Portal de Periódicos da CAPES

The pneumonia controversy: Hospitals grapple with 4 hour benchmark

2006; Elsevier BV; Volume: 47; Issue: 3 Linguagem: Inglês

10.1016/j.annemergmed.2006.01.027

1097-6760

Dacus Thompson,

Primary Care and Health Outcomes

IntroductionAnnals News and Perspective explores topics relevant to emergency medicine, in particular those in which our specialty interacts with the political, ethical, sociologic, legal and business spheres of our society. Discussion of specific clinical problems and their management will be rare. By design, it will not be a “breaking news” section with the latest (and undigested) developments, but instead a reflective investigation of recent and emerging trends. If you have any feedback about this section, please forward it to us at [email protected] .Candy dishes filled with penicillin in triage.Topical antibiotics applied to the hands of patients with pneumonia-like symptoms.These are some of the ways hospitals are rumored to be “complying” with the 4-hour, door-to-antibiotic federal benchmark for community-acquired pneumonia.No one would speak on the record about the candy dish, and the topical antibiotic was nervously chuckled off as an urban myth, but these shenanigans, even if apocryphal, illustrate the frustration with the measure, which is being linked to the bottom line.Community-acquired pneumonia is 1 of 4 diagnoses identified by the federal Centers for Medicare and Medicaid Services (CMS) for quality improvement. The agency, which administered $483.8 billion in Medicaid and Medicare funding in 2004, identified several “core measures” to improve treatment of each condition, but the 4-hour antibiotic time in pneumonia has generated the most controversy.“It’s a ridiculous number,” said Elizabeth Datner, the medical director of the Department of Emergency Medicine for the Hospital of the University of Pennsylvania, “especially when it may actually not even play out to show improved outcomes for patients.”JCAHO and the evidenceThe Joint Commission of Accreditation of Healthcare Organizations (JCAHO) based the standard on retrospective studies of tens of thousands of Medicare patients, showing slight decreases in 30-day mortality, length of stay, and readmission. CMS adopted it and required more than 3,800 hospitals across the country to report statistics on the timing of antibiotic administration in pneumonia. If they don’t, the hospitals will be penalized financially. The next step, already being tested with a pilot program, is to tie Medicaid funding to compliance with the core measures.“In general, giving antibiotics to someone who has pneumonia sooner rather than later can’t be a bad thing,” said David Schriger, MD, MPH, a professor of emergency medicine at UCLA. “But this idea that less than 4 hours is great and after 4 hours is bad is a little bit silly. I mean, it may be true for really sick patients, but it’s one of those pyramid things, where it’s true for the top of the pyramid but not for the rest of it.”In 2003, President Bush signed the Medicare Prescription Drug, Improvement, and Modernization Act, which provided CMS between $400-450 million to incentivize improvements in quality of care in 5 areas: heart attack, heart failure, surgical infection prevention, and community-acquired pneumonia. To get their share of the funding, all hospitals participating in Medicaid or Medicare must submit performance data for 10 quality measures. Hospitals are encouraged to submit 10 more measures voluntarily. CMS set aside about $25 million for its pay-for-performance pilot program contracted to Premier. The specter of pay-for-performance being applied to all Medicaid/Medicare hospitals has sent shockwaves through the medical community.Of the core measures, 6 fall under community-acquired pneumonia: pneumococcal vaccination, initial antibiotics within 4 hours after arrival, oxygenation assessment, smoking cessation advice and counseling, most appropriate initial antibiotics, and blood culture performed prior to first antibiotic received in hospital.The collected data are published at hospitalcompare.hhs.gov, a Web site where over a 4-step process a user can boil down a hospital’s quality of care (according to CMS) to a series of bar graphs.Hospitals cornered“The core measures were put together with an intention to try and rate hospitals on what JCAHO and Medicare saw as major areas of concern of service that they could probably put their finger on and say, ‘If you’re going by these measures in this amount of time then this hospital is considered a great facility and this is not,” explained Joseph Englanoff, assistant clinical professor of medicine and emergency medicine at UCLA Medical Center. “The measures JCAHO put together, I don’t know if these are of any benefit, and they’re pushing us into a corner with them.”Rumors have circulated about hospitals gaming the system by giving patients with pneumonia-like symptoms—fever, shortness of breath, even a slight cough—oral antibiotics before they’ve been properly diagnosed, sometimes as soon as they hit the door. One physician, who asked to remain anonymous, said a respectable university hospital’s emergency department set out 2 candy dishes for anyone who came in with pneumonia-like symptoms, 1 filled with penicillin and the other erythromycin (for the penicillin allergic).If emergency departments are using underhanded practices, they are doing so as a failsafe, so when it’s time to check the were-antibiotics-administered-within-4-hours box at discharge as a requirement for CMS, one could mark “yes.”Denise Remus, a former senior research scientist for Agency for Healthcare Research and Quality (AHRQ) and currently Premier’s Vice President for Clinical Informatics, found these practices discouraging.“Making sure that x-rays get in front of the clinicians and that they get read more quickly is more important than trying to get antibiotics to the patient just to meet a third party measure,” she said. “The most important thing is that you’re actually providing the quality of care for that patient.”Specter of pay for performanceThe 4-hour timeframe is gaining steam with Premier’s Hospital Quality Incentive Demonstration Project, the pilot project that is testing the waters of pay-for-performance.The demonstration launched in October 2003 to grade the performances of 268 participating hospitals in 5 clinical areas: heart attack, heart failure, pneumonia, coronary artery bypass graft, and hip and knee replacements. So far the demonstration appears to be achieving its goals. And CMS hopes $8.85 million, the amount the nonprofit disbursed to 123 top-performing hospitals this past November, will force hospitals to comply with the core measures.“The demonstration has been extremely successful,” said Remus. “The improvement in the overall composite score for all 5 areas that [Premier’s] focused on have seen significant statistical improvement from the first to the fourth quarters of the project. And it’s continuing to trend upward.”In the first year, the community-acquired pneumonia composite quality score for all measures jumped from 69 to 79 percent. The 4-hour, door-to-antibiotic measure improved less significantly, from 66 to 72 percent. But it’s unclear how much quality of care actually improved and how much hospitals were just learning their way around the new requirements in the first quarter.The Premier program functions like an honor role system with the top performers receiving large cash incentives. Facilities that finish in the top 10 percent in any of the 5 categories receive a 2 percent bonus for patients treated in that area; the second highest 10 percent get a 1 percent bonus. Baselines were set for the bottom 2 thresholds at the end of the first year, and any hospitals that fall below those limits in the third year will be penalized with a 1 or 2 percent reduction in Medicare payments.The monetary benefits from the first year at the upper end are substantial. Staten Island University Hospital received close to $750,000 after finishing in the top 10 percent in 4 of 5 categories; Hackensack (N.J.) University Medical Center wrapped up the year in the top 20 percent of each category, raking in an extra $848,000 for the year. The winner in community-acquired pneumonia was St. Francis Hospital at Broken Arrow, Tulsa, Okla., which took a purse of $12,209.Of the 17 common data sets between the pilot program hospitals and the others, the Premier hospitals are showing a statistically significant improvement in all but 3 measures. Hospitals not participating in the pilot program are grumbling at the comparison, but they are taking notice and making changes.Trimming time to treatmentAt 2 hospitals in the Los Angles area—Monterey Park Hospital and Community Hospital of Huntington Park, the time from when a community-acquired pneumonia patient entered the hospital to the initial administration of antibiotics was cut in half. “I think our timeline was about 8.5, maybe 9 hours for direct admit patients, which is astronomical,” said Englanoff, who is the director of emergency medicine for both facilities. “The emergency department was around 4.5, 5 hours, so together it came out to an average of about 7 hours.”Englanoff and staff implemented a pneumonia guideline order sheet, following the CMS core measures. Physicians were provided with a checklist that addressed every measure, so, Englanoff said, a physician would have very little to think about. “We cut our time down to under or around 180 minutes or less,” he boasted. “So I think our guidelines have worked very well.”At the Hospital of the University of Pennsylvania, chest x-rays are now given at triage to patients with pneumonia-like symptoms, and the hospital has initiated a new registration process to improve patient flow.But Datner and Englanoff both carefully pointed out that their hospitals are not adjusting strictly because of the CMS measures. “We want to improve patient flow for all of our patients and not prioritize less sick patients with pneumonia over potentially more sick patients,” Datner said. “That’s what CMS may be missing in this: by holding hospitals to this measure may be improving patient flow or flow to the emergency department or time to treatment to these patients, but it may undermine the efficiency of care provided for more ill patients.”Acknowledgement of acuityFor inner-city hospitals such as the Hospital of the University of Pennsylvania that don’t have the resources and finances to keep up, pay for performance may only compound the frustrations.“This program is comparing facilities without any particular adjustments, and there are some pretty wide differences in emergency rooms, both in terms of number of patients and the intensity or acuity of patients,” said UCLA quality of care director Tod Barry.A Wall Street Journal article published in April exposed UCLA as being the worst of 3 Los Angeles hospitals in terms of administering antibiotics to patients within 4 hours of arrival; Cedar-Sinai Medical Center and St. John’s Hospital Health Center ranked first and second, respectfully.UCLA blanched at the bad press, and soon thereafter the hospital administration became close readers of the CMS guidelines.What they found was that at the time of the article, UCLA’s emergency department hadn’t been involved with the counting of who was eligible to be included as a community-acquired pneumonia patient.“We were counting a lot of patients who had pneumonia we didn’t have to count,” said Schriger.The hospital, he explained, was numbering all patients diagnosed with pneumonia at any point during their stay as eligible. Under the guidelines, patients who have no working diagnosis of pneumonia at the time of admission should not be counted.“We just changed the way we count because we were actually being too stringent on ourselves,” Schriger said. “We’re not gaming the system. The rules in fact tell us that’s what we’re supposed to do. Our numbers improved simply because we counted properly and not because we improved the quality of care in any way, although of course we’re trying to improve the quality, as well.”Piles of paperworkDatner has found the paperwork that comes with meeting CMS’s core measures a burden. “We spend so much time charting now because there are these ridiculous charting requirements,” Datner said. “But if you don’t spend all of this time charting, which is totally a time-sink and not linked to the quality of care for patients, then you don’t get reimbursed. You’re spending more time doctoring the chart then you actually are at the bedside of the patient. It’s distressing.”It’s too early for any concrete evidence on how the CMS core measures may affect hospitals in the future, but it’s easy to speculate that if there are a number of patients in the waiting room approaching the 4-hour mark that those with pneumonia-like symptoms could receive preferential treatment. Or if a physician has been criticized a couple of times for missing the antibiotic deadline, she or he may be more likely to send a patient home who would otherwise be admitted. Patients don’t “count” if they are not admitted.An honest attemptBarry believes CMS is trying to do the right thing with the best available evidence. However, the core measures address the process of medical care, not the gold standard of patient outcomes, but that kind of data is hard to come by.“I think that ultimately this is good for the quality of care,” he said. “Getting valid, comparable information to the public is (important)…. They don’t address the most important measures, which would be outcome, but those are more difficult to get at, so the government has started out, probably smartly, by looking at process measures…. They reflect care for the typical patient coming in the door…. Yes, all patients that have pneumonia as the principal diagnosis and don’t have certain exclusions should receive antibiotics in a timely fashion. The 4 hour piece, I’m not sure how much literature is out there specifically if they got it in 4 hours versus 5 hours, but it’s a reasonable standard.”Remus admits that the record review burden is daunting and the core measures are far from perfect benchmarks.“Maybe we should have another system measure,” she said. “Maybe we should have hospitals look at why aren’t you getting that antibiotic to the patient within 4 hours. If they later on have a pneumonia diagnosis, what was the barrier to that? These are all lessons that we’re learning.” IntroductionAnnals News and Perspective explores topics relevant to emergency medicine, in particular those in which our specialty interacts with the political, ethical, sociologic, legal and business spheres of our society. Discussion of specific clinical problems and their management will be rare. By design, it will not be a “breaking news” section with the latest (and undigested) developments, but instead a reflective investigation of recent and emerging trends. If you have any feedback about this section, please forward it to us at [email protected] . Annals News and Perspective explores topics relevant to emergency medicine, in particular those in which our specialty interacts with the political, ethical, sociologic, legal and business spheres of our society. Discussion of specific clinical problems and their management will be rare. By design, it will not be a “breaking news” section with the latest (and undigested) developments, but instead a reflective investigation of recent and emerging trends. If you have any feedback about this section, please forward it to us at [email protected] . Annals News and Perspective explores topics relevant to emergency medicine, in particular those in which our specialty interacts with the political, ethical, sociologic, legal and business spheres of our society. Discussion of specific clinical problems and their management will be rare. By design, it will not be a “breaking news” section with the latest (and undigested) developments, but instead a reflective investigation of recent and emerging trends. If you have any feedback about this section, please forward it to us at [email protected] . Candy dishes filled with penicillin in triage. Topical antibiotics applied to the hands of patients with pneumonia-like symptoms. These are some of the ways hospitals are rumored to be “complying” with the 4-hour, door-to-antibiotic federal benchmark for community-acquired pneumonia. No one would speak on the record about the candy dish, and the topical antibiotic was nervously chuckled off as an urban myth, but these shenanigans, even if apocryphal, illustrate the frustration with the measure, which is being linked to the bottom line. Community-acquired pneumonia is 1 of 4 diagnoses identified by the federal Centers for Medicare and Medicaid Services (CMS) for quality improvement. The agency, which administered $483.8 billion in Medicaid and Medicare funding in 2004, identified several “core measures” to improve treatment of each condition, but the 4-hour antibiotic time in pneumonia has generated the most controversy. “It’s a ridiculous number,” said Elizabeth Datner, the medical director of the Department of Emergency Medicine for the Hospital of the University of Pennsylvania, “especially when it may actually not even play out to show improved outcomes for patients.” JCAHO and the evidenceThe Joint Commission of Accreditation of Healthcare Organizations (JCAHO) based the standard on retrospective studies of tens of thousands of Medicare patients, showing slight decreases in 30-day mortality, length of stay, and readmission. CMS adopted it and required more than 3,800 hospitals across the country to report statistics on the timing of antibiotic administration in pneumonia. If they don’t, the hospitals will be penalized financially. The next step, already being tested with a pilot program, is to tie Medicaid funding to compliance with the core measures.“In general, giving antibiotics to someone who has pneumonia sooner rather than later can’t be a bad thing,” said David Schriger, MD, MPH, a professor of emergency medicine at UCLA. “But this idea that less than 4 hours is great and after 4 hours is bad is a little bit silly. I mean, it may be true for really sick patients, but it’s one of those pyramid things, where it’s true for the top of the pyramid but not for the rest of it.”In 2003, President Bush signed the Medicare Prescription Drug, Improvement, and Modernization Act, which provided CMS between $400-450 million to incentivize improvements in quality of care in 5 areas: heart attack, heart failure, surgical infection prevention, and community-acquired pneumonia. To get their share of the funding, all hospitals participating in Medicaid or Medicare must submit performance data for 10 quality measures. Hospitals are encouraged to submit 10 more measures voluntarily. CMS set aside about $25 million for its pay-for-performance pilot program contracted to Premier. The specter of pay-for-performance being applied to all Medicaid/Medicare hospitals has sent shockwaves through the medical community.Of the core measures, 6 fall under community-acquired pneumonia: pneumococcal vaccination, initial antibiotics within 4 hours after arrival, oxygenation assessment, smoking cessation advice and counseling, most appropriate initial antibiotics, and blood culture performed prior to first antibiotic received in hospital.The collected data are published at hospitalcompare.hhs.gov, a Web site where over a 4-step process a user can boil down a hospital’s quality of care (according to CMS) to a series of bar graphs. The Joint Commission of Accreditation of Healthcare Organizations (JCAHO) based the standard on retrospective studies of tens of thousands of Medicare patients, showing slight decreases in 30-day mortality, length of stay, and readmission. CMS adopted it and required more than 3,800 hospitals across the country to report statistics on the timing of antibiotic administration in pneumonia. If they don’t, the hospitals will be penalized financially. The next step, already being tested with a pilot program, is to tie Medicaid funding to compliance with the core measures. “In general, giving antibiotics to someone who has pneumonia sooner rather than later can’t be a bad thing,” said David Schriger, MD, MPH, a professor of emergency medicine at UCLA. “But this idea that less than 4 hours is great and after 4 hours is bad is a little bit silly. I mean, it may be true for really sick patients, but it’s one of those pyramid things, where it’s true for the top of the pyramid but not for the rest of it.” In 2003, President Bush signed the Medicare Prescription Drug, Improvement, and Modernization Act, which provided CMS between $400-450 million to incentivize improvements in quality of care in 5 areas: heart attack, heart failure, surgical infection prevention, and community-acquired pneumonia. To get their share of the funding, all hospitals participating in Medicaid or Medicare must submit performance data for 10 quality measures. Hospitals are encouraged to submit 10 more measures voluntarily. CMS set aside about $25 million for its pay-for-performance pilot program contracted to Premier. The specter of pay-for-performance being applied to all Medicaid/Medicare hospitals has sent shockwaves through the medical community. Of the core measures, 6 fall under community-acquired pneumonia: pneumococcal vaccination, initial antibiotics within 4 hours after arrival, oxygenation assessment, smoking cessation advice and counseling, most appropriate initial antibiotics, and blood culture performed prior to first antibiotic received in hospital. The collected data are published at hospitalcompare.hhs.gov, a Web site where over a 4-step process a user can boil down a hospital’s quality of care (according to CMS) to a series of bar graphs. Hospitals cornered“The core measures were put together with an intention to try and rate hospitals on what JCAHO and Medicare saw as major areas of concern of service that they could probably put their finger on and say, ‘If you’re going by these measures in this amount of time then this hospital is considered a great facility and this is not,” explained Joseph Englanoff, assistant clinical professor of medicine and emergency medicine at UCLA Medical Center. “The measures JCAHO put together, I don’t know if these are of any benefit, and they’re pushing us into a corner with them.”Rumors have circulated about hospitals gaming the system by giving patients with pneumonia-like symptoms—fever, shortness of breath, even a slight cough—oral antibiotics before they’ve been properly diagnosed, sometimes as soon as they hit the door. One physician, who asked to remain anonymous, said a respectable university hospital’s emergency department set out 2 candy dishes for anyone who came in with pneumonia-like symptoms, 1 filled with penicillin and the other erythromycin (for the penicillin allergic).If emergency departments are using underhanded practices, they are doing so as a failsafe, so when it’s time to check the were-antibiotics-administered-within-4-hours box at discharge as a requirement for CMS, one could mark “yes.”Denise Remus, a former senior research scientist for Agency for Healthcare Research and Quality (AHRQ) and currently Premier’s Vice President for Clinical Informatics, found these practices discouraging.“Making sure that x-rays get in front of the clinicians and that they get read more quickly is more important than trying to get antibiotics to the patient just to meet a third party measure,” she said. “The most important thing is that you’re actually providing the quality of care for that patient.” “The core measures were put together with an intention to try and rate hospitals on what JCAHO and Medicare saw as major areas of concern of service that they could probably put their finger on and say, ‘If you’re going by these measures in this amount of time then this hospital is considered a great facility and this is not,” explained Joseph Englanoff, assistant clinical professor of medicine and emergency medicine at UCLA Medical Center. “The measures JCAHO put together, I don’t know if these are of any benefit, and they’re pushing us into a corner with them.” Rumors have circulated about hospitals gaming the system by giving patients with pneumonia-like symptoms—fever, shortness of breath, even a slight cough—oral antibiotics before they’ve been properly diagnosed, sometimes as soon as they hit the door. One physician, who asked to remain anonymous, said a respectable university hospital’s emergency department set out 2 candy dishes for anyone who came in with pneumonia-like symptoms, 1 filled with penicillin and the other erythromycin (for the penicillin allergic). If emergency departments are using underhanded practices, they are doing so as a failsafe, so when it’s time to check the were-antibiotics-administered-within-4-hours box at discharge as a requirement for CMS, one could mark “yes.” Denise Remus, a former senior research scientist for Agency for Healthcare Research and Quality (AHRQ) and currently Premier’s Vice President for Clinical Informatics, found these practices discouraging. “Making sure that x-rays get in front of the clinicians and that they get read more quickly is more important than trying to get antibiotics to the patient just to meet a third party measure,” she said. “The most important thing is that you’re actually providing the quality of care for that patient.” Specter of pay for performanceThe 4-hour timeframe is gaining steam with Premier’s Hospital Quality Incentive Demonstration Project, the pilot project that is testing the waters of pay-for-performance.The demonstration launched in October 2003 to grade the performances of 268 participating hospitals in 5 clinical areas: heart attack, heart failure, pneumonia, coronary artery bypass graft, and hip and knee replacements. So far the demonstration appears to be achieving its goals. And CMS hopes $8.85 million, the amount the nonprofit disbursed to 123 top-performing hospitals this past November, will force hospitals to comply with the core measures.“The demonstration has been extremely successful,” said Remus. “The improvement in the overall composite score for all 5 areas that [Premier’s] focused on have seen significant statistical improvement from the first to the fourth quarters of the project. And it’s continuing to trend upward.”In the first year, the community-acquired pneumonia composite quality score for all measures jumped from 69 to 79 percent. The 4-hour, door-to-antibiotic measure improved less significantly, from 66 to 72 percent. But it’s unclear how much quality of care actually improved and how much hospitals were just learning their way around the new requirements in the first quarter.The Premier program functions like an honor role system with the top performers receiving large cash incentives. Facilities that finish in the top 10 percent in any of the 5 categories receive a 2 percent bonus for patients treated in that area; the second highest 10 percent get a 1 percent bonus. Baselines were set for the bottom 2 thresholds at the end of the first year, and any hospitals that fall below those limits in the third year will be penalized with a 1 or 2 percent reduction in Medicare payments.The monetary benefits from the first year at the upper end are substantial. Staten Island University Hospital received close to $750,000 after finishing in the top 10 percent in 4 of 5 categories; Hackensack (N.J.) University Medical Center wrapped up the year in the top 20 percent of each category, raking in an extra $848,000 for the year. The winner in community-acquired pneumonia was St. Francis Hospital at Broken Arrow, Tulsa, Okla., which took a purse of $12,209.Of the 17 common data sets between the pilot program hospitals and the others, the Premier hospitals are showing a statistically significant improvement in all but 3 measures. Hospitals not participating in the pilot program are grumbling at the comparison, but they are taking notice and making changes. The 4-hour timeframe is gaining steam with Premier’s Hospital Quality Incentive Demonstration Project, the pilot project that is testing the waters of pay-for-performance. The demonstration launched in October 2003 to grade the performances of 268 participating hospitals in 5 clinical areas: heart attack, heart failure, pneumonia, coronary artery bypass graft, and hip and knee replacements. So far the demonstration appears to be achieving its goals. And CMS hopes $8.85 million, the amount the nonprofit disbursed to 123 top-performing hospitals this past November, will force hospitals to comply with the core measures. “The demonstration has been extremely successful,” said Remus. “The improvement in the overall composite score for all 5 areas that [Premier’s] focused on have seen significant statistical improvement from the first to the fourth quarters of the project. And it’s continuing to trend upward.” In the first year, the community-acquired pneumonia composite quality score for all measures jumped from 69 to 79 percent. The 4-hour, door-to-antibiotic measure improved less significantly, from 66 to 72 percent. But it’s unclear how much quality of care actually improved and how much hospitals were just learning their way around the new requirements in the first quarter. The Premier program functions like an honor role system with the top performers receiving large cash incentives. Facilities that finish in the top 10 percent in any of the 5 categories receive a 2 percent bonus for patients treated in that area; the second highest 10 percent get a 1 percent bonus. Baselines were set for the bottom 2 thresholds at the end of the first year, and any hospitals that fall below those limits in the third year will be penalized with a 1 or 2 percent reduction in Medicare payments. The monetary benefits from the first year at the upper end are substantial. Staten Island University Hospital received close to $750,000 after finishing in the top 10 percent in 4 of 5 categories; Hackensack (N.J.) University Medical Center wrapped up the year in the top 20 percent of each category, raking in an extra $848,000 for the year. The winner in community-acquired pneumonia was St. Francis Hospital at Broken Arrow, Tulsa, Okla., which took a purse of $12,209. Of the 17 common data sets between the pilot program hospitals and the others, the Premier hospitals are showing a statistically significant improvement in all but 3 measures. Hospitals not participating in the pilot program are grumbling at the comparison, but they are taking notice and making changes. Trimming time to treatmentAt 2 hospitals in the Los Angles area—Monterey Park Hospital and Community Hospital of Huntington Park, the time from when a community-acquired pneumonia patient entered the hospital to the initial administration of antibiotics was cut in half. “I think our timeline was about 8.5, maybe 9 hours for direct admit patients, which is astronomical,” said Englanoff, who is the director of emergency medicine for both facilities. “The emergency department was around 4.5, 5 hours, so together it came out to an average of about 7 hours.”Englanoff and staff implemented a pneumonia guideline order sheet, following the CMS core measures. Physicians were provided with a checklist that addressed every measure, so, Englanoff said, a physician would have very little to think about. “We cut our time down to under or around 180 minutes or less,” he boasted. “So I think our guidelines have worked very well.”At the Hospital of the University of Pennsylvania, chest x-rays are now given at triage to patients with pneumonia-like symptoms, and the hospital has initiated a new registration process to improve patient flow.But Datner and Englanoff both carefully pointed out that their hospitals are not adjusting strictly because of the CMS measures. “We want to improve patient flow for all of our patients and not prioritize less sick patients with pneumonia over potentially more sick patients,” Datner said. “That’s what CMS may be missing in this: by holding hospitals to this measure may be improving patient flow or flow to the emergency department or time to treatment to these patients, but it may undermine the efficiency of care provided for more ill patients.” At 2 hospitals in the Los Angles area—Monterey Park Hospital and Community Hospital of Huntington Park, the time from when a community-acquired pneumonia patient entered the hospital to the initial administration of antibiotics was cut in half. “I think our timeline was about 8.5, maybe 9 hours for direct admit patients, which is astronomical,” said Englanoff, who is the director of emergency medicine for both facilities. “The emergency department was around 4.5, 5 hours, so together it came out to an average of about 7 hours.” Englanoff and staff implemented a pneumonia guideline order sheet, following the CMS core measures. Physicians were provided with a checklist that addressed every measure, so, Englanoff said, a physician would have very little to think about. “We cut our time down to under or around 180 minutes or less,” he boasted. “So I think our guidelines have worked very well.” At the Hospital of the University of Pennsylvania, chest x-rays are now given at triage to patients with pneumonia-like symptoms, and the hospital has initiated a new registration process to improve patient flow. But Datner and Englanoff both carefully pointed out that their hospitals are not adjusting strictly because of the CMS measures. “We want to improve patient flow for all of our patients and not prioritize less sick patients with pneumonia over potentially more sick patients,” Datner said. “That’s what CMS may be missing in this: by holding hospitals to this measure may be improving patient flow or flow to the emergency department or time to treatment to these patients, but it may undermine the efficiency of care provided for more ill patients.” Acknowledgement of acuityFor inner-city hospitals such as the Hospital of the University of Pennsylvania that don’t have the resources and finances to keep up, pay for performance may only compound the frustrations.“This program is comparing facilities without any particular adjustments, and there are some pretty wide differences in emergency rooms, both in terms of number of patients and the intensity or acuity of patients,” said UCLA quality of care director Tod Barry.A Wall Street Journal article published in April exposed UCLA as being the worst of 3 Los Angeles hospitals in terms of administering antibiotics to patients within 4 hours of arrival; Cedar-Sinai Medical Center and St. John’s Hospital Health Center ranked first and second, respectfully.UCLA blanched at the bad press, and soon thereafter the hospital administration became close readers of the CMS guidelines.What they found was that at the time of the article, UCLA’s emergency department hadn’t been involved with the counting of who was eligible to be included as a community-acquired pneumonia patient.“We were counting a lot of patients who had pneumonia we didn’t have to count,” said Schriger.The hospital, he explained, was numbering all patients diagnosed with pneumonia at any point during their stay as eligible. Under the guidelines, patients who have no working diagnosis of pneumonia at the time of admission should not be counted.“We just changed the way we count because we were actually being too stringent on ourselves,” Schriger said. “We’re not gaming the system. The rules in fact tell us that’s what we’re supposed to do. Our numbers improved simply because we counted properly and not because we improved the quality of care in any way, although of course we’re trying to improve the quality, as well.” For inner-city hospitals such as the Hospital of the University of Pennsylvania that don’t have the resources and finances to keep up, pay for performance may only compound the frustrations. “This program is comparing facilities without any particular adjustments, and there are some pretty wide differences in emergency rooms, both in terms of number of patients and the intensity or acuity of patients,” said UCLA quality of care director Tod Barry. A Wall Street Journal article published in April exposed UCLA as being the worst of 3 Los Angeles hospitals in terms of administering antibiotics to patients within 4 hours of arrival; Cedar-Sinai Medical Center and St. John’s Hospital Health Center ranked first and second, respectfully. UCLA blanched at the bad press, and soon thereafter the hospital administration became close readers of the CMS guidelines. What they found was that at the time of the article, UCLA’s emergency department hadn’t been involved with the counting of who was eligible to be included as a community-acquired pneumonia patient. “We were counting a lot of patients who had pneumonia we didn’t have to count,” said Schriger. The hospital, he explained, was numbering all patients diagnosed with pneumonia at any point during their stay as eligible. Under the guidelines, patients who have no working diagnosis of pneumonia at the time of admission should not be counted. “We just changed the way we count because we were actually being too stringent on ourselves,” Schriger said. “We’re not gaming the system. The rules in fact tell us that’s what we’re supposed to do. Our numbers improved simply because we counted properly and not because we improved the quality of care in any way, although of course we’re trying to improve the quality, as well.” Piles of paperworkDatner has found the paperwork that comes with meeting CMS’s core measures a burden. “We spend so much time charting now because there are these ridiculous charting requirements,” Datner said. “But if you don’t spend all of this time charting, which is totally a time-sink and not linked to the quality of care for patients, then you don’t get reimbursed. You’re spending more time doctoring the chart then you actually are at the bedside of the patient. It’s distressing.”It’s too early for any concrete evidence on how the CMS core measures may affect hospitals in the future, but it’s easy to speculate that if there are a number of patients in the waiting room approaching the 4-hour mark that those with pneumonia-like symptoms could receive preferential treatment. Or if a physician has been criticized a couple of times for missing the antibiotic deadline, she or he may be more likely to send a patient home who would otherwise be admitted. Patients don’t “count” if they are not admitted. Datner has found the paperwork that comes with meeting CMS’s core measures a burden. “We spend so much time charting now because there are these ridiculous charting requirements,” Datner said. “But if you don’t spend all of this time charting, which is totally a time-sink and not linked to the quality of care for patients, then you don’t get reimbursed. You’re spending more time doctoring the chart then you actually are at the bedside of the patient. It’s distressing.” It’s too early for any concrete evidence on how the CMS core measures may affect hospitals in the future, but it’s easy to speculate that if there are a number of patients in the waiting room approaching the 4-hour mark that those with pneumonia-like symptoms could receive preferential treatment. Or if a physician has been criticized a couple of times for missing the antibiotic deadline, she or he may be more likely to send a patient home who would otherwise be admitted. Patients don’t “count” if they are not admitted. An honest attemptBarry believes CMS is trying to do the right thing with the best available evidence. However, the core measures address the process of medical care, not the gold standard of patient outcomes, but that kind of data is hard to come by.“I think that ultimately this is good for the quality of care,” he said. “Getting valid, comparable information to the public is (important)…. They don’t address the most important measures, which would be outcome, but those are more difficult to get at, so the government has started out, probably smartly, by looking at process measures…. They reflect care for the typical patient coming in the door…. Yes, all patients that have pneumonia as the principal diagnosis and don’t have certain exclusions should receive antibiotics in a timely fashion. The 4 hour piece, I’m not sure how much literature is out there specifically if they got it in 4 hours versus 5 hours, but it’s a reasonable standard.”Remus admits that the record review burden is daunting and the core measures are far from perfect benchmarks.“Maybe we should have another system measure,” she said. “Maybe we should have hospitals look at why aren’t you getting that antibiotic to the patient within 4 hours. If they later on have a pneumonia diagnosis, what was the barrier to that? These are all lessons that we’re learning.” Barry believes CMS is trying to do the right thing with the best available evidence. However, the core measures address the process of medical care, not the gold standard of patient outcomes, but that kind of data is hard to come by. “I think that ultimately this is good for the quality of care,” he said. “Getting valid, comparable information to the public is (important)…. They don’t address the most important measures, which would be outcome, but those are more difficult to get at, so the government has started out, probably smartly, by looking at process measures…. They reflect care for the typical patient coming in the door…. Yes, all patients that have pneumonia as the principal diagnosis and don’t have certain exclusions should receive antibiotics in a timely fashion. The 4 hour piece, I’m not sure how much literature is out there specifically if they got it in 4 hours versus 5 hours, but it’s a reasonable standard.” Remus admits that the record review burden is daunting and the core measures are far from perfect benchmarks. “Maybe we should have another system measure,” she said. “Maybe we should have hospitals look at why aren’t you getting that antibiotic to the patient within 4 hours. If they later on have a pneumonia diagnosis, what was the barrier to that? These are all lessons that we’re learning.”