Abstract
Objective This study aimed to investigate potential missed diagnoses of acute rheumatic fever and rheumatic heart disease during hospital-based care among persons subsequently identified with these conditions.Methods This retrospective cohort study used linked emergency department and inpatient administrative records from Queensland, Northern Territory, South Australia, and New South Wales during 2003-2018 (varying between jurisdictions by completeness of data) of all persons first identified with acute rheumatic fever or rheumatic heart disease while aged 8-24 years. Using coded discharge diagnoses from the preceding 3 years, we identified presentations (e.g. joint pains or heart murmur without specific identified cause) that potentially mimic and thereby represent a missed opportunity to detect acute rheumatic fever or rheumatic heart disease. Sociodemographic factors associated with experiencing >= 1 mimic diagnoses were investigated using multivariable logistic regression models.Results Among 1855 persons, 65 (3.5%) (using narrow diagnostic inclusions) and 146 (7.9%) (with broad inclusions) experienced >= 1 mimic diagnosis. Joint disorders predominated. Mimics categorised as 'high-likelihood' (most specific) were more frequent among persons subsequently diagnosed as young adults (18-24 years) than as children (8-12 years) (odds ratio [OR] 2.45, 95% confidence interval [CI] 1.34-4.47), and those from low-risk ethnic groups (including Australian-born non-Indigenous persons) compared with Aboriginal and Torres Strait Islander peoples (OR 2.44, 95% CI 1.02-5.85).Conclusion Missed opportunities to detect acute rheumatic fever and rheumatic heart disease continue to occur in Australian hospitals, and present disproportionately among persons from demographic groups considered to be at low risk, suggesting the need for enhanced clinical suspicion in these groups.
What is known about the topic? Rheumatic heart disease often presents without documented antecedent acute rheumatic fever or as advanced disease, implicating missed opportunities for early diagnosis. What does this paper add? A proportion of young persons in Australia identified with acute rheumatic fever and/or rheumatic heart disease, particularly those considered at low risk, may have had these conditions previously overlooked during emergency department or inpatient care, having received one or more prior diagnoses mimicking these conditions. What are the implications for practitioners? Clinical suspicion of acute rheumatic fever and/or rheumatic heart disease in Australian hospitals requires enhancement.
