Public Reporting of Antibiotic Timing in Patients with Pneumonia: Lessons from a Flawed Performance Measure

TLDR

The administration of antibiotics within 4 hours to patients with community‑acquired pneumonia has been criticized as a quality standard because it pressures clinicians to rapidly administer antibiotics despite diagnostic uncertainty at the time of patients' initial presentations. Based on the experience with the 4‑hour rule, the authors make five recommendations for the development of future publicly reported quality measures. The measure was recently revised to 6 hours; the authors recommend cautious extrapolation from known‑diagnosis samples, using performance bands instead of all‑or‑nothing thresholds, involving end users in development, building mechanisms to reassess measures over time, and minimizing financial and intellectual biases to reduce unintended consequences.

Abstract

The administration of antibiotics within 4 hours to patients with community-acquired pneumonia has been criticized as a quality standard because it pressures clinicians to rapidly administer antibiotics despite diagnostic uncertainty at the time of patients' initial presentations. The measure was recently revised (to 6 hours) in response to this criticism. On the basis of the experience with the 4-hour rule, the authors make 5 recommendations for the development of future publicly reported quality measures. First, results from samples with known diagnoses should be extrapolated cautiously, if at all, to patients without a diagnosis. Second, for some measures, "bands" of performance may make more sense than "all-or-nothing" expectations. Third, representative end users of quality measures should participate in measure development. Fourth, quality measurement and reporting programs should build in mechanisms to reassess measures over time. Finally, biases, both financial and intellectual, that may influence quality measure development should be minimized. These steps will increase the probability that future quality measures will improve care without creating negative unintended consequences.