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Original Investigation
November 02, 2016

Costs and Consequences Associated With Misdiagnosed Lower Extremity Cellulitis

Author Affiliations
  • 1Dept of Dermatology, Massachusetts General Hospital, Boston
  • 2Dept of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts
  • 3Dept of Biostatistics and Bioinformatics, Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana
JAMA Dermatol. Published online November 2, 2016. doi:10.1001/jamadermatol.2016.3816
Key Points

Question  What is the national health care burden of misdiagnosed lower extremity cellulitis in patients admitted to the hospital from the emergency department?

Findings  In this cross-sectional study that included 259 patients, 30% were misdiagnosed with cellulitis, of which 85% did not require hospitalization and 92% received unnecessary antibiotics. Combining these findings with previously published data, cost estimates, and and projections indicate that cellulitis misdiagnosis leads to 50 000 to 130 000 unnecessary hospitalizations in the United States and $195 million to $515 million in avoidable health care spending annually.

Meaning  Misdiagnosis of lower extremity cellulitis is common and may lead to unnecessary patient morbidity and considerable health care spending.

Abstract

Importance  Inflammatory dermatoses of the lower extremity are often misdiagnosed as cellulitis (aka “pseudocellulitis”) and treated with antibiotics and/or hospitalization. There is limited data on the cost and complications from misdiagnosed cellulitis.

Objective  To characterize the national health care burden of misdiagnosed cellulitis in patients admitted for treatment of lower extremity cellulitis.

Design, Setting, and Participants  Cross-sectional study using patients admitted from the emergency department (ED) of a large urban hospital with a diagnosis of lower extremity cellulitis between June 2010 and December 2012. Patients who were discharged with a diagnosis of cellulitis were categorized as having cellulitis, while those who were given an alternative diagnosis during the hospital course, on discharge, or within 30 days of discharge were considered to have pseudocellulitis. A literature review was conducted for calculation of large-scale costs and complication rates. We obtained national cost figures from the Medical Expenditure Panel Survey (MEPS), provided by the Agency for Healthcare Research and Quality (AHRQ) for 2010 to calculate the hospitalization costs per year attributed to misdiagnosed lower extremity pseudocellulitis.

Exposures  The exposed group was composed of patients who presented to and were admitted from the ED with a diagnosis of lower extremity cellulitis.

Main Outcomes and Measures  Patient characteristics, hospital course, and complications during and after hospitalization were reviewed for each patient, and estimates of annual costs of misdiagnosed cellulitis in the United States.

Results  Of 259 patients, 79 (30.5%) were misdiagnosed with cellulitis, and 52 of these misdiagnosed patients were admitted primarily for the treatment of cellulitis. Forty-four of the 52 (84.6%) did not require hospitalization based on ultimate diagnosis, and 48 (92.3%) received unnecessary antibiotics. We estimate cellulitis misdiagnosis leads to 50 000 to 130 000 unnecessary hospitalizations and $195 million to $515 million in avoidable health care spending. Unnecessary antibiotics and hospitalization for misdiagnosed cellulitis are projected to cause more than 9000 nosocomial infections, 1000 to 5000 Clostridium difficile infections, and 2 to 6 cases of anaphylaxis annually.

Conclusions and Relevance  Misdiagnosis of lower extremity cellulitis is common and may lead to unnecessary patient morbidity and considerable health care spending.

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