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• W4297524030 abstract "Study Objectives: The diagnosis of pneumonia in the emergency department (ED) is often uncertain, however to our knowledge the impact of this clinical uncertainty has not been studied. We examined the prevalence of and outcomes associated with changes in pneumonia from time of ED admission to time of hospital discharge, termed diagnostic discordance, among patients hospitalized at 118 US Department of Veterans Affairs Medical Centers.Study Design and MethodsThis retrospective cohort study of emergency department encounters resulting in hospitalization from 1/1/2015 -4/30/2021 utilized a previously validated approach that combines diagnostic coding with natural language processing of clinical notes to capture a diagnosis of pneumonia at (1) time of admission and (2) time of discharge. Using a two-by-two contingency table with the initial diagnosis as the “test” and discharge diagnosis as an imperfect reference standard, we categorized each initial diagnosis as “true positive” (TP), “true negative” (TN), “false positive” (FP) and “false negative” (FN). We calculated the prevalence of FP and FN cases and calculated crude rate of inpatient, 7-day, and 30-day mortality, along with ward-to-ICU transfer within first 72 hours. For each discordant group, we compared observed outcomes to expected outcomes estimated from logistic regression models using 49 patient factors to capture baseline characteristics and clinical illness severity as predictors.ResultsAmong 2.2 million hospitalizations from the ED, 336,102(15%) received a diagnosis of pneumonia, 231,707(10.5%) received an initial diagnosis, and 238,210 (10.8%) received a discharge diagnosis of pneumonia. Of the encounters with a diagnosis [AC1] of PNA at either time point, diagnostic discordance was found in 202,287 (60%) of encounters. Following an ED diagnosis of PNA, 97,892 encounters (42.2%) were found to be a false positive. Among those encounters with a discharge diagnosis of PNA, 104,39 encounters (43.8%) were a false negative at time of ED admission. Patients with FP or FN diagnoses had more comorbidities, presented with higher severity of illness, and had higher 7-day, inpatient, and 30-day mortality and ward-to-ICU transfers (Table 2) that exceeded the expected rates based upon patient factors.ConclusionDiscordances between ED and discharge diagnoses occurred in over half of all patients with pneumonia and were associated with worse outcomes that were not explained by patient characteristics and illness severity. Both false positive and false negative discordances demonstrated worse than expected outcomes. Recognition and research of diagnostic discordance at the system, provider, and patient levels could be a powerful way to create new paths to improvement in diagnosis and outcomes for patients with pneumonia.No, authors do not have interests to disclose Study Objectives: The diagnosis of pneumonia in the emergency department (ED) is often uncertain, however to our knowledge the impact of this clinical uncertainty has not been studied. We examined the prevalence of and outcomes associated with changes in pneumonia from time of ED admission to time of hospital discharge, termed diagnostic discordance, among patients hospitalized at 118 US Department of Veterans Affairs Medical Centers. Study Design and MethodsThis retrospective cohort study of emergency department encounters resulting in hospitalization from 1/1/2015 -4/30/2021 utilized a previously validated approach that combines diagnostic coding with natural language processing of clinical notes to capture a diagnosis of pneumonia at (1) time of admission and (2) time of discharge. Using a two-by-two contingency table with the initial diagnosis as the “test” and discharge diagnosis as an imperfect reference standard, we categorized each initial diagnosis as “true positive” (TP), “true negative” (TN), “false positive” (FP) and “false negative” (FN). We calculated the prevalence of FP and FN cases and calculated crude rate of inpatient, 7-day, and 30-day mortality, along with ward-to-ICU transfer within first 72 hours. For each discordant group, we compared observed outcomes to expected outcomes estimated from logistic regression models using 49 patient factors to capture baseline characteristics and clinical illness severity as predictors. This retrospective cohort study of emergency department encounters resulting in hospitalization from 1/1/2015 -4/30/2021 utilized a previously validated approach that combines diagnostic coding with natural language processing of clinical notes to capture a diagnosis of pneumonia at (1) time of admission and (2) time of discharge. Using a two-by-two contingency table with the initial diagnosis as the “test” and discharge diagnosis as an imperfect reference standard, we categorized each initial diagnosis as “true positive” (TP), “true negative” (TN), “false positive” (FP) and “false negative” (FN). We calculated the prevalence of FP and FN cases and calculated crude rate of inpatient, 7-day, and 30-day mortality, along with ward-to-ICU transfer within first 72 hours. For each discordant group, we compared observed outcomes to expected outcomes estimated from logistic regression models using 49 patient factors to capture baseline characteristics and clinical illness severity as predictors. ResultsAmong 2.2 million hospitalizations from the ED, 336,102(15%) received a diagnosis of pneumonia, 231,707(10.5%) received an initial diagnosis, and 238,210 (10.8%) received a discharge diagnosis of pneumonia. Of the encounters with a diagnosis [AC1] of PNA at either time point, diagnostic discordance was found in 202,287 (60%) of encounters. Following an ED diagnosis of PNA, 97,892 encounters (42.2%) were found to be a false positive. Among those encounters with a discharge diagnosis of PNA, 104,39 encounters (43.8%) were a false negative at time of ED admission. Patients with FP or FN diagnoses had more comorbidities, presented with higher severity of illness, and had higher 7-day, inpatient, and 30-day mortality and ward-to-ICU transfers (Table 2) that exceeded the expected rates based upon patient factors. Among 2.2 million hospitalizations from the ED, 336,102(15%) received a diagnosis of pneumonia, 231,707(10.5%) received an initial diagnosis, and 238,210 (10.8%) received a discharge diagnosis of pneumonia. Of the encounters with a diagnosis [AC1] of PNA at either time point, diagnostic discordance was found in 202,287 (60%) of encounters. Following an ED diagnosis of PNA, 97,892 encounters (42.2%) were found to be a false positive. Among those encounters with a discharge diagnosis of PNA, 104,39 encounters (43.8%) were a false negative at time of ED admission. Patients with FP or FN diagnoses had more comorbidities, presented with higher severity of illness, and had higher 7-day, inpatient, and 30-day mortality and ward-to-ICU transfers (Table 2) that exceeded the expected rates based upon patient factors. ConclusionDiscordances between ED and discharge diagnoses occurred in over half of all patients with pneumonia and were associated with worse outcomes that were not explained by patient characteristics and illness severity. Both false positive and false negative discordances demonstrated worse than expected outcomes. Recognition and research of diagnostic discordance at the system, provider, and patient levels could be a powerful way to create new paths to improvement in diagnosis and outcomes for patients with pneumonia.No, authors do not have interests to disclose Discordances between ED and discharge diagnoses occurred in over half of all patients with pneumonia and were associated with worse outcomes that were not explained by patient characteristics and illness severity. Both false positive and false negative discordances demonstrated worse than expected outcomes. Recognition and research of diagnostic discordance at the system, provider, and patient levels could be a powerful way to create new paths to improvement in diagnosis and outcomes for patients with pneumonia." @default.
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• W4297524030 title "194 Discordance of Pneumonia Diagnoses from Admission to Discharge: A Retrospective Cohort Analysis of 118 Veterans Affairs Emergency Departments" @default.
• W4297524030 doi "https://doi.org/10.1016/j.annemergmed.2022.08.218" @default.
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