Dx accuracy for CAP

Peggy Zuckerman peggyzuckerman at GMAIL.COM
Tue Nov 19 17:35:22 UTC 2013


How is this balanced against the drive to prevent the overuse of
antibiotics?  Seems that those regulations and the push to prevent the
creation of more "superbugs" is in conflict with this issue.

Unfortunately, I think that this kind of rigid regulation (is there another
kind?) is going to emerge more and more often as we see the standardization
of medicine imposed from above, trying to land on a dynamic and
ill-prepared landscape.

Right now the issues of which meds should be given to varying cancer types,
if applied as above, would mandate patients getting meds (or not) according
the location of their tumors, rather than due to the pathology and/or
genomic characteristics of the tumor.

Peggy Zuckerman


On Tue, Nov 19, 2013 at 8:57 AM, David Gordon, M.D.
<davidc.gordon at duke.edu>wrote:

>  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
>
>
>  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
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *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
> 301 Governors Drive
> Huntsville, AL 35801
>
>  Office: 256-539-7757
> Fax: 256-551-4451
>
>  Chair-Elect, ACP Board of Regents
>
>  Professor, General Internal Medicine
> UAB
>  FOT 720
> 1530 3rd Ave S
> Birmingham, AL 35294-3407
> Office: 205-975-4889
>
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-- 
Peggy Zuckerman
www.peggyRCC.wordpress.com








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