Annals of Internal MedicineDiagnostic Discordance, Uncertainty, and Treatment Ambiguity in Community-Acquired Pneumonia: A National Cohort Study of 115 US Veterans Affairs Hospitals

Diagnostic Challenges in Pneumonia: Implications for Patient Care and Hospital Systems

A large-scale study of US Veterans Affairs hospitals reveals significant diagnostic discordance and treatment variability in community-acquired pneumonia (CAP) cases, highlighting challenges in clinical decision-making and patient management.

Study Design:

• Retrospective cohort study of 2,383,899 hospitalizations across 118 US Veterans Affairs medical centers
• Patients aged 18 years or older hospitalized from the ED between January 1, 2015, and January 31, 2022
• Analyzed discordances between initial and discharge pneumonia diagnoses, radiographic findings, and antimicrobial treatment
• Examined expressions of uncertainty in clinical notes, patient illness severity, treatments, and outcomes

Key Findings:

• 13.3% of hospitalizations received an initial or discharge diagnosis and treatment for pneumonia
• 57% of cases showed discordances between initial and discharge diagnoses
• 33% of patients discharged with pneumonia and positive initial chest imaging lacked an initial diagnosis
• 36% of patients initially diagnosed with pneumonia lacked a discharge diagnosis
• High levels of uncertainty expressed in clinical notes (58% in ED, 48% at discharge)
• Varied treatment approaches: 27% received diuretics, 36% received corticosteroids, 10% received antibiotics, corticosteroids, and diuretics within 24 hours
• Patients with discordant diagnoses showed greater uncertainty and received more additional treatments
• Higher 30-day mortality (14.4% vs 10.6%) for patients lacking an initial pneumonia diagnosis compared to those with concordant diagnoses
• Diagnostic discordance was more likely in high-complexity facilities with high ED patient load and inpatient census

HCN Medical Memo
The high rates of diagnostic discordance and treatment variability observed in this study further illustrate the complexity of pneumonia diagnosis and management. Clinicians should be aware of the potential for diagnostic uncertainty and consider implementing strategies to improve diagnostic accuracy, such as standardized assessment tools or multidisciplinary case reviews. Additionally, healthcare systems may need to evaluate resource allocation and workflow processes, particularly in high-complexity facilities with heavy patient loads, to support more consistent and accurate pneumonia diagnoses.

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