Dx accuracy for CAP

Art Papier MD apapier at LOGICALIMAGES.COM
Sun Nov 24 15:56:21 UTC 2013


Harold, Great point.  In our world of dermatology, we have records that say
for instance "5 mm brown papule at back inferior to scapula", the assessment
"probable irritated normal nevus, consider atypical nevus", the plan
"re-check  in 6 months".  Patient returns in 6 months, and a colleague sees
the patient or you do not remember, but there are 5 nevi on the back.   So
you are not sure which nevus to recheck and you do not know what was meant
even by brown.  Color is subjective.  Do you trust the other observer? How
did it really look?  
  A digital image in the record was possible a decade ago, but the major
e-record companies (with the exception of a new EHR company for dermatology)
have punted on making it EASY to document with images.  Objective data such
as images are worth a thousand words and communicate location, morphology
and so much important data about the state and quality of the information.
Too often we only think in words.  Images and videos will become essential
to capturing what is going on in our patients.  Best Art


-----Original Message-----
From: Harold Lehmann [mailto:lehmann at JHMI.EDU] 
Sent: Saturday, November 23, 2013 8:50 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Dx accuracy for CAP

Wouldn't it be great it, in our electronic health records, we could indicate
trust or certainty or other concerns about individual data, let alone the
diagnosis? We spend so much time thinking about each datum, yet we don't
have a place to record our conclusions about the datum. ("The lab reports a
high Sodium, but I think it's a lab error". . ."The record says, 'murmur,'
but it's an intern's exam". . ."The doctor reports 'vertigo,'
but I don't know if that's her judgement or the patient's report" . .
."There's an indication of penicillin allergy, but I couldn't track down the
source nor verify it with the patient". . . )

Harold

On 11/23/13 5:10 PM, "Pat Croskerry" <croskerry at EASTLINK.CA> wrote:

>Robert: we do that here in Canada from the emergency department i.e. we 
>can admit with Chest pain NYD (not yet diagnosed), syncope NYD etc.
>Some have seen this as a significant milestone. It leaves things open, 
>indicating the uncertainty, and reduces premature diagnostic closure.
>Pat
> 
>
>_____________________________________________________________
>Pat Croskerry MD, PhD, FRCP(Edin)
>Professor,Department of Emergency Medicine, Director, Critical Thinking 
>Program, Division of Medical Education, Faculty of Medicine, Dalhousie 
>University, QE II - Health Sciences Centre, Halifax Infirmary, Suite 
>355
>1796 Summer Street, Halifax, Nova Scotia, B3H 2Y9 CANADA
>
>Phone:  902 821 2014 (home)
>               902 225 0360 (cell)
> 
>
>-----Original Message-----
>From: Robert M Centor [mailto:rcentor at UAB.EDU]
>Sent: Thursday, November 21, 2013 10:09 AM
>To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>Subject: Re: [IMPROVEDX] Dx accuracy for CAP
>
>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.IMPROVEDIAGN
>>O
>>SIS
>>.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://
>>u
>>rld
>>efense.proofpoint.com/v1/url?u=http://archinte.jamanetwork.com/article.
>>asp
>>x?articleid%3D413982&k=7DHVT22D9IhC0F3WohFMBA%3D%3D%0A&r=L8ZYphVQlmksl
>>4
>>oGw
>>c6Y0W9W%2Bk6y7%2BwB48qv3ANRRbw%3D%0A&m=GG7m1XoFc6WPcFFUZii8HIzbrggipfE
>>T
>>%2B
>>%2FPHOu8wFJk%3D%0A&s=70859c0bd3913b27edc077846958a067bf523b8ca72d04376
>>b
>>bb5
>>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:
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