In this study, we examined sociodemographic factors that might influence the development of CAA as a sequela of the vasculitis associated with acute Kawasaki syndrome. We found that the only significant independent risk factor for CAA was delayed diagnosis. Delayed diagnosis was further examined as the sum of the number of days before medical consultation by parents and the number of days before physicians diagnosed Kawasaki syndrome. We found that the most important factor in delayed diagnosis was a delay by the physician, which in turn was associated with multiple visits to a healthcare provider for the same illness and incomplete clinical signs. Hospitalization at another facility with an erroneous diagnosis was an independent risk factor for delayed diagnosis.
The study was conducted in San Diego, a border community of approximately 3 million residents with a population that is 52% non-Hispanic white, 28% Hispanic white and 10% Asian (estimated from the 2000 U.S. census). Studies have documented that many Mexican-born, U.S. residents preferentially seek health care across the border in Mexico where they perceive that they can receive more culturally competent care.9
Other reasons to seek health care in Mexico may include lower cost for individuals without health insurance and the widespread practice of evening office hours, obviating the need for parents to miss work. In the univariate analysis, Spanish as a primary language, lack of health insurance and seeking health care in Mexico were all significantly associated with the group that developed CAA. Restricted access to health care due to lack of health insurance may account for the findings in previous studies that Kawasaki syndrome patients are more likely to come from middle and upper-middle class families.7,10,11
However, our data show that these characteristics are not associated with delay in seeking medical consultation by parents but rather are associated with delayed diagnosis by physicians.
Our data further show that Spanish-speaking parents bring their children in, on average, even earlier than others, and that recognition of Kawasaki syndrome by physicians who serve this population needs improvement. A practical solution might be to target education about Kawasaki syndrome diagnosis to these healthcare providers.
Limitations of this study include the small sample size, the use of hospital records as the primary source of information and the retrospective study design. Potential biases introduced by the retrospective collection of data include omissions in the physician histories, use of parent self-reported ethnicity and date of initial appearance of symptoms and inaccuracies in dates of physician encounters.
In a recent study by Anderson et al,5
which examined factors contributing to delayed diagnosis of Kawasaki syndrome, it was also noted that the time to first physician visit was similar between the groups diagnosed before or after day 10 of illness. This suggests that parents easily recognized the severity of their child’s illness. With respect to the healthcare providers in the present study, recognition of Kawasaki syndrome was delayed in children who lacked one or more of the classic criteria. It should be emphasized that the clinical signs of Kawasaki syndrome are often not all present at any one point in time and the existence of a language barrier may have made accurate medical histories difficult to obtain. Thus, physicians may have missed important historical clues to the diagnosis due to communication failure. Appearance of the clinical signs of Kawasaki syndrome over a protracted period of time was also a risk factor for delayed diagnosis in the study by Anderson et al.5
Together, these studies suggest that resources should be directed toward healthcare provider education and adoption of the new American Heart Association guidelines that specifically address the approach to the patient with incomplete diagnostic criteria.3