New Study Disputes Value of an Antibiotic Standard as a Quality Measure

An American College of Emergency Physicians (ACEP) press release:

Washington, DC- A requirement set in 2004 that emergency physicians administer antibiotics within 4 hours to adult patients admitted with pneumonia may not only be unfeasible, but may inadvertently overmedicate some patients and contribute to growing antibiotic resistance.

Two articles appearing online this week in Annals of Emergency Medicine raise doubts about the value of a Centers for Medicare and Medicaid Services (CMS) and The Joint Commission quality measure requiring emergency physicians to administer antibiotics within 4 hours to any patient with symptoms of pneumonia ("Identification of Ninety Percent of Patients Ultimately Diagnosed with Community-Acquired Pneumonia Within Four Hours of Emergency Department Arrival May Not Be Feasible," and "Measuring Antibiotic Timing for Pneumonia in the Emergency Department: Another Nail in the Coffin").

"There is growing concern that to achieve an arbitrarily established performance standard on the antibiotic timing measure, as set by The Joint Commission and CMS, unnecessary antibiotics will be administered to patients who do not actually have pneumonia," said Christopher Fee, MD, of the Department of Emergency Medicine at the University of California, San Francisco Medical Center. "This may needlessly expose patients to additional side effects, and could be a contributing factor to growing antibiotic resistance in the population at large."

Dr. Fee's study, conducted from January 1 through December 31, 2005, assessed a sample group of 152 emergency patients meeting The Joint Commission's and CMS's eligibility criteria. Of those patients, 99 (65.1 percent) received antibiotics within 4 hours of arriving at the emergency department. Of those patients who did not receive antibiotics within 4 hours of arrival ("outliers"), more than half (58.5 percent) did not have a final diagnosis of pneumonia. Among the outliers, only 43 percent had an abnormal chest X-ray compared with 95 percent of those who received antibiotics within 4 hours.

"It may be that, despite our best efforts, patients who get late antibiotics just take longer to diagnose because of atypical clinical presentations," said Jesse M. Pines, MD, of the Department of Emergency Medicine at the Hospital of the University of Pennsylvania, whose supporting commentary appears alongside Dr. Fee's study. "This study reflects the real-life challenge of diagnosing pneumonia in the emergency department. Most emergency patients do not come in the door with a sign on their foreheads that reads, 'I have pneumonia, give me antibiotics now!'"

Delays in administering antibiotics within 4 hours were attributed to a variety of factors, including emergency physicians' consideration of diagnoses other than pneumonia and the ongoing difficulties of providing emergency care in a timely fashion due to routinely overcrowded emergency departments. The study recommends that The Joint Commission and CMS establish more attainable goals or change the quality measure definition to include only those patients for whom objective clinical, laboratory and radiographic evidence is available during the emergency department stay, and the emergency physician includes pneumonia in the final emergency department diagnosis.

"The Joint Commission and CMS need to carefully test in a real clinical setting whether full compliance is feasible and set reasonable expectations for performance," said Dr. Pines. "Without consideration of these important factors, government quality measures will continue to serve as both folly and woe to health care providers, administrators and patients caught in the fray."