using as a proxy the impact of substance and alcohol use disorder (SUD) on time to surgical intervention in patients with traumatic brain injury (TBI). Study Design: The 2017-2020 ACS-TQIP database was used to identify patients ≥18 years with isolated TBI who had craniotomy, intraventricular drain, or intracranial pressure-monitoring bolts. The primary analysis included only patients with GCS ≥13 since diagnostic overshadowing is more likely to happen in this group with only mild alteration in sensorium. Patients were stratified into those with and without SUD. Multivariable logistic regression examined the impact of SUD on delayed surgery (>48 hours) and outcomes (e.g., mortality, sepsis). A sensitivity analysis was conducted for TBI SUD and non-SUD patients with GCS <13.
Results: Out of a total of 15,207 included patients, 4,856 had GCS ≥13: 869 (18%) SUD and 3,987 (82%) non-SUD. The mean time to procedure was 46.7 ± 108 hours in SUD compared to 32.4 ± 65 hours in non-SUD (p<0.001). On multivariable analyses, SUD patients were more likely to experience delayed surgery (OR 1.31, CI 1.06-1.63), mortality (OR 1.36, CI 1.08-1.7), postoperative sepsis (OR 2.44, CI 1.34-4.41), and prolonged hospital length of stay (OR 1.53, CI 1.29-1.8) compared to non-SUD. Sensitivity analysis showed no difference in time to procedure or outcomes in SUD and non-SUD patients with GCS <13 (Figure 1).
Conclusions: Diagnostic overshadowing, exemplified here in TBI and GCS ≥13 patients with SUD, can be measured and can negatively impact patient care. Further studies and interventions are needed to explore the prevalence and impact of diagnostic overshadowing in trauma patients.
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