Caitlyn Stulpin , 2025-05-06 19:10:00
Key takeaways:
- Researchers presented survey data examining desirability of treatment outcome rankings for patients with pneumonia.
- Scores from clinicians and patients varied for many of the assessed outcomes.
ORLANDO — What clinicians think are the less desirable outcomes for patients with pneumonia may not align with what patients think, according to survey data presented at SHEA Spring.
“A desirability of outcome ranking (DOOR) score is an outcome measure used to capture the diverse range of potential outcomes that can occur in treatment of certain diseases such as community-acquired pneumonia,” Eli Finer, MD, internal medicine resident at University of Utah School of Medicine, told Healio.
“Currently, there is no standardized way to create this outcome measure, and studies have only intermittently included patient input,” Finer said. “We sought out to create our own DOOR endpoint by surveying patients and physicians and then compared answers to see if physicians and patients have differences in which type of outcomes they view are more or less preferable.”
The researchers created nine clinical scenarios covering a wide variety of potential outcomes for patients with community-acquired pneumonia 2 weeks after an initial ED visit.
Scored DOOR patient outcomes included:
- not hospitalized, no residual pneumonia symptoms, no antibiotic-associated adverse events;
- not hospitalized, no residual pneumonia symptoms, had antibiotic-associated adverse event (such as nausea and vomiting) requiring treatment during hospitalization;
- not hospitalized, no-activity limiting residual pneumonia symptoms (such as cough and shortness of breath), no antibiotic-associated adverse event;
- not hospitalized, no residual pneumonia symptoms, non-activity limiting antibiotic-associated adverse event (such as nausea and diarrhea) after hospitalization;
- not hospitalized, residual pneumonia symptoms limiting activities (such as shortness of breath), no antibiotic-associated adverse event;
- not hospitalized, no residual pneumonia symptoms, Clostridioides difficile infection requiring visit and treatment;
- not hospitalized, no residual pneumonia symptoms, multi-drug resistant organism urinary tract infection requiring intravenous antibiotics;
- hospitalized, any or no residual pneumonia symptoms, any or no antibiotic-associated adverse event; and
- patient has died.
The researchers used REDCap surveys, given to clinicians who cared for patients with pneumonia and patients who were hospitalized with pneumonia to assess their outcome rankings. Respondents were asked to rank the cases from most to least desirable in REDCap.
According to the study, 22 patients and 25 clinicians responded to the survey. Finer said that the survey results demonstrated patients and physicians “differ significantly” in what determined a favorable outcome from treatment of nonsevere community-acquired pneumonia.
The average ranked orders of DOOR outcomes of the nine listed outcomes were as follows for patients and clinicians, respectively:
- 1 vs. 1;
- 4 (3 to 4.5) vs. 3 (2 to 3);
- 2 (2 to 3) vs. 3 (2 to 4);
- 4 (3 to 6) vs. 3 (2 to 4);
- 5 (3 to 7) vs. 5 (5 to 6);
- 7 (6 to 7.5) vs. 6 (5 to 6);
- 5 (4.5 to 6) vs. 7 (6 to 7);
- 8 (7 to 8) vs. 8; and
- 9 vs. 9.
“I think this is about expectations,” Valerie M. Vaughn, MD, MSc,SFHM, FACP, an associate professor of medicine and director of clinical research for internal medicine at the University of Utah, told Healio. “They’re coming in already with cough and shortness of breath, right? So, if you tell them that they’re discharged from the hospital and they’re still going to have cough and shortness of breath, but it’s not going to limit their daily activities, they’re like, ‘Hey, that’s an improvement.’ Whereas, if you say, ‘Well, you’re not going to have any symptoms of your pneumonia, but you are going to have nausea and vomiting,’ that’s a new thing and a worsening thing and something that they don’t associate with being part of pneumonia care.
“That’s the difference,” Vaughn said.
Some comments posed by a patient and family advisory committee for why patients might rank certain outcomes differently than clinicians include:
- “I agree that C. [difficile] is the worst. It’s a significant risk throughout a patient’s life once infected. I rate it very high on the severity scale,” for the patient outcome “not hospitalized, no residual [pneumonia] symptoms, C. difficile infection requiring visit and treatment” which patients ranked as “more undesirable”;
- “Doctors might not prioritize what patients have to live with in terms of symptoms. Patients are focused on what’s bad for them personally,” for the patient outcomes “not hospitalized, no pneumonia symptoms, nausea and vomiting requiring antiemetic during hospitalization” and “not hospitalized, no pneumonia symptoms, non-limiting nausea and diarrhea after hospitalization,” which patients ranked as “more undesirable”; and
- “Sometimes, when very ill, patients might feel like they’ve had enough. Chronic discomfort can make death seem like a relief. The severity of symptoms can be very subjective,” for the patient outcome of “patient has died,” which the researchers noted patients considered “more desirable,” although available study data showed both clinicians and patients both ranked this outcome as 9.
Finer said that based on these data, it may be beneficial to include patient input “to some degree” in clinical trial design.
“What we think is the worst potential outcome, or the preferential outcome, may not be what our patients think,” Vaughn said. “It’s helpful to kind of think about their perspective and maybe even talk to them about it.”
For more information:
Eli Finer, MD, can be reached at eli.finer@hsc.utah.edu.
Valerie M. Vaughn, MD, MSc, SFHM, FACP, can be reached at valerie.vaughn@hsc.utah.edu.
Sources/Disclosures
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Finer E, et al. Abstract 304. Presented at: SHEA Spring; April 27-30, 2025; Orlando.
Disclosures:
Finer and Vaughn report no relevant financial disclosures.
