News: Patient records with pneumonia have high rates of uncertainty, study shows

More than half of inpatient pneumonia diagnoses changed from the emergency department (ED) to discharge, and uncertainty in clinical notes was more common than not, according to a nationwide retrospective analysis of Veterans Affairs (VA) data in the Annals of Internal Medicine. Researchers found that 58% of ED notes and 49% of discharge notes expressed diagnostic uncertainty, and patients with discordant diagnoses had greater uncertainty documented in clinical notes and received more treatments than those with concordant diagnoses, MedPage Today reported.

Researchers pulled from 2.4 million patient encounters at EDs that resulted in hospitalizations in the VA healthcare system and identified 317,000 hospitalizations for pneumonia based on notes from the ED, clinician, discharge, and radiology. They found that 57% of the reviewed records had discordance between initial and discharge diagnoses, and 58% indicated uncertainty in diagnosis.

Among the different sources of diagnostic error, the most common were:

• Misinterpretation of chest imaging as positive when it was negative
• Failure to see chest image reports
• Failure to appreciate whether signs of infection were present or absent

The analysis data revealed patients with diagnostic discordance compared to those with concordant diagnoses experienced:

• Slightly higher rates of renal disease and heart failure
• Higher rates of ED stay of longer than eight hours
• Higher rates of treatment with corticosteroids and diuretics
• Lower likelihood to have severe illness
• Lower levels of inflammatory markers
• Substantially fewer CT scans (7.4% versus 33.2%)
• Fewer microbiology tests performed
• Roughly the same percentage of positive cultures

On the other hand, researchers found that patients with concordant diagnoses were more likely to present with fever, abnormal white blood cell count, and elevated C-reactive protein and procalcitonin.

“We should anticipate diagnostic discordances and uncertainty in pneumonia,” the authors of the study wrote. “Clinicians often encounter pressure to provide distinct diagnostic labels to facilitate hospital admission, simplify handoffs, or satisfy patients.”

Editor’s note: To read MedPage Today’s coverage of this story, click here. To read the analysis, click here.