Dx accuracy for CAP

Harold Lehmann lehmann at JHMI.EDU
Sun Nov 24 23:48:09 UTC 2013


You might throw in digital sound, as well
(http://www.stethocloud.com/howitworks.html). I.e., provide the raw data
and not the interpretation. But interpretation is important (I rather read
that an extra heart sound is interpreted as a physiologically split S2
rather than S3, and not have to interpret it all over again. . .wrongly.)
And this is what doctors do and is their responsibility.

Harold

BTW, does ambient lighting affect the image's color?


On 11/24/13 10:56 AM, "Art Papier MD" <apapier at logicalimages.com> wrote:

>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:
>>>IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGN
>>>O
>>>SIS
>>>.ORG>
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>>>wc6
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>>>d40
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>>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
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>>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=IM
>>PRO
>>VE
>>DX&A=1"
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>>?SU
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>>D1=IMPROVEDX&A=1</a>
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>>
>>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=IM
>>PRO
>>VEDX&A=1" 
>>target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe
>>?SU
>>BED1=IMPROVEDX&A=1</a>
>></p>
>
>
>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
>VE
>DX&A=1"
>target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SU
>BE
>D1=IMPROVEDX&A=1</a>
></p>
>


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=IMPROVEDX&A=1" target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1</a>
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