Focussing on performance measures may lead to inappropriate antibiotic use

Jul 10 2006

Patients with suspected pneumonia may receive antibiotics unnecessarily as a result of hospital and physician efforts to meet certain performance measures.

The Centers for Medicare and Medicaid Services (CMS) uses the timing of pneumonia-related antibiotic therapy as a core performance measure, recommending that patients with pneumonia receive antibiotics within four hours of arrival to the hospital. However, a new study in the July issue of CHEST, the peer-reviewed journal of the American College of Chest Physicians (ACCP), shows that one in five patients with suspected pneumonia initially present with factors not suggestive of pneumonia, which, in turn, may delay diagnosis and appropriate antibiotic treatment. Researchers believe this diagnostic uncertainty may lead to premature antibiotic treatment in order to ensure performance measures are met.

"With the recent trend in using antibiotic timing and other performance measures as the basis for public reporting and pay for performance programs, there is increasing pressure for hospitals and physicians to drive their performance rates as high as possible," said lead author Mark Metersky, MD, FCCP, University of Connecticut School of Medicine, Farmington, CT. "In order to achieve 100 percent performance, physicians may be compelled to give antibiotics before a firm diagnosis can be established. This is a practice known as 'shoot first and ask questions later.'"

Dr. Metersky and colleagues from Christiana Care Health system, Newark, DE, Family Care Medical Center, Chalfont, PA, and the Oklahoma Foundation for Medical Quality, Inc, Oklahoma City, OK, determined how frequently Medicare patients with pneumonia presented in a manner that could potentially lead to diagnostic uncertainty and, therefore, delayed antibiotic treatment. Independent clinicians reviewed the hospital charts of 86 Medicare patients (mean age 7919) who had a discharge diagnosis of pneumonia. For each patient, clinicians identified whether or not there was a potential reason for a delay of antibiotics other than quality of care. Consensus among the reviewers was achieved in 99 percent of the charts. Overall, 22 percent of cases (n=19) were identified as having factors that had potential to delay antibiotic treatment, independent of quality of care. Of these patients, 68.4 percent (n=13) received antibiotic treatment within four hours of hospital admission. However, the findings suggest that as many as one in five patients may receive antibiotic treatment before a firm pneumonia diagnosis is made.

"We must also consider the numerous patients who receive antibiotics due to suspected pneumonia but are discharged with another diagnosis," said Dr. Metersky. Furthermore, researchers believe their findings are not unique in that overzealous medicating may be seen in other performance measures, including vaccinations.

According to researchers, the inappropriate use of antibiotics could lead to increases in antibiotic resistance, side effects from antibiotics, and difficulty to identify the underlying medical problem. To reduce the incidence of inappropriate antibiotic use and mitigate the negative consequences associated with unmet performance standards, researchers suggest changing the performance goal from 100 percent to the percentage of patients who present in a manner that would not likely delay diagnosis.

"CMS has already adapted the performance measure for antibiotic timing to exclude patients with negative chest radiographs, which, more than likely, indicates they do not have pneumonia," added Dr. Metersky.

"Health-care professionals must continue to work with institutions that are developing performance measures to ensure they are accurately representing clinical patient care," said W. Michael Alberts, MD, FCCP, President of the American College of Chest Physicians.