Hospital‐reported Data on the Pneumonia Quality Measure “Time to First Antibiotic Dose” Are Not Associated With Inpatient Mortality: Results of a Nationwide Cross‐sectional Analysis

Abstract

Objectives Significant controversy exists regarding the Centers for Medicare & Medicaid Services (CMS) “time to first antibiotics dose” (TFAD) quality measure. The objective of this study was to determine whether hospital performance on the TFAD measure for patients admitted from the emergency department (ED) for pneumonia is associated with decreased mortality. Methods This was a cross-sectional analysis of 95,704 adult ED admissions with a principal diagnosis of pneumonia from 530 hospitals in the 2007 Nationwide Inpatient Sample. The sample was merged with 2007 CMS Hospital Compare data, and hospitals were categorized into TFAD performance quartiles. Univariate association of TFAD performance with inpatient mortality was evaluated by chi-square test. A population-averaged logistic regression model was created with an exchangeable working correlation matrix of inpatient mortality adjusted for age, sex, co-morbid conditions, weekend admission, payer status, income level, hospital size, hospital location, teaching status, and TFAD performance. Results Patients had a mean age of 69.3 years. In the adjusted analysis, increasing age was associated with increased mortality with ORs > 2.3. Unadjusted inpatient mortality was 4.1% (95% confidence interval [CI] = 3.9% to 4.2%). Median time to death was five days (25-75th interquartile range [IQR]: 2-11). Mean TFAD quality performance was 77.7% across all hospitals (95% CI = 77.6% to 77.8%). The risk adjusted odds ratio (OR) of mortality was 0.89 (95% CI = 0.77 to 1.02) in the highest performing TFAD quartile, compared to the lowest performing TFAD quartile. The second highest performing quartile OR was 0.94 (95% CI = 0.82 to 1.08), and third highest performing quartile was 0.91 (95% CI = 0.79 to 1.05). Conclusions In this nationwide heterogeneous 2007 sample, there was no association between the publicly reported TFAD quality measure performance and pneumonia inpatient mortality.

The role of antimicrobials in the treatment of sepsis and critical illness‐related bacterial infections: Examination of the evidence

“…This has led some experts to propose using time to first antimicrobial administration more as a surrogate marker or measure of the quality of medical practice rather than a prognostic marker of patient survival. Administering early antimicrobial therapy is of equal importance as diagnosing sepsis and implementing hemodynamic support and monitoring, but may not have as large as an effect on outcome as originally thought …”

Association Between Weekend and Holiday Admission with Pneumonia and Mortality in a Tertiary Center in Portugal: A Cross-Sectional Study

“…In a cross-sectional analysis of 95 704 emergency department admissions in the United States with pneumonia, weekend admissions were not associated with increased mortality. 11 Schmulewitz L et al assessed 3244 hospital admissions to the Royal Infirmary of Edinburgh including patients with pneumonia, chronic obstructive pulmonary disease, cerebrovascular accidents, pulmonary embolism, collapse and upper gastrointestinal bleed. 13 The authors concluded that the mortality rate was significantly lower for patients admitted with pneumonia during the weekend (OR 0.50; p = 0.015).…”

“…Although we considered several widely-accepted surrogates of severity such as the need for ICU treatment, development of sepsis and organ failure, we did not stratify patients according with a severity score such as the CURB-65 or the pneumonia severity index. 10,11 While most studies have used these scores as markers of severity, grouping patients according with the need for intensive care management and development of sepsis and organ failure may better assess mortality in critical care patients. 22 It is true that organ failure and sepsis were defined according with ICD-9 diagnosis and procedure codes rather than by laboratory data or physician documentation.…”

“…7,8 Studies exploring the existence of a weekend effect in acute pneumonia have shown mixed results. [9][10][11][12][13] In this study, we sought to evaluate the impact of weekend and holiday admissions on the outcomes of acute bacterial pneumonia using a large cohort of patients from a major tertiary center. To our knowledge, this will be the first study evaluating the weekend effect in Portuguese patients with acute pneumonia.…”

Time to first antibiotic and mortality in adults hospitalised with community-acquired pneumonia: a matched-propensity analysis

“…However, the studies cited in support of these recommendations have been variously criticised for their restrictions on included age groups, lack of adjustment for disease severity, small sample sizes and single-centre designs. Other studies have also failed to show a mortality benefit from early administration of antibiotics in adults hospitalised with CAP 3 4…”