Division of Pulmonary & Critical Care Medicine, University of Utah and Salt Lake City VA Healthcare System, Salt Lake City, Utah (B.E.J.).
Division of Epidemiology, University of Utah and Salt Lake City VA Healthcare System, Salt Lake City, Utah (A.B.C., J.Y., M.R.N., M.M.J., M.H.S.).
Ann Intern Med. 2024 Sep;177(9):1179-1189. doi: 10.7326/M23-2505. Epub 2024 Aug 6.
Evidence-based practice in community-acquired pneumonia often assumes an accurate initial diagnosis.
To examine the evolution of pneumonia diagnoses among patients hospitalized from the emergency department (ED).
Retrospective nationwide cohort.
118 U.S. Veterans Affairs medical centers.
Aged 18 years or older and hospitalized from the ED between 1 January 2015 and 31 January 2022.
Discordances between initial pneumonia diagnosis, discharge diagnosis, and radiographic diagnosis identified by natural language processing of clinician text, diagnostic coding, and antimicrobial treatment. Expressions of uncertainty in clinical notes, patient illness severity, treatments, and outcomes were compared.
Among 2383899 hospitalizations, 13.3% received an initial or discharge diagnosis and treatment of pneumonia: 9.1% received an initial diagnosis and 10.0% received a discharge diagnosis. Discordances between initial and discharge occurred in 57%. Among patients discharged with a pneumonia diagnosis and positive initial chest image, 33% lacked an initial diagnosis. Among patients diagnosed initially, 36% lacked a discharge diagnosis and 21% lacked positive initial chest imaging. Uncertainty was frequently expressed in clinical notes (58% in ED; 48% at discharge); 27% received diuretics, 36% received corticosteroids, and 10% received antibiotics, corticosteroids, and diuretics within 24 hours. Patients with discordant diagnoses had greater uncertainty and received more additional treatments, but only patients lacking an initial pneumonia diagnosis had higher 30-day mortality than concordant patients (14.4% [95% CI, 14.1% to 14.7%] vs. 10.6% [CI, 10.4% to 10.7%]). Patients with diagnostic discordance were more likely to present to high-complexity facilities with high ED patient load and inpatient census.
Retrospective analysis; did not examine causal relationships.
More than half of all patients hospitalized and treated for pneumonia had discordant diagnoses from initial presentation to discharge. Treatments for other diagnoses and expressions of uncertainty were common. These findings highlight the need to recognize diagnostic uncertainty and treatment ambiguity in research and practice of pneumonia-related care.
The Gordon and Betty Moore Foundation.
社区获得性肺炎的循证实践通常假设初始诊断准确。
检查急诊科（ED）住院患者的肺炎诊断演变。
回顾性全国队列研究。
美国 118 个退伍事务医疗中心。
年龄在 18 岁或以上，2015 年 1 月 1 日至 2022 年 1 月 31 日期间从 ED 住院。
通过临床医生文本、诊断编码和抗菌治疗的自然语言处理识别初始肺炎诊断、出院诊断和放射学诊断之间的差异。比较了临床记录中表达的不确定性、患者疾病严重程度、治疗和结局。
在 2383899 例住院患者中，有 13.3%接受了初始或出院诊断和肺炎治疗：9.1%接受了初始诊断，10.0%接受了出院诊断。初始诊断和出院诊断之间存在差异，占 57%。在出院时被诊断患有肺炎且初始胸部图像呈阳性的患者中，有 33%缺乏初始诊断。在最初被诊断为肺炎的患者中，有 36%缺乏出院诊断，有 21%缺乏初始胸部影像学检查。在临床记录中经常表达不确定性（在 ED 为 58%；在出院时为 48%）；27%接受利尿剂，36%接受皮质类固醇，10%在 24 小时内接受抗生素、皮质类固醇和利尿剂。诊断不一致的患者具有更大的不确定性，并接受了更多的额外治疗，但只有缺乏初始肺炎诊断的患者的 30 天死亡率高于一致患者（14.4%[95%CI，14.1%至 14.7%] vs. 10.6%[CI，10.4%至 10.7%]）。诊断不一致的患者更有可能前往高复杂性设施就诊，这些设施的 ED 患者人数多，住院人数多。
回顾性分析；未检查因果关系。
超过一半的因肺炎住院并接受治疗的患者，从最初就诊到出院时都存在诊断不一致的情况。针对其他诊断的治疗和不确定性的表达很常见。这些发现突出表明，在肺炎相关护理的研究和实践中，需要认识到诊断不确定性和治疗模糊性。
戈登和贝蒂·摩尔基金会。
