That was the question that led to a cohort study of 17,290 hospitalized adults treated for pneumonia in 48 Michigan hospitals. The research led by the University of Michigan Medical School and the Veterans Affairs (VA) Healthcare System found a 12.0% rate of inappropriate diagnosis.
The article in the Journal of the American Medical Association Internal Medicine stated that patients who were most often diagnosed inappropriately were old, had dementia, and presented with altered mental status. The authors added that “for those inappropriately diagnosed, receipt of a full antibiotic duration was associated with antibiotic-associated adverse events.”
Pointing out that not much was known about incidence of, risk factors for, and harms associated with inappropriate diagnosis of CAP, the study team sought to characterize inappropriate diagnosis of CAP in hospitalized patients.
For the prospective cohort study, which included medical record review and patient telephone calls, trained abstractors retrospectively assessed hospitalized patients who were treated for CAP between July 1, 2017, and March 31, 2020. Eligible for inclusion were adult patients admitted to general care with a discharge diagnostic code of pneumonia who received antibiotics on Day 1 or 2 of hospitalization. Data were analyzed from February 2023 to December 2023.
Inappropriate diagnosis of CAP was defined using a National Quality Forum–endorsed metric as CAP-directed antibiotic therapy in patients with fewer than two signs or symptoms of CAP or negative chest imaging. “Risk factors for inappropriate diagnosis were assessed and, for those inappropriately diagnosed, 30-day composite outcomes (mortality, readmission, emergency department visit, Clostridioides difficile infection, and antibiotic-associated adverse events) were documented and stratified by full course (>3 days) vs. brief (≤3 days) antibiotic treatment using generalized estimating equation models adjusting for confounders and propensity for treatment,” the authors explained.
Of the 17,290 hospitalized patients treated for CAP, the 12.0% who met criteria for inappropriate diagnosis had a median age of 71.8 and were 50.3% female, according to the report. A high percentage (87.6%) received full antibiotic courses, the authors pointed out.
“Compared with patients with CAP, patients inappropriately diagnosed were older (adjusted odds ratio [AOR], 1.08; 95% CI, 1.05-1.11 per decade) and more likely to have dementia (AOR, 1.79; 95% CI, 1.55-2.08) or altered mental status on presentation (AOR, 1.75; 95% CI, 1.39-2.19),” the study noted. “Among those inappropriately diagnosed, 30-day composite outcomes for full vs brief treatment did not differ (25.8% vs. 25.6%; AOR, 0.98; 95% CI, 0.79-1.23). Full vs. brief duration of antibiotic treatment among patients was associated with antibiotic-associated adverse events (31 of 1821 [2.1%] vs. 1 of 258 [0.4%]; P = .03).”
Background information in the report advised that lower respiratory tract infection, including CAP, is the fourth most common cause of medical hospitalization and most common infectious cause of hospitalization in the United States. “While many hospitalized patients treated for pneumonia have an infection, inaccurate or inappropriate diagnosis of pneumonia (i.e., pneumonia diagnosis when pneumonia is not present) is common,” the researchers pointed out.
“While some inappropriate diagnosis of CAP is unavoidable due to diagnostic uncertainty when patients are first hospitalized, many patients remain inappropriately diagnosed even on hospital discharge,” they added. “Inappropriate diagnosis of CAP may harm patients through delayed recognition and treatment of acute (e.g., exacerbations of congestive heart failure), chronic (e.g., pulmonary cancer), or novel diagnoses (e.g., pulmonary cancer) and may lead to unnecessary antibiotic use, adverse effects, and antibiotic resistance.”
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