Hospitals Getting Graded Using Wrong Test Questions

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So the Department of Health and Human Services’ “report card” grading hospitals on how well the hospitals “care for all their adult patients with certain medical conditions” just keeps getting worse and worse. Now we’re seeing that the “quality indicators” the government is using are nothing of the sort. One recent study shows that at least one set of “quality indicators”

  1. Increases the likelihood of misdiagnosis,
  2. Causes patients to receive unnecessary antibiotics,
  3. Has no effect on patient length of stay or death rates
  4. Not mentioned in the article, but just as important – increases the costs that patients have to pay due to all the unnecessary antibiotics and blood cultures

Jumping through all the government hoops makes patients more likely to be misdiagnosed and more likely to receive unnecessary antibiotics. And they’re the ones grading the hospitals?

The HHS home page states “This information will help you compare the quality of care hospitals provide.” Funny thing . . . if you look around on the web site, it shows nothing about where the quality indicators came from or what scientific methods were used to come up with the indicators. This page lists all of the quality indicators that HHS uses to determine whether or not patients are receiving “quality care.” If you go to the Pneumonia “Process of Care Measures” you’ll see that HHS thinks that “quality hospitals” give antibiotics within 4 hours because “Timely use of antibiotics can improve the treatment of pneumonia caused by bacteria.” Great. So why the 4 hour time frame? There are no data on the web site to support the government’s “quality indicators.” Now at least one study shows that the 4 hour time frame may actually harm patients. And why does HHS equate quality of care with giving unnecessary antibiotics to patients with viral pneumonia?

Some of the quality indicators are valid. But let’s not use smoke and mirrors to coerce hospitals into providing unnecessary and potentially harmful care so that they can be at the top of some report card. The patients in the US deserve better than this.

On tap in the future – more than 100 new “quality indicators” by which hospitals will be expected to abide. Just how many of them will have a scientific basis? I’m not keeping my hopes up. This micromanagement is going to make healthcare in the US more expensive and less effective.

One more thing – has anyone ever noticed that government-run hospitals aren’t on the HHS “Hospital Compare” website? Try searching for Walter Reed Army Medical Center or Tripler Army Medical Center, for example. If civilian hospitals are performing as well as government-run facilities, they should get a great grade, right? Why aren’t government-run hospitals available for comparison?

Bottom line: If everyone ignores these indicators, they become meaningless.

No quality indicators for the Department of Health and Human Services leadership . . . yet.

Pneumonia guideline may lead to wrong treatment

Reuters Health

Wednesday, July 4, 2007

NEW YORK (Reuters Health) – Tight adherence to guidelines for managing people who catch pneumonia in the community — such as starting antibiotics within 4 hours of arrival at the hospital — raises the risk of misdiagnosis and inappropriate use of antibiotics, doctors in Detroit have found.
Based on their research, Dr. Mohamad G. Fakih and associates at St. John Hospital and Medical Center advocate a 6-hour window between arrival at the emergency department and administration of antibiotics as a more feasible target.
“This target may provide more time for physicians to provide a better evaluation of the patient,” Fakih and colleagues write in the journal Chest.
They looked at outcomes of patients admitted to the ED with a diagnosis of community-acquired pneumonia during 6-month periods prior to and after publication of the guidelines. There were 199 patients treated between January and June, 2003, and 319 patients treated between January and June, 2005.
Since publication of the guidelines, “we have seen almost a 60 percent increase in the hospital admitting diagnosis of community-acquired pneumonia compared to a less than 25 percent increase in the hospital discharge diagnosis of community-acquired pneumonia,” the researchers note.
Results showed that the goal of starting antibiotic treatment within 4 hours increased from 54 percent before the guidelines were published to 66 percent after publication.
However, more patients in 2005 (after publication) had a diagnosis of community-acquired pneumonia without radiographic evidence of abnormalities (28.5 percent versus 20.6 percent), suggesting an incorrect diagnosis.
Of those misdiagnosed, only a minority were diagnosed with any type of infection, implying that they were treated unnecessarily with antibiotics.
Fakih’s group also failed to see any significant improvement over time in average hospital length of stay or in-hospital mortality following publication of the guidelines.
They conclude based on their observations that a 6-hour time frame is perhaps more appropriate than a 4-hour time frame for people arriving at the hospital with suspected pneumonia.

SOURCE: Chest, June 2007.

Things are getting worse …

CMS metric may prompt excessive antibiotic use

Pressed to measure up in public reports, physicians at one hospital may have been too quick to diagnose patients with pneumonia, researchers say.

By Kevin B. O’Reilly, AMNews staff. March 17, 2008.

A new study says physicians are 39% more likely to misdiagnose hospital patients as having community-acquired pneumonia due to the high-stakes environment fostered by mandatory public reporting of quality measures — in this case, whether pneumonia patients got antibiotics within four hours of arriving at the hospital.
The results, published in the Feb. 25 Archives of Internal Medicine, are similar to those found in a Chest study published last year and echo many physicians’ complaints about the measure of initial antibiotic timing, known as door-to-needle time. A February 2007 Infection Control and Hospital Epidemiology study tied excessive use of antibiotics encouraged by the performance metric to a severe outbreak of Clostridium difficile at a small rural hospital.
The performance measure is part of the Joint Commission’s and the Centers for Medicare & Medicaid Services’ hospital quality reporting initiatives and was first rolled out in 2004. It represented a change from the earlier goal of getting antibiotics to hospital patients with community-acquired pneumonia within eight hours of arrival.
CMS said that beginning this month, it will not report hospitals’ results on the four-hour antibiotic timing metric and report performance on a new, six-hour goal. The change still must go through the federal rule-making process.
How performance metrics drive changes in medical practice raises a larger question, experts say, about how best to balance the benefits of public reporting against the potential for negative unintended consequences.
“The process of reducing door-to-needle time to under four hours requires major changes in how ERs function,” said Jack D. McCue, MD, co-author of the Archives study and clinical professor of medicine at the University of California, San Francisco, School of Medicine.
“When you make major changes in the way patients are handled in the ER, you have to be very careful that what you’re doing is worth it. And I think everybody’s conclusion from this adventure is that this is not worth it.”
Dr. McCue and his colleagues retrospectively examined 548 adult admissions for pneumonia at the Franklin Square Hospital Center in Baltimore for six months before the four-hour antibiotic timing metric was rolled out, and for the same six-month period a year later.
Using criteria for diagnosing pneumonia developed as part of Food and Drug Administration-directed clinical trials of antibiotics, researchers found that pneumonia misdiagnoses at admission increased 36% under the four-hour goal, while discharge misdiagnoses went up 15%.
These misdiagnoses led to a 23% increase in delays in making the correct diagnosis under the four-hour goal, researchers found.

The shift to the four-hour measure

Massive retrospective studies of pneumonia patients had supported moving to the four-hour metric. For example, a March 22, 2004, Archives of Internal Medicine study found that elderly patients with pneumonia who received antibiotics within four hours of arrival were less likely to die in the hospital or within a month after discharge. But there are no randomized controlled trials showing the effectiveness of earlier antibiotic administration.
The door-to-needle time goal is “a moving target,” said Mark L. Metersky, MD, professor of medicine in the division of pulmonary and critical care medicine at the University of Connecticut School of Medicine and a member of an expert panel for CMS’ National Pneumonia Project.
“When this first started, there were just too many patients who were not getting antibiotics until they got up on the floor, which could take six, eight or 10 hours, and that was too long, and patients were dying from it,” Dr. Metersky said. “Now that everyone is more cognizant of it and patients are getting antibiotics quicker, we have to examine these measures and make sure they’re still having benefits.”
It is better for patients with pneumonia to get antibiotics within four hours, but CMS compromised because they recognized “there may have been unintended consequences,” he said.
Dr. McCue said the change to six hours is “a weak attempt at saving face,” and the evidence is not strong enough to support the measure.
Dale W. Bratzler, DO, helped conduct much of the research showing that earlier administration of antibiotics can save lives. He said the argument that measuring door-to-needle time performance drives doctors to err on the side of a pneumonia diagnosis “makes no sense at all.”
In 2005, after the study period, changes to the measure clearly spelled out that if a physician is uncertain about a pneumonia diagnosis, that patient will be excluded from reporting, Dr. Bratzler said.
“This is a single-institution study, and it doesn’t, in my opinion, provide evidence that there’s a systematic problem across hospitals,” added Dr. Bratzler, who is medical director of the Oklahoma Foundation for Medical Quality in Oklahoma City.

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