Why Can’t We Properly Identify Cellulitis?

If you read the lay medical news, that’s the question being posed, indirectly, to Emergency Physicians at large. Why, oh why, are you terrible at accurately diagnosing and hospitalizing patients for cellulitis:

“Approximately One-Third Of People Diagnosed With Cellulitis Do Not Actually Have It, Study Suggests.”(HealthDay)

And, if you believe the authors of the cited article, cellulitis misdiagnosis leads to up to 130,000 unnecessary hospitalizations and $515M in avoidable healthcare costs, let alone the costs of various secondary harms.

Unfortunately, this well-covered indictment of our care of cellulitis comes from a not-so-reliable study: a retrospective evaluation of 259 patients hospitalized over a 2 year period. Of these patient charts reviewed, the authors felt as though 79 (30.5%) were misdiagnosed with cellulitis. The authors then plugged these numbers into their meandering cost calculations for unnecessary care, resulting in the numbers above.

The actual conclusions, however, bear no resemblance to the circulating headline. It is not “one-third of people diagnosed with cellulitis” – it is one-third of a narrowly defined cohort of hospitalized patients with lower extremity cellulitis. The misdiagnosis rate is based only on the shadowy shapes discernible through chart review, with all its omissions and inaccuracies. I doubt the sort of complicated medical presentations common at a teaching facility and referral hospital are generalizable to the vast majority of the ~2.5 million annual ED visits for cellulitis, most of whom are probably more straightforward. Then, even their cost numbers are probably inflated by using the average cost of an “unnecessary” 4.3 day medical stay – $12,656.90 – generalized to their cohort.

In many instances, in the setting of diagnostic uncertainty, it is absolutely reasonable to err on the side of caution and treatment. I am not certain these authors’ interpretation of their narrow slice of the healthcare spectrum accurately reflects the larger reality. Amusingly, though, their article ends with the statement “Our study serves as a call to arms for improving the care of patients with suspected lower extremity cellulitis.” Their proposed solution? A Dermatology consult on every case of suspected lower extremity cellulitis!

“Costs and Consequences Associated With Misdiagnosed Lower Extremity Cellulitis”
http://jamanetwork.com/journals/jamadermatology/fullarticle/2578851

One thought on “Why Can’t We Properly Identify Cellulitis?”

  1. Reading the methods , I’m sort of er… miffed seing the study is retrospective and seated reviewers who never saw the patient in his initial presentation tag all diagnoses eventually proved wrong (days later in a different presentation) as “misdiagnoses” . Yeap! I’m miffed, maybe peeved or even a bit cross.
    Now who would refuse a dermatology consult at 3 am ?
    Reading further, maybe that will take me down to the “miffed” status.

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