Comment on: Clinical Performance of Existing Diagnostic Criteria for Pneumonia in Older Emergency Patients: A Prospective Cohort Study

We have read the recently published article “Clinical performance of existing diagnostic criteria for pneumonia in older emergency patients: A prospective cohort study” on pneumonia in older adults seen in the emergency department with great interest [1]. The study, with its robust design and well-written methods, provides valuable insights, particularly regarding the diagnostic performance of various pneumonia criteria [1]. However, we would like to highlight some minor points that may further strengthen the findings, building on the solid foundation of the study's design and methods.

First, because some characteristics were significantly different in the three groups in the table, post hoc analyses would be helpful in better understanding where these differences were derived (e.g., post hoc Bonferroni adjusted z-test for chi-squared test).

Secondly, while p-values were presented for some comparisons in tab. 2, they were notably absent for the demographic characteristics in tab. 1. Without p-values for age, gender, race, marital status, and education level, assessing whether these factors significantly differed between the pneumonia and non-pneumonia groups is difficult. Including these p-values would provide a clearer understanding of the role of demographic factors and others in pneumonia diagnosis and enhance the interpretation of the results [2].

Additionally, a receiver operating characteristic (ROC) curve analysis would have helped illustrate the discriminative ability of the criteria, offering a more comprehensive view of the data [3]. Although sensitivity, specificity, and negative and positive predictive values of the different diagnosing criteria for pneumonia were given, it would be better to document these relations with the help of ROC analyses. It would provide some cutoff values, the area under the curve (AUC) levels, p-values, sensitivity, specificity, and negative and positive predictive values; moreover, it would be possible to compare these calculated AUCs to decide which criteria were more predictive in diagnosing pneumonia.

Furthermore, it would be better considering pneumonia's clinical outcomes, including mortality and requiring intensive care unit (ICU) admission, in the analyses. Considering the severity of pneumonia in individuals aged 65 and older, these outcomes are essential for assessing the effectiveness of diagnostic methods. ICU admission rates and mortality data would provide additional insights into the clinical implications of early diagnosis and management strategies in this population [4].

Finally, while the study highlighted the problem of overdiagnosis, it did not address the potential side effects of medications prescribed in these cases. Overdiagnosis may lead to unnecessary antibiotic use, particularly when pneumonia is misdiagnosed or treated empirically. However, by addressing this issue, we have the potential to significantly reduce unnecessary antibiotic use and the associated risks, especially in the older population, where polypharmacy and adverse drug events are prevalent [5].

These points might not only strengthen the study's findings but also pave the way for more comprehensive and insightful research in this field, thereby lightening the burden on future studies and inspiring further contributions to the understanding of pneumonia diagnosis in individuals aged 65 and older.

Zeynep Iclal Turgut and Muhammet Cemal Kizilarslanoglu wrote the letter, and all co-authors have read and approved the final version of the manuscript.

The authors have nothing to report.

The authors declare no conflicts of interest.