Dx accuracy for CAP

David Gordon, M.D. davidc.gordon at DUKE.EDU
Tue Nov 19 16:57:17 UTC 2013

Thank you for sending this out.  I think it really speaks to the double-edged sword of these core quality care measures. If the person really has that disease, then meeting the timeline can be of benefit to the individual, but the problem is that the measures  changes the way we approach a population - resulting in a lot of unnecessary treatment and needless exposure to antibiotics to patients who don't have the disease.  As an emergency medicine, I can tell you the administrative pressure not to miss treating a single case of pneumonia is immense.  There is no penalty for the physician for unnecessary antibiotic treatment and no reward for astutely withholding antibiotics in equivocal cases.

In essence, I think these core measures have the effect of recalibrating treatment thresholds. Before, it would be SOB+ abnormal CXR + fever before ordering antibiotics.  Now it is SOB +abnormal CXR + administrative penalty for missing CAP that is enough to cross the treatment threshold. So it may be more accurate to frame this problem as inappropriate treatment thresholds rather than errors in diagnosis.

I fear we will be seeing the same story and a similar study with sepsis -- especially in NY.  I can only imaging the number of patients with viral illnesses who presents with fever and tachycardia who will receive unnecessary antibiotics.


David Gordon, MD
Assistant Professor
Undergraduate Education Director
Division of Emergency Medicine
Duke University

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From: Robert M Centor [rcentor at UAB.EDU]
Sent: Tuesday, November 19, 2013 7:43 AM
Subject: [IMPROVEDX] Dx accuracy for CAP

My pet peeve as an academic hospitalist is the “diagnosis” of CAP (community acquired pneumonia).  Once I hear that phrase I immediately become skeptical.  CAP has seemingly become a waste basket diagnosis for dyspnea and an abnormal CXR.  I love collecting  and presenting patient stories that start as community acquired pneumonia.  In preparing to more formally study this topic, I have spent much time thinking about the problem.   Just yesterday I recalled this paper.  I have not seen it in the diagnostic error literature previously, and thought I would share it with the group.  If you know of other similar articles, I would greatly appreciate the references.

Given the lower diagnostic accuracy on CAP, I urge all physicians to be skeptical of the diagnosis, until collecting appropriate clinical information to support the diagnosis.

http://archinte.jamanetwork.com/article.aspx?articleid=413982 (article available for free)

1. Welker JA, Huston M, McCue JD. Antibiotic timing and errors in diagnosing pneumonia. Arch Intern Med. 2008 Feb 25;168(4):351–6.

Robert M Centor, MD, FACP

Regional Dean, UAB Huntsville Regional Medical Campus
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