Are Age-Based Criteria the Best Way to Determine Eligibility for Prostate Cancer Screening? Authors' reply
Authors: Badrinath R. Konety, Matthew R. Cooperberg, Peter R. Carroll, Manfred Gogol, Ned Calonge, Diana B. Petitti, Kenneth W. Lin
Journal: Annals of Internal Medicine (2009)

Letters Annals of Internal Medicine C OMMENTS AND R ESPONSES The Unintended, Negative Consequences of the Door-to-Antibiotic Measure for Pneumonia TO THE EDITOR: I read with interest the recent article by Wachter and colleagues (1). An additional consequence of policies from the Centers for Medicare & Medicaid Services (CMS) has been the dis- ruption of local pneumonia guideline processes. The 2007 American Thoracic Society–Infectious Disease Society of America pneumonia guideline (2) recommended that “locally adapted guidelines should be implemented to improve process of care variables and relevant clinical outcomes.” In addition, “CAP [community-acquired pneu- monia] guidelines should address a comprehensive set of elements in the process of care, rather than a single element in isolation.” A guideline was implemented in the Intermountain Healthcare System (Utah and Idaho) beginning in 1995, with a demonstrated decrease in 30-day all-cause mortality and pneumonia admission rates (3, 4). As part of multiple care elements, Intermountain’s guideline recommends specific antibiotics (for example, ceftriaxone plus azithromycin for admitted patients) and recommends that anti- biotics be administered at the site of initial care as soon as the diag- nosis of pneumonia has been confirmed. With initiation of public reporting of CMS criteria, a competing focus developed within In- termountain Healthcare to achieve antibiotic administration within a 4-hour, and now 6-hour, window instead of our previous standard. In addition, the CMS list of acceptable antibiotics is broader than our local guideline, leading physicians at Dixie Regional Medical Center (St. George, Utah) to rewrite the local guideline to include CMS-accepted antibiotics, such as ertapenem. Compliance at Dixie Regional with Intermountain’s guideline as measured by initial anti- biotic prescribed decreased from 90% in January 2005 to only 55% in January 2008 (Compliance rate for community-acquired pneumo- nia for Dixie Regional Medical Center. Intermountain.net. Internal system Web site). Although Intermountain Healthcare System has more than 90% compliance with the CMS antibiotic timing mea- sure, the focus of internal processes has shifted to meeting these performance measures instead of reinforcing the use of the local guideline. An earlier consequence of CMS payment policies was to reduce payments to Intermountain Healthcare for patients with pneumonia by approximately $500 000 per year (5). Our guideline recommends treating more patients with pneumonia at home, which resulted in revenue loss under CMS payment policies because reim- bursement for care of a hospitalized patient with pneumonia was much higher than care of a similar patient at home. Unlike CMS pneumonia performance measures, our guideline has been shown to improve patient outcomes. Unlike reporting of specific care ele- ments, severity-adjusted measures of outcome, such as survival to discharge home, time to return to usual activities, and 30-day mor- tality rate, would support local guideline development and imple- mentation. Real improvement in pneumonia outcomes would prob- ably result instead of what we are seeing from well-intended but flawed performance measures. Nathan C. Dean, MD Intermountain Health Care Murray, UT 84107 Potential Financial Conflicts of Interest: None disclosed. References 1. Wachter RM, Flanders SA, Fee C, Pronovost PJ. Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure. Ann Intern Med. 2008;149:29-32. [PMID: 18591635] 2. Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, et al. Infectious Diseases Society of America. Infectious Diseases Society of America/ American Thoracic Society consensus guidelines on the management of community- acquired pneumonia in adults. Clin Infect Dis. 2007;44 Suppl 2:S27-72. [PMID: 3. Suchyta MR, Dean NC, Narus S, Hadlock CJ. Effects of a practice guideline for com- munity-acquired pneumonia in an outpatient setting. Am J Med. 2001;110:306-9. [PMID: 11239849] 4. Dean NC, Bateman KA, Donnelly SM, Silver MP, Snow GL, Hale D. Improved clinical outcomes with utilization of a community-acquired pneumonia guideline. Chest. 2006;130:794-9. [PMID: 16963677] 5. Porter ME, Teisberg EO. Redefining Health Care. Boston: Harvard Business School Pr; 2006:263. TO THE EDITOR: I work at a tertiary community geriatric and neuro- logic hospital specializing in acute, subacute, and rehabilitation care. I fully agree with Wachter and colleagues’ critique (1) of the flawed sci- entific basis of defining a time window for antibiotic administration for CAP in hospitalized patients. In 2006 and 2007, there were 40 428 inpatients with CAP in Lower Saxony (Germany). Forty-four patients were treated at my hospital. Data derived from the quality measurement tool for hospitalized patients with CAP found no association between time to first antibiotic administration and death. Because our patients have had higher CURB-65 (confusion, respiratory rate, blood pressure, and age 65 years or older) scores, were older, more often came from other hospitals or rehabilitation units, were more often bedridden, and were cognitively impaired, we add more data to the growing evidence that questions the sense of shorter door-to-antibiotic time. In a time when some physicians treat guidelines as gospel truth, it seems necessary to cite the most recent U.S. guideline (2): “ . . . [T]he first antibiotic dose should be administered while still in the ED [emergency depart- ment]” is judged only as a “[m]oderate recommendation; level III evi- dence,” but “[f]or these and other reasons, the committee did not feel that a specific time window for delivery of the first antibiotic dose should be recommended. However, the committee does feel that therapy should be administered as soon as possible after the diagnosis is consid- ered likely.” We hope that randomized, controlled trials will lead us to more reasonable quality measurement tools in future. Manfred Gogol, MD Krankenhaus Lindenbrunn, Klinik fuer Geriatrie Coppenbruegge 31863, Germany Potential Financial Conflicts of Interest: None disclosed. References 1. Wachter RM, Flanders SA, Fee C, Pronovost PJ. Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure. Ann Intern Med. 2008;149:29-32. [PMID: 18591635] 2. Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, et al. Infectious Diseases Society of America. Infectious Diseases Society of America/ American Thoracic Society consensus guidelines on the management of community- acquired pneumonia in adults. Clin Infect Dis. 2007;44 Suppl 2:S27-72. [PMID: © 2009 American College of Physicians 219 Downloaded From: http://annals.org/ by a Univ of California San Francisco User on 07/07/2016