Performance Measures May Lead to Overuse of Antibiotics

One in five elderly patients gets the drugs before pneumonia diagnosis, study suggests

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By Kathleen Doheny
HealthDay Reporter

MONDAY, July 10, 2006 (HealthDay News) -- Elderly patients hospitalized for suspected pneumonia may be getting antibiotics before their doctor is certain about the diagnosis, a new study suggests.

Among health-care professionals, the practice is known as "shoot first and ask questions later." And the premature use of antibiotics for elderly patients with suspected pneumonia is often done to meet federal performance standards that dictate giving the drugs within four hours of arrival at a hospital.

"Some patients are probably getting antibiotics inappropriately in an attempt to deliver antibiotics quickly to meet externally mandated standards," said lead study author Dr. Mark L. Metersky, a professor of medicine at the University of Connecticut School of Medicine.

The result can lead to increases in antibiotic resistance, unwanted side effects from the drugs, and difficulty identifying the underlying medical problem, the researchers said.

The findings are published in the July issue of the journal Chest.

Metersky's team reviewed the charts of 86 Medicare patients who had ultimately received a diagnosis of pneumonia. Three reviewers evaluated each case to determine how often patients arrived at a hospital with symptoms that weren't typical of pneumonia, calling into question whether the diagnosis was actually pneumonia -- and the course of treatment.

Overall, the researchers found that 22 percent of the patients -- 19 -- had factors suggesting a delay in antibiotic treatment, because there was uncertainty about the diagnosis. Of those patients -- 13, or 68 percent -- received antibiotic treatment within four hours of hospital admission, even though their physician wasn't sure about the diagnosis.

Administering antibiotics within four hours is based on medical evidence that "patients who receive antibiotics within four hours survive at a higher rate than those who don't," Metersky said. "Four hours has been set as the benchmark. But it may take more than four hours in some patients to determine whether they have pneumonia or not."

The study suggests that quality of care may be suffering as hospitals strive to meet standards of care that can determine reimbursements from Medicare and other health plans, Metersky said.

"Every hospital is striving for 100 percent and, ultimately, will be paid by [its] performance, by Medicare and other insurance companies," Metersky said. But, he added, his study found that 22 percent of patients arrive at hospitals without the usual symptoms of pneumonia, making it difficult to determine the diagnosis.

For hospital officials and those who establish standards of care, the message is that "100 percent [antibiotic adherence within four hours] is not an appropriate goal, because it leads to inappropriate care," Metersky said.

"Seventy-five or 80 percent is probably more appropriate," he said.

Metersky said patients should ask their doctor for a diagnosis before agreeing to antibiotic therapy.

Dr. Peter Houck is clinical assistant professor of epidemiology at the University of Washington School of Public Health and Community Medicine, and former director of the Centers for Medicare and Medicaid Services National Pneumonia Project and the Surgical Infection Prevention Project. In an accompanying editorial in the journal, he discussed the seriousness of pneumonia, especially among the elderly. He noted that the disease accounts for more than 750,000 hospitalizations of Americans 65 and older each year, with a death rate of 7 percent while in the hospital and 12 percent within 30 days.

The new study, he said, points to the need for those who establish quality-improvement programs to consider how the measures are being applied, and whether 100 percent is the ideal goal in this case.

In an interview, Houck elaborated on the issue. "Research has shown that if you are over 65, and you have pneumonia severe enough to be hospitalized, your chances of survival are better if you receive your antibiotic sooner rather than later," he said. "If you have pneumonia, you want to receive antibiotics. If you don't, say it is something else, you don't want the antibiotic."

Another expert, Dr. Henry Chambers, chief of infectious diseases at San Francisco General Hospital, said "the methodology [used for the study] is somewhat limited because it is based on chart reviews." Still, he said, the study demonstrates what can happen if too much emphasis is placed on standards over quality of individual patient care. "You start taking care of performance measures, and you don't take care of patients," he said.

Chambers agreed that, in this case, the 100 percent goal is unrealistic. "Anything set at 100 percent encourages gaming the system," he added.

More information

To learn more about pneumonia, visit the American Lung Association.

SOURCES: Mark L. Metersky, M.D., professor of medicine, University of Connecticut School of Medicine, Farmington; Peter Houck, M.D., clinical assistant professor of epidemiology, University of Washington, Seattle; Henry Chambers, M.D., chief of infectious diseases, San Francisco General Hospital; July 2006, Chest

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