Investigators found that older adults, adults with dementia, and adults with altered mental status were more likely to be inappropriately diagnosed with CAP when hospitalized.
The inappropriate diagnosis of community-acquired pneumonia (CAP) among adults who are hospitalized is common, according to results of a study published in JAMA International Medicine. Investigators of the study found this to be particularly true among older adults who have geriatric symptoms.
In the study, the authors said the inappropriate diagnosis of CAP is unavoidable in some cases due to diagnostic uncertainty when patients are first hospitalized, but some continue to be inappropriately diagnosed even at discharge. The authors stated that inappropriately diagnosing patients could cause harm due to delayed recognition and treatment of acute, chronic, or novel diagnoses and lead to unnecessary antibiotic use, sometimes causing resistance.
The investigators used a metric to quantify the inappropriate diagnosis of CAP in 48 hospitals in Michigan to better understand the outcomes associated with the diagnosis. Individuals hospitalized and treated with pneumonia between July 1, 2017, and March 31, 2020, were included in the study. They were considered eligible if they were admitted to general care with a discharge diagnosis of pneumonia and received antibiotics on day 1 or 2 of hospitalization, according to the study authors.
The primary outcome included the inappropriate diagnosis of CAP, and the secondary outcomes included a composite of 30-day patient outcomes, such as 30-day all-cause post-discharge mortality, hospital readmission, emergency department visit, C difficile infection, and/or physician-documented antibiotic adverse events (AEs).
There were 2079 individuals who were inappropriately diagnosed with CAP, according to the study authors, which equated to 12% of patients. Approximately 62.5% of hospitals inappropriately diagnosed 10% or more of patients with CAP.
Of the inappropriately diagnosed patients, 73.6% didn’t match radiographic criteria, 24.4% had fewer than 2 signs or symptoms of pneumonia, and 2% met neither criterion, according to the study authors. They noted there was no difference in median length of stay for those who met and did not meet CAP criteria, but those who were inappropriately diagnosed were more likely to be 75 years or older, have public insurance, have an altered mental status, have decreased mobility, or have had an inpatient hospitalization within 90 days. In a multivariable analysis, investigators found that the inappropriate diagnosis was associated with older patients and patients who were more likely to have dementia or present with an altered mental status, according to the results.
Additionally, those inappropriately diagnosed with CAP received a median of 7 days of antibiotics with 4 inpatient days, and 87.6% received a full course of antibiotics, according to the study authors. Investigators also said that empirical antibiotics were more likely to be given to white patients, those with a history of chronic obstructive pulmonary disease (COPD), or those who present with a concurrent COPD exacerbation.
Furthermore, the composite outcome of any 30-day post-discharge AEs occurred in 25.8% of patients who were inappropriately diagnosed with CAP. Full and brief antibiotic therapy was not associated with 30-day composite outcomes, but only physician-documented antibiotic-associated AEs were.
Investigators noted that limitations of the study included reliance on medical record reviews that had limited associated documentation of alternative causes for the signs, symptoms, or radiographic findings, according to the study authors. They believe that this could result in the underestimation of inappropriate diagnosis of CAP.
