Ear, Nose and Throat (ENT) disease diagnostic error in low-resource health care: Observations from a hospital-based cross-sectional study

PLOS ONE RESEARCH ARTICLE Ear, Nose and Throat (ENT) disease diagnostic error in low-resource health care: Observations from a hospital-based crosssectional study Lufunda Lukama ID1,2*, Colleen Aldous2, Charles Michelo3,4, Chester Kalinda ID5,6 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 1 Department of Otorhinolaryngology, Head and Neck Surgery, Ndola Teaching Hospital, Ndola, Zambia, 2 College of Health Sciences, Nelson R Mandela School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa, 3 School of Public Health, Department of Epidemiology, Harvest University, Lusaka, Zambia, 4 Strategic Centre for Health Systems Metrics & Evaluations (SCHEME), School of Public Health, University of Zambia, Lusaka, Zambia, 5 Bill and Joyce Cummings Institute of Global Health, University of Global Health Equity, Kigali, Rwanda, 6 Howard College Campus, College of Health Sciences, School of Public Health and Nursing, University of KwaZulu-Natal, Durban, South Africa * OPEN ACCESS Citation: Lukama L, Aldous C, Michelo C, Kalinda C (2023) Ear, Nose and Throat (ENT) disease diagnostic error in low-resource health care: Observations from a hospital-based crosssectional study. PLoS ONE 18(2): e0281686. https://doi.org/10.1371/journal.pone.0281686 Editor: Jorge Spratley, University of Porto Faculty of Medicine, PORTUGAL Received: September 30, 2022 Accepted: January 28, 2023 Published: February 9, 2023 Peer Review History: PLOS recognizes the benefits of transparency in the peer review process; therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. The editorial history of this article is available here: https://doi.org/10.1371/journal.pone.0281686 Copyright: © 2023 Lukama et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: The data used in this study can be accessed here: Lukama, Lufunda; Aldous, Colleen; Michelo, Charles; Kalinda, Chester (2022), “Dataset on diagnostic errors of Ear, Nose Abstract Although the global burden of ear, nose and throat (ENT) diseases is high, data relating to ENT disease epidemiology and diagnostic error in resource-limited settings remain scarce. We conducted a retrospective cross-sectional review of ENT patients’ clinical records at a resource-limited tertiary hospital. We determined the diagnostic accuracy and appropriateness of patient referrals for ENT specialist care using descriptive statistics. Cohens kappa coefficient (κ) was calculated to determine the diagnostic agreement between non-ENT clinicians and the ENT specialist, and logistic regression applied to establish the likelihood of patient misdiagnosis by non-ENT clinicians. Of the 1543 patients studied [age 0–87 years, mean age 25(21) years (mean(SD)], non-ENT clinicians misdiagnosed 67.4% and inappropriately referred 50.4%. Compared to those aged 0–5 years, patients aged 51–87 years were 1.77 (95%CI: 1.03–3.04) fold more likely to have a referral misdiagnosis for specialist care. Patients with ear (aOR: 1.63; 95% CI: 1.14–2.33) and those with sinonasal diseases (aOR: 1.80; 95% CI: 1.14–2.45) had greater likelihood of referral misdiagnosis than those with head and neck diseases. Agreement in diagnosis between the ENT specialist and nonENT clinicians was poor (κ = 0.0001). More effective, accelerated training of clinicians may improve diagnostic accuracy in low-resource settings. Introduction Diseases affecting the ear, nose and throat (ENT) constitute 20–50% of disorders treated at health facilities [1]. In most resource-limited settings, they are associated with poor outcomes [2]. Despite their high prevalence, ENT diseases have been disregarded in global health [3]. In Zambia and other developing countries, ENT health care is poorly funded and has inadequate PLOS ONE | https://doi.org/10.1371/journal.pone.0281686 February 9, 2023 1 / 12 PLOS ONE and Throat (ENT) diseases ”, Mendeley Data, v1 (http://dx.doi.org/10.17632/6tgz2db7yn.1). Funding: The authors received no specific funding for this work. However, during the course of this study, Lufunda Lukama received a tuition fee waiver from the University of KwaZulu-Natal (https://ukzn.ac.za) and a scholarship (tuition fees, living cost stipend) from the Canon Collins Educational and Legal Assistance Trust (https:// canoncollins.org/) for his Doctor of Philosophy studies at the University of KwaZulu-Natal College of Health Sciences in South Africa [no grant numbers available]. There was no additional external funding received for this study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. Ear, Nose and Throat (ENT) disease diagnostic error in low-resource health care infrastructure, equipment, medication, human resources and training facilities [4, 5]. The few available ENT specialists are distributed to limited overwhelmed urban units. Thus, most ENT patients are treated by clinicians not trained in ENT disease management [4]. Although these clinicians must be competent in the basic management of ENT conditions, many countries have deemed them inadequately trained to treat ENT diseases [6]. As a result, the true incidence of diagnostic error (delayed, missed or wrong diagnosis) [7] and inappropriate or late ENT patient referrals for treatment among non-ENT clinicians is likely high. Diagnostic error contributes up to 70% of all medical errors [8]. In well-resourced countries, the incidence of diagnostic error varies between 0.7 to 15%, of which half is harmful [9, 10]. However, in low-resource settings, data relating to harmful diagnostic error remains sparse due to limited access to diagnostic resources, shortage of qualified medical professionals and poverty of electronic record-keeping systems [11]. While inappropriate referral of patients can undermine the quality of patient care [12], misdiagnosis increases the risk of death, elevates the financial strain on the already stretched health systems and may result in significant litigation [13]. In Zambia, there has not been an investigation into the prevalence and impact of diagnostic errors in health facilities. In this study, we determined the diagnostic accuracy and estimated the appropriateness of referrals among patients treated at Zambia’s highest ENT treatment facility. In addition, we determined the level of agreement of ENT diagnoses between the ENT specialist and referring clinicians. Methods Design and setting We conducted a retrospective cross-sectional review of clinical case records of patients presenting to the University Teaching Hospitals (UTH) ENT outpatient clinic in Zambia be (...truncated)