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The 4-Hour Rule for CAP Antibiotic Administration Backfires

In one study, it was the patients without pneumonia who got (unnecessary) antibiotics more quickly.

Recent guidelines for management of community-acquired pneumonia (CAP) call for administering antibiotics within 4 hours of presentation to the emergency department. This standard has become a "quality indicator" for some insurance payers, even though studies disagree on the strength of clinical evidence supporting the policy (Journal Watch Aug 29 2006).

Researchers reviewed CAP admissions to a single Michigan teaching hospital over a 6-month period in 2003 (before the 4-hour guidelines were published), and a similar period in 2005 (a year after publication). Of 518 patients, significantly more received antibiotics within 4 hours in 2005 than in 2003 (66% vs. 54%). However, significantly more also left the hospital with a diagnosis other than CAP (41% vs. 24%), most of which were noninfectious cardiac and pulmonary conditions. Among the patients who did prove to have CAP, the mean time to antibiotic administration was similar in 2003 and 2005; among the patients who did not have CAP, antibiotic administration was significantly accelerated in 2005. In-hospital mortality was similar during the two periods.

Comment: This study suggests that when a patient clearly has pneumonia, the 4-hour mandate may not have that much influence on the timeliness of antibiotic administration. It may, however, cause patients with uncertain diagnoses to receive antibiotics in short order, resulting in a considerable increase in unnecessary antibiotic use. This conclusion is intuitively logical, but more data must be assembled to sort out the overall costs and benefits more clearly.

— Abigail Zuger, MD

THE JW EMERGENCY MEDICINE PERSPECTIVE

This study’s findings provide a classic demonstration of the "law of unintended consequences." These authors found an astounding increase in misdiagnosis and inappropriate antibiotic use in ED patients without clear radiographic evidence of CAP. When payment and the definition of "quality" are linked to an unproven benchmark, even the most well-intentioned physician will stumble. The real question should be: Does it work? CAP patients 65 and older and those in septic shock seem to benefit from antibiotic administration within 4 hours, but in other patient groups the data are tenuous at best. In April 2007, after revisiting the CAP measures, the National Quality Forum (NQF) extended the time interval for antibiotic administration to 6 hours and clarified that the measures apply to cases of pneumonia that are diagnosed in the ED (see JAMA 2007; 297:1758). Although the NQF’s responsive softening of the "rule" is a step in the right direction, our patients, and we, deserve a more deliberate and scientific approach to "quality" definitions. Implementing a standard that actually worsens care is a quality misstep of gargantuan proportion. As you read this, the NQF and the Centers for Medicare and Medicaid Services are rolling out additional, unvalidated "quality" measures for individual emergency physicians, with little regard for the data collection burden and the lack of proven outcome benefit. Is there an end in sight for the "ready-fire-aim" approach to national "quality" standards?

— Tiffany M. Osborn, MD

Published in Journal Watch Emergency Medicine July 13, 2007

Citation(s):

Kanwar M et al. Misdiagnosis of community-acquired pneumonia and inappropriate utilization of antibiotics: Side effects of the 4-h antibiotic administration rule. Chest 2007 Jun; 131:1865-9.

• Medline abstract (Free)