Misdiagnosis and professional disagreement

[MeSci]

This short non-ME-related (but relevant?) in NEJM Journal Watch gives some interesting insight into misdiagnosis and strong disagreement between physicians.

June 10, 2015
Emergency Department Clinicians Struggle to Diagnose Influenza on Clinical Grounds Alone
http://www.jwatch.org/editors/u721
Daniel J. Pallin, MD, MPH reviewing Dugas AF et al. Am J Emerg Med 2015 Jun.

With PCR as the gold standard, clinical diagnosis had a sensitivity of only 36%.

The CDC recommends antiviral treatment for patients with influenza who have a severe or complicated course of illness, are at high risk for complications, or require hospitalization. In a prospective observational cohort study conducted at a single U.S. emergency department (ED), investigators assessed clinicians' ability to diagnose influenza based on history and physical exam alone, with blinded polymerase chain reaction (PCR) results as the gold standard. All participants met CDC criteria for antiviral treatment, if diagnosed with influenza.

Of the 270 patients, 16% had influenza by PCR. Clinical diagnosis of influenza had a sensitivity of 36% and a specificity of 78%. Only 36% of the patients with PCR-confirmed influenza received antiviral medication, whereas 11% of those without influenza received it.

Comment

This study adds to a body of literature showing that history and physical exam are not accurate for influenza treatment decisions. We should advocate for rapid PCR assays in our EDs. More controversially, I would suggest that we alter our thinking and first consider whether a patient with a respiratory illness would be eligible for treatment if she had influenza. If so, either test or treat for influenza; if not, don't worry about the etiology of the respiratory illness, and treat symptomatically as required. Even if results were delayed, we could call the patient back as we do for other infectious diseases, such as chlamydia and gonorrhea. However, bear in mind that relatively few patients with influenza are actually eligible (generally patients with comorbidities) for treatment.

Reader Comment

RICK ABBOTT Physician, Emergency Medicine

11 Jun 2015 1:26 AM

Wait a minute! "Don't worry about the etiology.....". A long time ago, I heard that there were actually other treatable etiologies for fever and respiratory illnesses: CAP comes to mind. Ever hear of Hanta? Did your dog cough on you, did you visit other countries, did your parakeet get a runny nose and then die? Take a history man. That kind of silly statement ("Don't worry about the etiology....") makes my head hurt, and is only appropriate in an ER that cares only about throughput, and not about quality.

 

[minkeygirl]

This is interesting because an ID doc will give me Valcyte if I'm positive for CMV by PCR which rarely is positive for herpesvirus