Dx accuracy for CAP

Swerlick, Robert A rswerli at EMORY.EDU
Tue Nov 19 18:35:39 UTC 2013


What we are running into is the fact that we are not operating airplanes or similar machinery. When we deal with patients with illnesses, whether they be possible infections or malignancies, the world we must deal with is not so predictable as an airplane.  For every patient who presents with fever on its way to sepsis, we will see thousands if not tens of thousands of patients who present with virtually identical signs and symptoms whose clinical course will not warrant an intervention. We are left with two choices; intervene literally thousands of times where no intervention is really required or fail to prevent rare bad outcomes. No matter where we set the bar for interventions, there will still be failures. The question will then be whether we set an even lower threshold for intervention and end up treating even more people who really don't require treatment.

I believe we have not yet arrived at the place where we have an acceptable failure rate but at some point we will need to accept that bad outcomes are perfectly compatible with approaches and systems which are near optimal given our current tools and knowledge. We really do not want legislative approaches to codify responses to what may end up being random anecdote.  Such anecdotes may be useful to market our message but we need to be careful these do not result in the creation of a new set of errors.

Bob Swerlick

From: Peggy Zuckerman [mailto:peggyzuckerman at GMAIL.COM]
Sent: Tuesday, November 19, 2013 12:35 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Dx accuracy for CAP

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<mailto: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<mailto:rcentor at UAB.EDU>]
Sent: Tuesday, November 19, 2013 7:43 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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.
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Robert M Centor, MD, FACP

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--
Peggy Zuckerman
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