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Performance Measures and Pneumonia Diagnoses: Not So Fast!

Reducing the target time to first antibiotic dose to <4 hours also reduced the accuracy of community-acquired pneumonia diagnoses.

Delivering the first antibiotic dose within 4 hours of presentation to patients with community-acquired pneumonia (CAP) is a core quality measure in U.S. hospitals. In an industry-funded study, investigators sought to determine whether such time pressure has affected the accuracy of CAP diagnosis in the emergency department (ED).

The researchers conducted a retrospective analysis of patients who were diagnosed with CAP at a Baltimore ED and admitted to the hospital during one of two periods: from November 2003 through April 2004, when the recommended target time to first antibiotic dose (TFAD) was <8 hours, and from November 2004 through April 2005, after the recommended TFAD had been reduced to <4 hours. Between the two periods, ED physicians received an educational program emphasizing the new 4-hour TFAD expectation. The researchers reviewed discharge diagnoses and medical records to determine whether the patients met predefined criteria for CAP.

The 255 patients admitted under the 8-hour measure were more likely than the 293 patients admitted under the 4-hour measure to have had a discharge diagnosis of CAP (75% vs. 67%; P=0.05) and to have met predefined CAP criteria at admission (46% vs. 34%; P=0.004) and at discharge (62% vs. 54%; P=0.06). Interestingly, the mean TFAD was similar for the two groups — and <3 hours for both.

Comment: Although limited by its retrospective, single-center design, this study adds to the accumulating evidence that a 4-hour TFAD for CAP is not a valid quality measure. In addition to reducing the accuracy of CAP diagnoses, this measure can lead to inappropriate antibiotic use and its complications (e.g., antibiotic resistance and Clostridium difficile disease). Although the measure has been amended in response to such concerns (the TFAD goal is now 6 hours), the saga of the 4-hour target time should remind us of the "law of unintended consequences" and prompt us to examine future quality measures more carefully before they are widely adopted.

— Daniel J. Diekema, MD, MS

Published in Journal Watch Infectious Diseases March 5, 2008

Citation(s):

Welker JA et al. Antibiotic timing and errors in diagnosing pneumonia. Arch Intern Med 2008 Feb 25; 168:351.

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