Dx accuracy for CAP

Harold Lehmann lehmann at JHMI.EDU
Sun Nov 24 23:44:09 UTC 2013


So it sounds like we have 4 qualitative probabilities: r/o (low), NYD (middle), NYC (high), NYP (even higher?).

When, in the 1980s, a group at Stanford worked at converting Jack Myers' brain, as represented in INTERNIST-1 (QMR), we found we needed at most 5 levels of probability to turn his qualitative system into a probabilistic one (5%, 10%, 50%, 90%, 95%).

In my own querying of residents for 15 years, looking for the threshold below which they would not want to do an LP on a 1 year old with fever and "concern for meningitis," the modal threshold was 1/1,000 (except for the former lawyer, who said 1/million). [no IRB!, but n=like 300.] So perhaps that (1/1,000) is below "r/o". And now we have 5 probabilities, just like in our converted system, although the values of the numbers are different. [Of course, the actual value of the probability related to NYD, etc., depends on the specific dx.]

Harold

Middleton B, Shwe MA, Heckerman DE, Henrion M, Horvitz EJ, Lehmann HP, Cooper
GF. Probabilistic diagnosis using a reformulation of the INTERNIST-1/QMR
knowledge base. II. Evaluation of diagnostic performance. Methods Inf Med. 1991
Oct;30(4):256-67. PubMed PMID: 1762579.

From:  Pat Croskerry <croskerry at eastlink.ca<mailto:croskerry at eastlink.ca>>
Date:  Sunday, November 24, 2013 11:27 AM
To:  'Society to Improve Diagnosis in Medicine' <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Harold Lehmann <lehmann at jhmi.edu<mailto:lehmann at jhmi.edu>>
Subject:  RE: [IMPROVEDX] Dx accuracy for CAP


I meant to add an alternate optionto NYP
which may allow a little more flexibility:NYC (not yet confirmed)
_____________________________________________________________
Pat Croskerry MD, PhD,
FRCP(Edin)
Professor,Department of Emergency Medicine,

Director, Critical Thinking Program, Division of Medical Education,
Faculty of Medicine,
Dalhousie University,
Halifax, Nova Scotia,

CANADA


-----Original Message-----
From: Harold Lehmann [mailto:lehmann at JHMI.EDU]
Sent: Saturday, November 23, 2013 9:50 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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<mailto: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<mailto: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<mailto: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<mailto:robert-hamm at ouhsc.edu>
________________________________________
From: Dr Wil [dr.will at FUSE.NET<mailto:dr.will at FUSE.NET>]
Sent: Wednesday, November 20, 2013 5:56 AM
To:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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><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><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><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><mailto:IMPROVEDX at LIST.IMPROVEDIAGN
O
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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

________________________________

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