A recent JAMA study of over 17,000 hospitalized adult patients who were treated for pneumonia across 48 hospitals in Michigan reported that 12% of them received a pneumonia diagnosis even though they did not have any lung infection. The researchers further observed that older patients with dementia who were in an altered mental state were at the highest risk of being misdiagnosed with pneumonia and being put on a full antibiotic regimen, which could be harmful to them,
“While some inappropriate diagnosis of community-acquired pneumonia is unavoidable due to diagnostic uncertainty when patients are first hospitalized, many patients remain inappropriately diagnosed even on hospital discharge,” the researchers explained. “Inappropriate diagnosis of community-acquired pneumonia may harm patients through delayed recognition and treatment of acute (eg, exacerbations of congestive heart failure), chronic (eg, pulmonary cancer), or novel diagnoses (eg, pulmonary cancer and may lead to unnecessary antibiotic use, adverse effects, and antibiotic resistance.”
To investigate how commonly patients are misdiagnosed with pneumonia, the researchers collected data from the Michigan Hospital Medicine Safety Consortium (HMS) database. HMS is an initiative that was developed to improve health care for hospitalized patients and 75% of non-federal hospitals in Michigan participate in it and also share data on antibiotic use. The team analyzed data from 17,290 adult patients who were hospitalized and treated for pneumonia between June 2017 to March 2020.
They found that 2079 or 12% were incorrectly diagnosed with pneumonia. Out of the 2079, close to 74% did not meet the criteria required for undergoing X-ray tests and 24.4% had less than two pneumonia symptoms. Despite that, most of them (87.6%) received a full course of antibiotics.
The researchers highlighted several reasons why doctors inaccurately diagnose community-acquired pneumonia. “Because it is common, physicians are at high risk for cognitive biases such as availability bias (ie, the tendency to make decisions based on information that comes most readily to mind). Second, community-acquired pneumonia symptoms are nonspecific and may overlap with other cardiopulmonary diseases (eg, congestive heart failure exacerbation), making diagnosis difficult,” they wrote.
“Given poor outcomes associated with community-acquired pneumonia, in the setting of uncertainty, health care professionals may favor over-treatment rather than potentially missing a diagnosis. Third, historical quality metrics imposed by organizations such as The Joint Commission (eg, requiring antibiotics within 6 hours of presentation) may have unintentionally led to more inappropriate diagnoses of community-acquired pneumonia. These measures, in place in the 2000s and 2010s, may continue to affect healthcare professional practice behaviors related to diagnosis,” they added.
The authors further explained that older adults with dementia or those experiencing altered mental status are also most likely to be misdiagnosed with other conditions, such as urinary tract infections.
“While altered mental status may be a sign of infection, including severe infection, it has a broad differential diagnosis (eg, polypharmacy, pain, dehydration), and anchoring on community-acquired pneumonia may delay proper diagnosis and management. Finally, because older patients with community-acquired pneumonia (CAP) typically experience worse health outcomes, here may be an increased tendency to rapidly diagnose and treat presumed CAP, leading to higher rates of inappropriate diagnosis,” they wrote in the JAMA Internal Medicine study published on March 25, 2024.
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