Dx accuracy for CAP

Robert M Centor rcentor at UAB.EDU
Thu Nov 21 14:09:17 UTC 2013


I agree with Dr. Hamm¹s point.  I presented the article, not just for the
problem of unnecessary antibiotic use, but also because the policy leads
to significant diagnostic delay.  Many patients should have an admission
diagnosis of uncertain disease causing dyspnea and an abnormal chest Xray.
 Perhaps our billing systems cannot handle that.  Perhaps we cannot
certify admissions with such a diagnosis.  I believe that we should label
undiagnosed disease for what it is - and often it is an appropriate reason
for admission.

We would likely make less diagnostic errors and have shorter diagnostic
delays if we labeled the problem as undiagnosed with a series of signs and
symptoms.
==============

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





On 11/20/13, 11:23 PM, "Hamm, Robert M. (HSC)" <Robert-Hamm at OUHSC.EDU>
wrote:

>While hospital antibiotic stewardship campaigns are doing heroic work,
>Donald Kennedy (once an FDA commissioner) has an editorial in Science
>pointing out that more of the responsibility for the drug resistant
>bacteria lies with using antibiotics in animal feed, than over use in
>medicine. He feels there is finally a chance for a change (after more
>than 30 years of advocacy) to get that addressed; doctors should speak
>out for it. 
>
>https://www.sciencemag.org/content/342/6160/777.full
>
>"Last month, a distinguished panel of experts assembled by the Johns
>Hopkins University's Center for a Livable Future concluded that the use
>of antibiotics in managing animal health and production has become a
>major public health problem. Moreover, new analyses show that there are
>links between antibiotic use in animals and antibiotic-resistant
>pathogens in humans who live near, or care for, the animals. Accordingly,
>the FDA issued in April 2012 a preliminary regulatory proposal to
>finalize ³Food and Drug Administration Guidance #213.² The guidance would
>end antibiotic use for growth promotion and ³unnecessary disease
>prevention²: i.e., prophylactic administration to animals whose health is
>threatened by crowding. It also would require veterinary oversight of
>antibiotics introduced into animal feed. Taken together, the provisions
>of this guidance offer a serious chance for ending the abuses that have
>brought about today's medical disaster of widespread antibiotic
>resistance. Guidance #213 makes clear the distinction between the use of
>antibiotics for treating sick animals and uses that are actually aimed at
>increasing production. It should be finalized as soon as possible."
>
>Rob
>
>
>Robert M. Hamm, PhD
>Clinical Decision Making Program
>Department of Family and Preventive Medicine
>University of Oklahoma Health Sciences Center
>900 NE 10th Street
>Oklahoma City OK 73104
>405 271 5362 ext 32306       Fax 405 271 2784
>robert-hamm at ouhsc.edu
>________________________________________
>From: Dr Wil [dr.will at FUSE.NET]
>Sent: Wednesday, November 20, 2013 5:56 AM
>To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>Subject: Re: [IMPROVEDX] Dx accuracy for CAP
>
>Particularly since hospitals are listed in their local newspaper for time
>of door to first dose of antibiotic for "pneumonia", not differentiating
>viral versus bacterial. No wonder we have MDROs. On further inquiry if
>the progress note denotes viral pneumonia then CMS or JCAHO(?) will not
>penalize the facility. Hmmm!
>A battle I have fought with ED docs for years. They usually call me as
>the first dose of antibiotic is being administered.
>Will Sawyer,MD
>
>Sent from my iPad
>
>On Nov 19, 2013, at 1:02 PM, Alan Sanders
><amsidp at AOL.COM<mailto:amsidp at AOL.COM>> wrote:
>
>David
>You hit it on the nose. We will be forced to increase and intensify our
>antibiotic stewardship interventions with these protocol driven orders.
>Isaac Newton had it pegged!  We will have to hold the line on usage of
>antibiotics like no time before
>Alan Sanders
>
>Sent from my iPhone
>
>On Nov 19, 2013, at 11:57 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
>
>The information in this electronic mail is sensitive, protected
>information intended only for the addressee(s). Any other person,
>including anyone who believes he/she might have received it due to an
>addressing error, is requested to notify the sender immediately by return
>electronic mail, and to delete it without further reading or retention.
>The information is not to be forwarded to or shared unless in compliance
>with Duke Medicine policies on confidentiality and/or with the approval
>of the sender.
>________________________________
>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 ³diagnosis² 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<https://urld
>efense.proofpoint.com/v1/url?u=http://archinte.jamanetwork.com/article.asp
>x?articleid%3D413982&k=7DHVT22D9IhC0F3WohFMBA%3D%3D%0A&r=L8ZYphVQlmksl4oGw
>c6Y0W9W%2Bk6y7%2BwB48qv3ANRRbw%3D%0A&m=GG7m1XoFc6WPcFFUZii8HIzbrggipfET%2B
>%2FPHOu8wFJk%3D%0A&s=70859c0bd3913b27edc077846958a067bf523b8ca72d04376bbb5
>b2976ad751f> (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):351­6.
>==============
>
>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
>
>________________________________
>
>Address messages to:
>IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS
>.ORG>
>
>To unsubscribe from IMPROVEDX: click the following link:
>http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A
>=1<https://urldefense.proofpoint.com/v1/url?u=http://list.improvediagnosis
>.org/scripts/wa-IMPDIAG.exe?SUBED1%3DIMPROVEDX%26A%3D1&k=7DHVT22D9IhC0F3Wo
>hFMBA%3D%3D%0A&r=L8ZYphVQlmksl4oGwc6Y0W9W%2Bk6y7%2BwB48qv3ANRRbw%3D%0A&m=G
>G7m1XoFc6WPcFFUZii8HIzbrggipfET%2B%2FPHOu8wFJk%3D%0A&s=a0d6dd3588bb81fe2d5
>c4efe0a7385f3593917dff28da53a7286b4c2514864df>
>
>or send email to: 
>IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX-SIGNO
>FF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>
>
>Visit the searchable archives or adjust your subscription at:
>http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX<https://urld
>efense.proofpoint.com/v1/url?u=http://list.improvediagnosis.org/scripts/wa
>-IMPDIAG.exe?INDEX&k=7DHVT22D9IhC0F3WohFMBA%3D%3D%0A&r=L8ZYphVQlmksl4oGwc6
>Y0W9W%2Bk6y7%2BwB48qv3ANRRbw%3D%0A&m=GG7m1XoFc6WPcFFUZii8HIzbrggipfET%2B%2
>FPHOu8wFJk%3D%0A&s=f420a4fa055bbb219f58c1ccc00692b520c95512398706a09e7bd40
>694671bf0>
>
>Moderator: Lorri Zipperer Lorri at ZPM1.com<mailto:Lorri at ZPM1.com>,
>Communication co-chair, Society for Improving Diagnosis in Medicine
>
>To learn more about SIDM visit:
>http://www.improvediagnosis.org/<https://urldefense.proofpoint.com/v1/url?
>u=http://www.improvediagnosis.org/&k=7DHVT22D9IhC0F3WohFMBA%3D%3D%0A&r=L8Z
>YphVQlmksl4oGwc6Y0W9W%2Bk6y7%2BwB48qv3ANRRbw%3D%0A&m=GG7m1XoFc6WPcFFUZii8H
>IzbrggipfET%2B%2FPHOu8wFJk%3D%0A&s=3a05c25052686a1aab776cbe4e2f24e96f8b872
>e1560903495ae2513c878c18e>
>
>________________________________
>
>Address messages to:
>IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS
>.ORG>
>
>To unsubscribe from IMPROVEDX: click the following link:
>http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A
>=1<https://urldefense.proofpoint.com/v1/url?u=http://list.improvediagnosis
>.org/scripts/wa-IMPDIAG.exe?SUBED1%3DIMPROVEDX%26A%3D1&k=7DHVT22D9IhC0F3Wo
>hFMBA%3D%3D%0A&r=L8ZYphVQlmksl4oGwc6Y0W9W%2Bk6y7%2BwB48qv3ANRRbw%3D%0A&m=G
>G7m1XoFc6WPcFFUZii8HIzbrggipfET%2B%2FPHOu8wFJk%3D%0A&s=a0d6dd3588bb81fe2d5
>c4efe0a7385f3593917dff28da53a7286b4c2514864df>
>
>or send email to: 
>IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX-SIGNO
>FF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>
>
>Visit the searchable archives or adjust your subscription at:
>http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX<https://urld
>efense.proofpoint.com/v1/url?u=http://list.improvediagnosis.org/scripts/wa
>-IMPDIAG.exe?INDEX&k=7DHVT22D9IhC0F3WohFMBA%3D%3D%0A&r=L8ZYphVQlmksl4oGwc6
>Y0W9W%2Bk6y7%2BwB48qv3ANRRbw%3D%0A&m=GG7m1XoFc6WPcFFUZii8HIzbrggipfET%2B%2
>FPHOu8wFJk%3D%0A&s=f420a4fa055bbb219f58c1ccc00692b520c95512398706a09e7bd40
>694671bf0>
>
>Moderator: Lorri Zipperer Lorri at ZPM1.com<mailto:Lorri at ZPM1.com>,
>Communication co-chair, Society for Improving Diagnosis in Medicine
>
>To learn more about SIDM visit:
>http://www.improvediagnosis.org/<https://urldefense.proofpoint.com/v1/url?
>u=http://www.improvediagnosis.org/&k=7DHVT22D9IhC0F3WohFMBA%3D%3D%0A&r=L8Z
>YphVQlmksl4oGwc6Y0W9W%2Bk6y7%2BwB48qv3ANRRbw%3D%0A&m=GG7m1XoFc6WPcFFUZii8H
>IzbrggipfET%2B%2FPHOu8wFJk%3D%0A&s=3a05c25052686a1aab776cbe4e2f24e96f8b872
>e1560903495ae2513c878c18e>
>
>________________________________
>
>Address messages to:
>IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS
>.ORG>
>
>To unsubscribe from IMPROVEDX: click the following link:
>http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A
>=1<https://urldefense.proofpoint.com/v1/url?u=http://list.improvediagnosis
>.org/scripts/wa-IMPDIAG.exe?SUBED1%3DIMPROVEDX%26A%3D1&k=7DHVT22D9IhC0F3Wo
>hFMBA%3D%3D%0A&r=L8ZYphVQlmksl4oGwc6Y0W9W%2Bk6y7%2BwB48qv3ANRRbw%3D%0A&m=G
>G7m1XoFc6WPcFFUZii8HIzbrggipfET%2B%2FPHOu8wFJk%3D%0A&s=a0d6dd3588bb81fe2d5
>c4efe0a7385f3593917dff28da53a7286b4c2514864df>
>
>or send email to: 
>IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX-SIGNO
>FF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>
>
>Visit the searchable archives or adjust your subscription at:
>http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX<https://urld
>efense.proofpoint.com/v1/url?u=http://list.improvediagnosis.org/scripts/wa
>-IMPDIAG.exe?INDEX&k=7DHVT22D9IhC0F3WohFMBA%3D%3D%0A&r=L8ZYphVQlmksl4oGwc6
>Y0W9W%2Bk6y7%2BwB48qv3ANRRbw%3D%0A&m=GG7m1XoFc6WPcFFUZii8HIzbrggipfET%2B%2
>FPHOu8wFJk%3D%0A&s=f420a4fa055bbb219f58c1ccc00692b520c95512398706a09e7bd40
>694671bf0>
>
>Moderator: Lorri Zipperer Lorri at ZPM1.com<mailto:Lorri at ZPM1.com>,
>Communication co-chair, Society for Improving Diagnosis in Medicine
>
>To learn more about SIDM visit:
>http://www.improvediagnosis.org/<https://urldefense.proofpoint.com/v1/url?
>u=http://www.improvediagnosis.org/&k=7DHVT22D9IhC0F3WohFMBA%3D%3D%0A&r=L8Z
>YphVQlmksl4oGwc6Y0W9W%2Bk6y7%2BwB48qv3ANRRbw%3D%0A&m=GG7m1XoFc6WPcFFUZii8H
>IzbrggipfET%2B%2FPHOu8wFJk%3D%0A&s=3a05c25052686a1aab776cbe4e2f24e96f8b872
>e1560903495ae2513c878c18e>
>
>________________________________
>
>Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>
>To unsubscribe from IMPROVEDX: click the following link:
>http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A
>=1<https://urldefense.proofpoint.com/v1/url?u=http://list.improvediagnosis
>.org/scripts/wa-IMPDIAG.exe?SUBED1%3DIMPROVEDX%26A%3D1&k=7DHVT22D9IhC0F3Wo
>hFMBA%3D%3D%0A&r=L8ZYphVQlmksl4oGwc6Y0W9W%2Bk6y7%2BwB48qv3ANRRbw%3D%0A&m=G
>G7m1XoFc6WPcFFUZii8HIzbrggipfET%2B%2FPHOu8wFJk%3D%0A&s=a0d6dd3588bb81fe2d5
>c4efe0a7385f3593917dff28da53a7286b4c2514864df>
>
>or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>
>Visit the searchable archives or adjust your subscription at:
>http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
>
>Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society
>for Improving Diagnosis in Medicine
>
>To learn more about SIDM visit:
>http://www.improvediagnosis.org/
>
>To unsubscribe from the IMPROVEDX:
>mail to:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>or click the following link: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>
>Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>
>For additional information and subscription commands, visit:
>http://www.lsoft.com/resources/faq.asp#4A
>
>http://LIST.IMPROVEDIAGNOSIS.ORG/ (with your password)
>
>Visit the searchable archives or adjust your subscription at:
>http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
>
>Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society
>for Improving Diagnosis in Medicine
>
>To unsubscribe from the IMPROVEDX list, click the following link:<br>
><a 
>href="http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPRO
>VEDX&A=1" 
>target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SU
>BED1=IMPROVEDX&A=1</a>
></p>










More information about the Test mailing list