Public Reporting Of Pneumonia Antibiotic Timing Has Not Resulted In Adverse Effects

Ruzanna Harutyunyan's picture
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In 2004, the Hospital Quality Alliance (HQA) began publicly reporting hospitals’ performance on 10 quality measures. One measure, the percentage of patients admitted to a hospital with pneumonia who are given antibiotics within four hours of arriving, was considered controversial because of concerns that patients would suffer unintended consequences as hospitals tried to improve their scores. Now, researchers at Brigham and Women’s Hospital (BWH), have studied the nationwide effects of this measure on patient care for the first time. Their results are published online in the American Journal of Managed Care.

Researchers, led by Dr. Mark Friedberg at Brigham and Women’s Hospital, found no evidence that publicly reporting hospital performance on this quality measure resulted in adverse effects for patients seeking care in hospital emergency departments (ED). “Public reporting of the antibiotic timing measure did not appear to lead to over diagnosis of pneumonia, excessive antibiotic use, or inappropriate prioritization for patients coming to hospital emergency departments with respiratory symptoms,” said Friedberg.

In 2007, due to concerns about the potential for diagnostic errors, antibiotic resistance, and other adverse side effects of unnecessary antibiotic use, the HQA’s window for giving antibiotics to patients with pneumonia was lengthened from four hours to six hours.

“It can be difficult to diagnose a patient with pneumonia within four hours, especially in a busy ED,” said Friedberg. “Some policy makers were worried that if emergency physicians were focused too closely on pneumonia, other respiratory conditions might be missed. Additionally, there were concerns that patients who were more likely to have pneumonia would be fast tracked through the ED, resulting in longer wait times for other patients.”

Friedberg and colleagues set out to detect evidence of these unintended consequences in a nationally representative sample of more than 13,000 patient visits to approximately 400 hospital EDs. The researchers evaluated data from before and after the start of public reporting on the antibiotic timing measure. They asked three questions:

1. Did the rate of pneumonia diagnosis for patients with cough, shortness of breath and difficulty breathing increase?

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2. Were patients with cough, shortness of breath and difficulty breathing more likely to receive antibiotics after reporting began?

3. Did waiting times for patients with respiratory symptoms decrease, relative to patients less likely to have pneumonia?

They found that:

1. Rates of pneumonia diagnosis did not increase after reporting.

2. Rates of patients who received antibiotics with pneumonia symptoms did not increase.

3. Waiting times in the ED increased by similar amounts for patients with and without respiratory symptoms.

When looking for differences between ED visits to hospitals with higher and lower scores on the antibiotic timing measure, researchers found that the major difference was the length of time patients waited to see a doctor. On average, patients waited 38 minutes at the highest-scoring hospitals, compared with 66 minutes at the lowest-scoring hospitals.

“It was interesting to find that by comparing two hospitals’ publicly reported scores on pneumonia antibiotic timing, you could potentially make a good guess about whether one ED will have a longer waiting time than the other,” said Friedberg. “This information is not publicly reported anywhere else.”

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Comments

Pneumonia Thoughts Pneumonia is an inflammation and consolidation of lung tissue to due to an infectious agent, such as a bacteria, or virus. Most pneumonia cases are usually acquired in a community setting Bacterial pneumonia occurs more often due to bacteria called S. Pneumo. About half of all people infected with this bacteria show no overt symptoms. Also, in comparison with viral pneumonia, bacterial pneumonia has a shorter duration and is also more severe in the damage the bacteria can do to the patient. If left untreated, pneumonia can lead to the critical diseases of meningitis or sepsis, if not death. In fact, pneumonia was the number one cause of death in the United States before the advent of antibiotics. Approximately 2 million, if not more, people acquire pneumonia every year. 40 to 60 thousand people die due to pneumonia every year, and pneumonia is the most common infectious cause of death that exists. More men get pneumonia than women. About 20 percent of CAP cases are viral rather than bacterial. So most of the time, an antibiotic will be needed for the pneumonia patient. Also, about 10 million doctor visits are due to CAP and the symptoms from the disease. Pneumonia acquired while a patient is in a medical institution for another medical reason is called nosocomial pneumonia. Often, the symptoms are more severe, as the patient usually has another serious medical issue that is being treated in the medical facility as they acquire this type of pneumonia. If this type of pneumonia is acquired at such a location, it usually happens after the first 48 hours of a patient being in such a facility. Also, the microbe that causes nosocomial pneumonia is usually S. Aureus, according to others. However, frequently the cause of pneumonia is by resistant bacteria that are difficult to kill, as they are shielded from adaptation, these bacteria, from the many existing antibiotics historically used as therapy for patients invaded by bacteria. Such bacteria, as MRSA or VRE, are most resistant to most antibiotics. Treatment for nosocomial pneumonia usually requires a longer period to restore the health of a patient with this diagnosis. About 25 percent of ICU patients without pneumonia acquire nosocomial pneumonia while there for another medical issue. Symptoms for the typical pneumonia patient may be a fever, a high heart rate, a productive cough, and inflamed lungs noted on an X-ray. A sputum sample is usually obtained from the suspected patient in order to determine what is causing the pneumonia. If it is bacterial, antibiotic therapy is initiated for a certain length of time to cure the infection. At the same time, the health care provider should rule out lung cancer or tuberculosis as the provider is assessing the patient. Chest X-Rays usually are taken to rule out such diseases. Patients who are suspected or are diagnosed with community acquired pneumonia (CAP) are often started an antibiotic regimen from what is called the macrolide class of antibiotics. Macrolides have been proven to shorten the length of time the disease exists in the patient who has pneumonia. How serious CAP is with a patient can be determined by what is called a risk stratification point system- which lists various symptoms and conditions that may be present in the suspected patient who may have pneumonia. Points are assigned to these symptoms, and the severity of them regarding the disease of pneumonia. If the point number exceeds 90 points, the pneumonia patient is admitted to a hospital for more aggressive treatment and evaluation. About a third of all patients with community acquired pneumonia require hospitalization. Elderly patients usually experience this type of severity with their CAP illness, as well as those people with compromised immune systems for whatever reason. Also, primary care physicians diagnose and treat typical pneumonia in the United States. In the United States, about 2 million or more people acquire pneumonia, and over 4 thousand people die from this disease every year. Worldwide, about 2 million children less than 5 years of age die every year due to pneumonia. Two pneumonia vaccinations are available presently. It has recently been proven that the polysaccharide pneumonia vaccine is not useful in preventing pneumonia. However, the conjugate pneumonia vaccine has been shown to prevent the disease, according to recent studies. The effective vaccine has experienced greater worldwide access recently to prevent what may be a very deadly disease without prevention and treatment, as it is believed to protect well over 50 percent of people who receive this vaccination from pneumonia. www.lungusa.org Dan Abshear