Thursday, March 13, 2014

Overdiagnosis of pneumonia

The overdiagnosis of pneumonia, which is becoming increasingly recognized, was the topic of a recent article in the Cleveland Clinic Journal of Medicine. As is apparent from the review the reasons for this trend in overdiagnosis are multiple and complex. One factor, I believe, is time pressure. This pressure comes in many forms including throughput initiatives to reduce ER crowding, time based performance measures, pressure to identify a “principal problem” on admission and incentives to place hospitalized patients on care pathways. Vague problem statements like “pulmonary opacity” and “breathing difficulty”, while often more honestly and accurately reflective of problem resolution at a given time, are frowned upon in today's regulatory and performance environment. “Systems improvements”thus lead to diagnostic inaccuracy.

Another problem pointed out in the article is the disconnect between application of a simple diagnostic label and discrimination between patients who will and will not benefit from antibiotics. As the article points out:

The central problem with pneumonia, as with many long-recognized clinical conditions, is that the diagnosis is separated from the treatment. In other words, although physicians are confident that antibiotics benefit patients who have what Sir William Osler would have called pneumonia (elevated white blood cell count, fever, cough, dyspnea, pleurisy, egophany, lobular infiltrate), we don’t know whether the treatment benefits patients whose pneumonia would have been unrecognizable decades ago (with cough, low-grade fever, and infiltrate on CT alone). Improvements in imaging may exacerbate the problem. In this sense, pneumonia exists on a spectrum, as do many medical diagnoses. Not all cases are equally severe, and some may not deserve to be labeled as pneumonia.

It goes on to say that there is equipoise for the performance of clinical trials to determine whether antibiotics can be withheld in dubious cases.

1 comment:

Bryan said...

Thanks Dr. RW. That was a fascinating read.

Like you mentioned, what stood out to me was the section about the diagnosis being "in the eye of the beholder." It's kind of amazing that something so common as pneumonia has so much uncertainty around it--at least pertaining to the physicians who are treating patients.

Your mention of the time crunch being a big issue seems apt. In the article, Dr. Prasad says that efforts to have physicians deliver antibiotics to patients within four hours has actually led to LESS accuracy in actually diagnosing pneumonia.

It seemed that the article, at least to some degree, suggests that pneumonia exists in a bit of a gray area (scale wise at least), making it either difficult to wholly diagnose due to symptoms that may not be clearly defined, or how the advancement of technology (or maybe more of a reliance on it?) has led to increasing the problem and confusion.