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Doctors Commonly Misdiagnose Older Patients With Pneumonia: Study
BERLIN, GERMANY - JUNE 17: An elderly patient lies in a bed at the Unfallkrankenhaus Berlin (UKB) ... [+] hospital in Marzahn district on June 17, 2013 in Berlin, Germany. The UKB hospital has among the most modern emergency care services in Germany. (Photo by Theo Heimann/Getty Images)
Getty ImagesA 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.
Ozempic-like Drugs Linked To Low, But Increased Risk Of Post-endoscopy Pneumonia, Study Finds
Diabetes and obesity GLP-1 drugs like Ozempic, which can delay stomach emptying, have introduced a predicament for patients undergoing surgeries and endoscopies — the patients in some cases may still have food in their stomach even if they've fasted, raising concerns that they could accidentally breathe food into their lungs during the procedures.
These concerns have been based on anecdotes, and it's so far unclear how big an issue this is, but a new study published in Gastroenterology Wednesday offers some early clues. It links GLP-1 drugs to a higher risk of aspiration pneumonia — lung infection caused by food breathed into the lungs — following endoscopies.
Researchers, analyzing a large dataset of health records, found that people taking GLP-1 drugs overall had a very low 0.83% risk of this infection, but they had a 33% greater risk compared with people who weren't on GLP-1 treatments.
Zooming in on the different types of endoscopies, the researchers found that among people undergoing upper endoscopies, GLP-1 drug users had an 48% higher risk of aspiration pneumonia, and for combined upper endoscopies and colonoscopies, they had more than double the risk. The researchers did not find a higher risk among people getting only colonoscopies.
For patients who used the sedative propofol for their endoscopies, GLP-1 users had a 49% higher risk of aspiration pneumonia, according to the analysis, which included records of nearly 800,000 patients.
The study looked at data from 2018 to 2020, when Ozempic had already been on the market, but before the latest GLP-1 treatments like Wegovy, Mounjaro, and Zepbound were approved. It's unclear how exactly these newer and more potent treatments might affect patients' risk for aspiration, but they do utilize the same or similar drug mechanisms as Ozempic, and the study points to the need for more research to help guide doctors as more people start taking these highly popular medications.
"They're here to stay and their use is going to increase. They just have this complication," said Ali Rezaie, senior author of the study and medical director of the GI Motility Program at Cedars-Sinai. "This is all about awareness. This is not about, 'OK, let's not use GLP-1s' or anything. It's just about, 'let's be careful when you're doing procedures on these patients.'"
Prior to this study, two doctor groups issued differing statements about what to do with GLP-1 drugs before procedures. The American Society of Anesthesiologists suggested that patients should stop taking the treatments ahead of procedures. Meanwhile, the American Gastroenterological Association said that there is insufficient evidence for a formal guideline and suggested doctors should evaluate each patient individually.
Barbara Jung, president of the AGA, said that given the limitations of the study, she doesn't think it would change what the association said in its statement, and "we need more information before we would."
This study is limited as it's observational and does not prove that GLP-1 drug use causes an increased risk of aspiration. Despite the study's reliance on health records, the researchers could not confirm how consistently patients were taking GLP-1 drugs before the procedures. Also, they included cases of aspiration pneumonia that occurred within a month of the procedures, but had no way of confirming whether the infection necessarily stemmed from the procedures.
Rezaie, the senior author, said that even though the absolute risk of aspiration pneumonia for people taking GLP-1 drugs was under 1%, there are more than 20 million endoscopies performed in the U.S. Each year, so a small percentage could amount to many cases. And while aspiration pneumonia can often be treated with antibiotics, they can cause complications in some cases for people who are immunocompromised or have pre-existing lung problems, he added.
It's likely there is a higher risk in procedures that involve upper endoscopies specifically, since the patient is intermittently lying down and their stomachs get expanded with carbon dioxide, which can increase the chances of aspiration, the authors wrote. There is probably also a higher risk with the use of propofol, since the sedative blocks the body's reflexes for protecting the airway, the authors said.
They note that not all cases of aspiration during endoscopies result in aspiration pneumonia, and so there were likely many more cases of aspiration that weren't captured in the study.
Given the study design, the study should be considered "as mainly hypothesis-generating," said Andrew Wang, chief of the division of gastroenterology and hepatology at University of Virginia who was not involved in the study. Wang co-authored the AGA statement about the use of GLP-1 drugs.
He noted that the study also doesn't provide information on whether stopping the drugs ahead of procedures would mitigate the risk of aspiration.
Overall, though, he said, "this study is important as we need more data about the possible consequences for patients using [GLP-1 drugs] prior to GI endoscopy."
STAT's coverage of chronic health issues is supported by a grant from Bloomberg Philanthropies. Our financial supporters are not involved in any decisions about our journalism.
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Pneumonia overviewPneumonia is a serious infection that causes inflammation and fluid in the lungs. It can be caused by bacteria, viruses, fungi, or chemical irritants. It occurs in four stages: congestion, red hepatization, grey hepatization, resolution. Symptoms include cough, which may produce greenish, yellow, or even bloody mucus, fever, sweating and shaking chills. Complications from pneumonia include respiratory failure, sepsis, and lung abscess. Antibiotics are used for bacterial pneumonia. Antifungal medicines are prescribed to treat fungal pneumonia. Viral pneumonia is often mild and goes away on its own within a few weeks.
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