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Clinician Practice Patterns That Result in the Diagnosis of Coccidioidomycosis Before or During Hospitalization.

  • Pu, Jie1
  • Donovan, Fariba M2, 3
  • Ellingson, Kate2, 4
  • Leroy, Gondy2, 5
  • Stone, Jeff3, 6
  • Bedrick, Edward4
  • Galgiani, John N2, 3, 7
  • 1 Division of Data Analytics, Banner Health Corporation, Phoenix, Arizona, USA.
  • 2 Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA.
  • 3 Department of Medicine, University Arizona College of Medicine-Tucson, Tucson, Arizona, USA.
  • 4 Department of Epidemiology and Biostatistics, University of Arizona College of Public Health, Tucson, Arizona, USA.
  • 5 Management Information Systems, University of Arizona Eller College of Business, Tucson, Arizona, USA.
  • 6 Arizona Cancer Center, University of Arizona-Tucson, Tucson, Arizona, USA.
  • 7 Department of Medicine, University Arizona College of Medicine-Phoenix, Phoenix, Arizona, USA.
Published Article
Clinical Infectious Diseases
Oxford University Press
Publication Date
Oct 05, 2021
DOI: 10.1093/cid/ciaa739
PMID: 32511677


Coccidioidomycosis (CM) is common and important within endemic regions, requiring specific testing for diagnosis. Long delays in diagnosis have been ascribed to ambulatory clinicians. However, how their testing practices have impacted patient care has not been systematically unexplored. We analyzed practice patterns for CM diagnoses over 3 years within a large Arizona healthcare system, including diagnosis location, patient characteristics, and care-seeking patterns associated with missed diagnosis. For 2043 CM diagnoses, 72.9% were made during hospital admission, 21.7% in ambulatory clinics, 3.2% in emergency units, and only 0.5% in urgent care units. A 40.6% subgroup of hospitalized patients required neither intensive care unit or hospital-requiring procedures, had a median length of stay of only 3 days, but still incurred both substantial costs ($27.0 million) and unnecessary antibiotic administrations. Prior to hospital diagnosis (median of 32 days), 45.1% of patients had 1 or more visits with symptoms consistent with CM. During those visits, 71.3% were not tested for CM. Diagnoses were delayed a median of 27 days. Lack of testing for CM in ambulatory care settings within a region endemic for CM resulted in a large number of hospital admissions, attendant costs, and unneeded antibacterial drug use, much of which would otherwise be unnecessary. Improving this practice is challenging since many clinicians did not train where CM is common, resulting in significant inertia to change. Determining the best way to retrain clinicians to diagnose CM earlier is an opportunity to explore which strategies might be the most effective. © The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: [email protected]

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