Nadine Srouji, MD
Potential Financial Conflicts of Interest: None disclosed.
Srouji N. The Unintended, Negative Consequences of the Door-to-Antibiotic Measure for Pneumonia. Ann Intern Med. 2009;150:220. doi: 10.7326/0003-4819-150-3-200902030-00016
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Published: Ann Intern Med. 2009;150(3):220.
TO THE EDITOR:
The recent article by Wachter and colleagues (1) reported that a widely used performance measure, the administration of antibiotics within 4 hours to patients with pneumonia, may have led to increased inappropriate antibiotic use and less cost-effective care without decreasing mortality. This benchmark was used by the Joint Commission, CMS, and insurance companies. The Centers for Medicare & Medicaid Services publicly reported hospital performance on this measure, and some managed care companies tied reimbursements to it. From my own experience on a hospital committee charged with ensuring at least 90% compliance with this 4-hour requirement, I know that our organization allocated substantial resources to accomplishing this goal. We surveyed hospitals that had successfully met the 4-hour benchmark by instituting a protocol whereby patients automatically received antibiotics if they met certain criteria in triage. The 4-hour benchmark changed patterns of care. The Joint Commission recently relaxed this window to 6 hours, seemingly in recognition of the metric's limitations. Yet no study has shown a benefit from a 6-hour rule. Isn't one of the main components of quality improvement a feedback loop? There has been much press recently about the report by the Commonwealth Fund (2) which concluded that U.S. health care, while expensive, does not rate accordingly high in quality when compared with other industrialized nations. The report specifically identified pneumonia as one of the few diagnoses for which treatment has improved. This conclusion was based on 3 metrics, 1 of which was administration of antibiotics within 4 hours of patient presentation. Reporting on these findings, the New York Times(3) quoted the president of the National Business Group on Health as saying that “it proves once again that if you have quantitative information and metrics and make people pay attention, they change.” How true, and how concerning then when the metrics are wrong.
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