Public Reporting of Antibiotic Timing in Patients with Pneumonia: Lessons from a Flawed Performance Measure

Public Reporting of Antibiotic Timing in Patients with Pneumonia: Lessons from a Flawed Performance Measure

From the University of California, San Francisco, San Francisco, California; University of Michigan School of Medicine, Ann Arbor, Michigan; and Johns Hopkins School of Medicine and School of Public Health, Baltimore, Maryland.

Abstract

The administration of antibiotics within 4 hours to patients with community-acquired pneumonia has been criticized as a quality standard because it pressures clinicians to rapidly administer antibiotics despite diagnostic uncertainty at the time of patients' initial presentations. The measure was recently revised (to 6 hours) in response to this criticism. On the basis of the experience with the 4-hour rule, the authors make 5 recommendations for the development of future publicly reported quality measures. First, results from samples with known diagnoses should be extrapolated cautiously, if at all, to patients without a diagnosis. Second, for some measures, “bands” of performance may make more sense than “all-or-nothing” expectations. Third, representative end users of quality measures should participate in measure development. Fourth, quality measurement and reporting programs should build in mechanisms to reassess measures over time. Finally, biases, both financial and intellectual, that may influence quality measure development should be minimized. These steps will increase the probability that future quality measures will improve care without creating negative unintended consequences.

Article and Author Information

Potential Financial Conflicts of Interest:Consultancies: R.M. Wachter (American Board of Internal Medicine, Healthcare Advisory Board, Google). Honoraria: R.M. Wachter (Dr. Wachter has done more than 100 talks on issues of quality and patients safety to several health care organizations.). Grants received: R.M. Wachter (Agency for Healthcare Research and Quality).
Requests for Single Reprints: Robert M. Wachter, MD, Room M-994, Department of Medicine, 505 Parnassus Avenue, University of California, San Francisco, San Francisco, CA 94143-0120; e-mail, bobw{at}medicine.ucsf.edu.
Current Author Addresses: Dr. Wachter: Room M-994, Department of Medicine, 505 Parnassus, University of California, San Francisco, San Francisco, CA 94143-0120.
Dr. Flanders: University of Michigan, 3119F Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-03766.
Dr. Fee: University of California, Box 0208, 505 Parnassus, San Francisco, CA 94143-0208.
Dr. Pronovost: Departments of Anesthesiology and Critical Care, Surgery, and Health Policy and Management, The Johns Hopkins University School of Medicine, 1909 Thames Street, 2nd Floor, Baltimore, MD 21231.
Author Contributions: Conception and design: R.M. Wachter, S.A. Flanders, P.J. Pronovost.
Drafting of the article: R.M. Wachter, S.A. Flanders, C. Fee, P.J. Pronovost.
Critical revision of the article for important intellectual content: S.A. Flanders, C. Fee, P.J. Pronovost.
Final approval of the article: R.M. Wachter, S.A. Flanders, C. Fee, P.J. Pronovost.
Administrative, technical, or logistic support: R.M. Wachter.

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