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Ideas and Opinions |

Ventilator-Associated Pneumonia—The Wrong Quality Measure for Benchmarking

Michael Klompas, MD, MPH; and Richard Platt, MD, MSc
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From Harvard Medical School, Harvard Pilgrim Health Care, and Brigham and Women's Hospital, Boston, Massachusetts.


Acknowledgment: The authors thank Julia Przedworski for her invaluable assistance in researching state regulatory requirements for reporting ventilator-associated pneumonia.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Michael Klompas, MD, MPH, Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, 133 Brookline Avenue, 6th Floor, Boston, MA 02215.

Current Author Addresses: Drs. Klompas and Platt: Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, 133 Brookline Avenue, 6th Floor, Boston, MA 02215.


Ann Intern Med. 2007;147(11):803-805. doi:10.7326/0003-4819-147-11-200712040-00013
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Legislators, payers, and quality-of-care advocates across the United States are considering requiring hospitals to report ventilator-associated pneumonia rates as a way to benchmark and reward quality of care. Accurate diagnosis of ventilator-associated pneumonia, however, is notoriously difficult because several common complications of critical care can mimic the clinical appearance of ventilator-associated pneumonia. The challenge is compounded by substantial subjectivity inherent in the current surveillance definition. These sources of variability make ventilator-associated pneumonia rates difficult to acquire, interpret, and compare both within and among institutions. Ventilator-associated pneumonia should be excluded from compulsory reporting initiatives until we develop and validate more objective outcome measures that meaningfully reflect quality of care for ventilated patients.

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Comment and Response: "Ventilator-Associated Pneumonia - The Wrong Quality Measure for Benchmarking
Posted on January 28, 2008
Didier Pittet
University of Geneva Hospitals, Geneva, Switzerland
Conflict of Interest: None Declared

TO THE EDITOR:

We fully agree with the conclusions of Drs Klompas and Platt (1) that ventilator-associated pneumonia (VAP) should be excluded from benchmarking. Nevertheless, we should like to emphasize two issues in more detail.

Heterogeneity in case-mix. The importance of adjusting for case-mix in any outcome benchmarking should not be underestimated (2). Invasively ventilated patients usually differ across multiple variables, even dental hygiene. More confounding, they are dynamic hosts themselves, varying over time during hospital stay and changing in terms of risk factors (3).

Alternatives to benchmark VAP rates. The authors state that "currently, we have no obvious alternative quality measures for ventilated patients" and propose to include all possible pulmonary outcome measures. In the meantime, they recommend to track evidence-based process-of-care measures (1) until a clear and unequivocal VAP definition is established. Here, we partly disagree for the following reasons: first, the recording of all possible outcomes would make surveillance much more time- and resource-consuming than surveillance for VAP rates. Second, outcome measures do not necessarily have to be the ultimate goal for benchmarking since they can be replaced easily by quality indicators (3). According to Donabedian, quality indicators can be stratified by structure, process and outcome levels (4). Among many examples (3), process-oriented measures could be compliance with guidelines or the correct timing of elective intubation.

Provided that the data are of good quality, surveillance systems based on process indicators are simpler to conduct than outcome-based surveillance (3). For example, errors in ventilation procedures are more frequent than VAP rates. Moreover, outcome variations emerge slowly and need a larger sample size to be detected. Finally, structure or process indicators allow to circumvent case-mix and diagnosis problems almost entirely (3). National organizations and international societies already recommend to use quality indicators on process levels (3). The US 100k Lives Campaign (1,3) promotes a "ventilator bundle" based on process indicators. Similar interventions with "bundled" process indicators are gaining momentum in VAP prevention. Improvement on a process level could favorably change the outcome of VAP and, a priori, with no reason to assume the contrary. Donabedian argued that neither the measurement of process nor that of outcome is inherently superior (5).

To conclude, we consider that benchmarking of process-oriented quality indicators is easier, feasible, much less vulnerable for misuse and should be encouraged (3). There is no need to wait for the ideal definition of VAP.

References

1. Klompas M, Platt R. Ventilator-associated pneumonia - the wrong quality measure for benchmarking. Ann Intern Med. 2007;147:803-05.

2. Sax H, Pittet D; Swiss-NOSO Network. Interhospital differences in nosocomial infection rates: importance of case-mix adjustment. Arch Intern Med. 2002; 162:2437-42.

3. Uçkay I, Ahmed QA, Sax H, Pittet D. Ventilator-associated pneumonia as a quality indicator for patient safety? Clin Infect Dis. 2008 Jan 16; [Epub ahead of print].

4. Donabedian A. Contributions of epidemiology to quality assessment and monitoring. Infect Control Hosp Epidemiol. 1990;11:117-21.

5. Donabedian A. The quality of care. How can it be assessed? JAMA 1988;260:1743-48.

Conflict of Interest:

None declared

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