Qualidigm - Appropriate Care Measures

Appropriate Care Measure (ACM)

Project Overview
What's New
Tools & Resources
FAQs
Our Partners
Project Team
Events

Project Overview

The ACM is a composite of the ten publicly reported quality measures (five acute myocardial infarction (AMI), two heart failure and three pneumonia). These measures are combined at the patient level into one rate that provides a more accurate description of how a hospital cares for patients with AMI, heart failure and pneumonia.

Participating Hospital Goals - Qualidigm works intensively with seven hospitals to:

Improve care for patients with diagnoses of:

Qualidigm’s Approach

Qualidigm works with these hospitals to use best practices in closing the gap that exists between actual care provided to the patient and evidence-based patient care by:

Partnership Building

Working with hospital leaders, federal and state agencies and industry associations to create partnerships that expand our collective knowledge and resources to promote quality improvement.

Performance Feedback

Assisting hospitals with their submission of performance data to CMS on the ACM measures.
Providing hospital-specific quarterly data reports with state and national comparisons.
Conducting presentations related to the ACM project for the Connecticut Hospital Association and its membership.

Quality Improvement Training and Support

Sharing effective quality improvement strategies, expertise and educational materials via face-to-face meetings, conference calls and electronic communication.
Conducting onsite consultation and providing individualized quality improvement support.

Marketing and Communications

Recognizing outstanding quality improvement efforts through the Qualidigm Quality Awards program.
Preparing customizable press releases for local media use that highlight and describe the hospital's quality improvement efforts.

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What's New

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Tools & Resources

MedQIC is a website where health care professionals can find and share quality improvement resources and browse through recommended interventions developed by colleagues and experts in their field. MedQIC offers tools, articles and links to resources about how to transform organizational culture, adopt health information technology, redesign care processes, and measure and report performance.
QualityNet Quest - QualityNet Quest is the online questions and answers database for MedQIC. QualityNet Quest provides centralized and standardized management of questions and answers submitted by individuals in the health care quality improvement and patient safety professions.

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FAQs

What is the ACM?
Why is it important to aggregate individual measures?
How often is a participating hospital required to submit performance data?
What are my responsibilities as a participating hospital?
How can the delivery of antibiotics to patients presenting to the hospital with community-acquired pneumonia be expedited in an institution where many antibiotics require approval from the infectious diseases (ID) physician before they can be administered?
Is there evidence to support the need to obtain blood cultures in all patients admitted with community-acquired pneumonia (CAP)?
Should all hospitalized patients 65 and older who have not been vaccinated receive pneumococcal and influenza vaccine during their hospital admission?
Is there evidence to support the requirement that patients with community-acquired pneumonia (CAP) receive an initial antibiotic dose within four hours of hospital arrival?

What is the ACM?
The ACM is an aggregate measure that indicates whether or not a hospitalized patient with a diagnosis of AMI, heart failure or pneumonia received all the care s/he was eligible to receive based on the 10 publicly reported measures (five for AMI, two for heart failure and three for pneumonia). These measures are often referred to as the core measures, and all of them are completely aligned with the measures required by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). At this time there are no plans to publicly report a hospital’s ACM; however, each of the 10 individual measures is publicly reported.

Why is it important to aggregate individual measures?
An aggregated measure provides hospitals with an overall measure of quality and helps create a more accurate assessment of how a hospital cares for its patients. An appropriate measure also promotes informed choice by providing consumers with hospital quality data in an easy to understand format.

How often is a participating hospital required to submit performance data?
A participating hospital is required to submit performance data on the 10 publicly reported measures on a quarterly basis.

What are my responsibilities as a participating hospital?
A participating hospital will be asked to:

Form a dedicated team for planning and implementing ACM and other quality improvement activities.
Develop an overall action plan and timeline.
Actively participate in all related workgroup events.
Share progress, barriers and successes during group meetings, WebEx sessions and conference calls.
Secure senior leadership commitment and support.

How can the delivery of antibiotics to patients presenting to the hospital with community-acquired pneumonia be expedited in an institution where many antibiotics require approval from the infectious diseases (ID) physician before they can be administered?

The requirement for approval from the infectious diseases service before administering a dose of antibiotics to a patient will often result in a delay in antibiotic treatment. While, in theory, approval can be obtained in a few minutes, in actuality this process often delays antibiotic treatment enough that antibiotics are not administered within the four-hour window. Delays often occur because the ID physician may not be immediately available or the Emergency Department (ED) physician may be with another patient when the ED physician returns the page. In addition, independent of the antibiotic timing issue, the need to page the ID physician, and interrupt workflow to have the discussion creates increased work for the already busy ED staff. Finally, in many institutions where ID approval is needed for the use of certain antibiotics, the antibiotics are stored in the pharmacy so that control can be maintained. Thus, the time needed to transport the antibiotic to the ED creates an additional delay.

There are several possible systems solutions to this problem that can remove the delay associated with obtaining antibiotic approval, yet maintain the integrity of an antibiotic approval system:

Allow the ED physician to give one dose of a “restricted” antibiotic to a patient in the ED without approval, but require that any further doses receive ID approval. In practice, most of the antibiotics used for community-acquired pneumonia are given once a day, so this provides 24 hours before approval is needed. (It also avoids the need for a 2 AM call to the ID physician for antibiotic approval, so it is a win-win for all involved.)
Remove the antibiotics most commonly used for community-acquired pneumonia from the list of restricted antibiotic list (for the hospital as a whole or just the ED). For most hospitals across the country, the majority of patients are treated with one or two of the following three antibiotics. 1. An anti-pneumococcal third-generation cephalosporin such as Ceftriaxone or Cefotaxime, 2. An advanced generation Quinolone such as Levofloxacin or Moxifloxicin 3. Azithromycin. While some patients will require alternative antibiotics due to allergies or risk factors for unusual organisms such as Pseudomonas or MRSA, the above antibiotics are appropriate therapy for a very high percentage of patients with community-acquired pneumonia.
Remove just one of the above antibiotics from the restricted list so that it can be used in the ED for all patients with community-acquired pneumonia for whom it is appropriate. While some patients will need an additional antibiotic within 24 hours to adhere to quidelines, it should be remembered that the timing measure allows ANY antibiotic to be given within four hours. The measure regarding appropriate antibiotic choices considers all antibiotics administered within the first 24 hours after admission. Thus a patient who receives only Ceftriaxone at three hours and then a dose of Azithromycin at 18 hours will “pass” both the antibiotic timing and the appropriate antibiotic regimen measures.
Independent of the issue of whether or not antibiotics are restricted, significant delays in antibiotic therapy can occur when there is a need to transport antibiotics to the ED. This can be prevented by storing doses of antibiotics in the ED. Even in the setting of a restricted antibiotic policy, compliance can be assured via retrospective review to ensure that there is not abuse.

Is there evidence to support the need to obtain blood cultures in all patients admitted with community-acquired pneumonia (CAP)?

Expert opinion has long been that all patients admitted to the hospital with community-acquired pneumonia (CAP) should have two sets of blood cultures (BCs) performed. The logic was that this would allow definitive identification of the pathogen in 5-10% of patients and a higher percentage of the more severely ill patients. There are no randomized controlled data to support these practice results in improved outcomes. One observational study has demonstrated approximately 10% lower adjusted 30-day mortality among Medicare patients admitted to the hospital with CAP who did have BCs performed relative to those who did not. However, it is unlikely that this was a causal relationship, as less than 10% of Medicare patients are bacteremic and there is no logical explanation for why the performance of BCs could have any benefit for a patient who is not bacteremic.

Many investigators have questioned the need to obtain BCs from all patients hospitalized with pneumonia.^1-6 The cost associated with this low-yield test is commonly sited. Others have noted the low yield of BC’s, but, nonetheless, recommended them for all patients hospitalized with pneumonia.^7,8 Chalasani et al noted that 4.8% of pneumonia patients had contaminated BCs, similar to the rate at which a pathogen was identified.² Metersky⁹ et al found that there were almost as many false positive (contaminated) BCs as true positive BCs among Medicare patients admitted to the hospital with pneumonia and that a false positive BC was associated in a one day increased length of stay and almost a three times greater rate of Vancomycin use compared to patients with negative BCs. They, therefore, recommended that BCs be preferentially obtained from higher-risk patients. Metersky⁹ et al also demonstrated that BCs drawn after the administration of antibiotics had only a 50% positive rate compared to blood cultures obtained prior to antibiotic dosing.

Based on these concerns and the strongly suggestive evidence of negative consequences associated with routine BC performance, the soon-to-be released joint ATS-IDSA guidelines will not recommend that blood cultures be routinely obtained from all patients admitted to the hospital with CAP. Rather, they will suggest that BCs be obtained from all patients being admitted to the ICU as well as patients with other characteristics that suggest an increased likelihood of bacteremia. They also stress that it is never bad practice to obtain blood cultures on any individual patient. Similarly, the CMS Pneumonia Technical Advisory Panel, has changed the Pneumonia Performance Measures as follows:

The rate of performance of BCs within 24 hours in patients with CAP who are admitted to the ICU during the first 24 hours of hospital stay.
IF blood cultures are obtained, the percentage of BCs obtained prior to antibiotics will also be measured.

References

Campbell SG, Marrie TJ, Anstey R, Dickinson G, Ackroyd-Stolarz S. The contribution of blood cultures to the clinical management of adult patients admitted to the hospital with community-acquired pneumonia: A prospective observational study. Chest 2003;123:1142-1150.
Chalasani NP, Valdecanas MA, Gopal AK, McGowan JE, Jr., Jurado RL. Clinical utility of blood cultures in adult patients with community-acquired pneumonia without defined underlying risks. Chest 1995;108:932-936.
Levy M, Dromer F, Brion N, Leturdu F, Carbon C. Community-acquired pneumonia: Importance of initial noninvasive bacteriologic and radiographic investigations. Chest 1988;92:43-48.
Waterer GW, Jennings SG, Wunderink RG. The impact of blood cultures on antibiotic therapy in pneumococcal pneumonia. Chest 1999;116:1278-1281.
Theerthakarai R, El-Halees W, Ismail M, et. al. Nonvalue of the initial microbiological studies in the management of non-severe community-acquired pneumonia. Chest 2001;119:181-184.
Waterer GW, Wunderink RG. The influence of the severity of community-acquired pneumonia on the usefulness of blood cultures. Respir Med 2001;95:78-82.
Woodhead MA, Arrowsmith J, Chamberlain-Webber R, Wooding S, Williams I. The value of routine microbial investigation in community-acquired pneumonia. Respir Med 1991;85:313-317.
Ewig S, Bauer T, Hasper E, Marklein G, Kubini R, Luderitz B. Value of routine microbial investigation in community-acquired pneumonia treated in a tertiary care center. Respiration 1996;63:164-169.
Metersky ML, Ma A, Bratzler DW, Houck PM. Predicting bacteremia in patients with community-acquired pneumonia. Am J Resp Crit Care Med, 2004; 169:342-347.

Should all hospitalized patients 65 and older who have not been vaccinated receive pneumococcal and influenza vaccine during their hospital admission?

While it would seem that the best place for patients to receive these vaccines would be their primary care physician’s office, many patients are admitted to the hospital who have not received these vaccinations. Some patients do not see a physician regularly. Others may see a physician who does not make vaccination a priority. Thus, only 66% of Americans age 65 or above have received an influenza vaccination in 2005, and the same percentage ever received the pneumococcal vaccine.¹ We also know that many, if not most, patients who are admitted to the hospital have chronic illnesses that render them high risk for subsequently developing pneumonia. Studies have demonstrated that approximately 60% of patients admitted to the hospital with pneumonia had been admitted to the hospital during the preceding four years.² Thus, attempting to vaccinate patients admitted to the hospital targets a high risk population.

Some physicians have expressed concerns that patients who are hospitalized may not be able to mount an adequate antibody response to vaccination, rendering the vaccination ineffective. Clearly, acute severe illness can impair humoral immunity in some patients. There are no outcome data to either support or refute this being relevant to the average hospitalized patient. However, a prospective, controlled trial demonstrated that hospitalized patients and control outpatients had equivalent rates of seroconversion and seroprotection after receiving influenza vaccine. ³ Unfortunately, similar data is lacking for the pneumococcal vaccine, but there is no reason to predict that results would differ for this vaccine.

Other issues:

Standing orders (Nurses providing vaccination based on a protocol assessing indications and contradindications.) This is allowable by Connecticut statute.

Consent

Written consent is not required, although it is often obtained.⁴ (Think about the much more risky therapies we administer routinely without written consent. Some of these include anticoagulation, intravenous contrast and narcotics, all of which entail much greater risk than influenza and pneumococcal vaccination.)

References

Influenza and pneumococcal vaccination coverage among persons aged ≥65 years--United States, 2004-2005 Lindley MC, Euler L, Shimabukuro T. Morbidity and Mortality Weekly Report. Oct 6, 2006 v55 i39 p1065.
Fedson DS, Houck P, Bratzler DW. Hospital-based influenza and pneumococcal vaccination: Sutton’s law applied to prevention. Infect Control Hosp Epidemiol. 2000;21:692-699.
Berry B, Ehlert DA, Battiola RJ, Sedmak G. Influenza vaccine is safe and immunogenic when administered to hospitalized patients. Vaccine 2001;19:3493-98.
Kissam S. Gifford DR. Patry G. BratzlerDW. Is signedconsent for influenza or pneumococcal polysaccharide vaccination required?Archof Intern Med 2004;164:13-6.

Is there evidence to support the requirement that patients with community-acquired pneumonia (CAP) receive an initial antibiotic dose within four hours of hospital arrival?

The case for timely antibiotic delivery for patients with pneumonia began to be made in 1992 with a study by Torres et al, ¹ showing that delayed appropriate antibiotics for patients with severe community-acquired pneumonia (CAP) was associated with a higher mortality rate. In 1997, Meehan et al ² demonstrated lower 30-day adjusted mortality among Medicare patients admitted to the hospital with pneumonia who received antibiotics within eight hours after presentation compared to those who did not. In a similar study, ³ with a larger database, the finding of improved mortality with earlier antibiotics was seen at four hours, supporting the four-hour threshold.

While few argue against the logic of providing antibiotics as soon as feasible for patients with a potentially life-threatening infection such as pneumonia, several concerns have been raised about the appropriateness of aiming for 100% of patients to receive antibiotics within four hours. These concerns include the fact that there are no prospective randomized studies in support of timely antibiotics. All three of the studies quoted above are retrospective cohort studies. Therefore, it has been suggested that the apparent improved outcomes associated with rapid antibiotics could be due to confounding factors. For example, patients who present with altered mental status are at higher risk of mortality but may receive antibiotics later merely because the diagnosis of pneumonia is more difficult to make in these patients.⁴ Given the relatively low quality of the evidence in support of antibiotic delivery within four hours, any unintended negative consequences of aiming for rapid antibiotic delivery may assume greater importance if we can not be assured that there is significant benefit. Unfortunately, several potential negative consequences have been suggested, although generally these have been anecdotal.⁵ A recent study suggested that in approximately 20-25% of Medicare patients with pneumonia, due to atypical presentations, the diagnosis is unlikely to be made within four hours.⁵ Thus, in order to achieve 100% performance, physicians may be compelled to give antibiotics before a firm diagnosis can be established. Inappropriate antibiotic use could induce increases in antibiotic resistance, antibiotic-related adverse events and may decrease the yield of subsequently required diagnostic test. Another commonly voiced concern is that the increased focus on patients with pneumonia may delay care given to other acutely ill patients.

In large part based on these concerns, the soon-to-be published joint ATS-IDSA community-acquired pneumonia guidelines will not recommend antibiotic delivery within a specific number of hours but will suggest antibiotic delivery in the Emergency Department (ED) as soon as feasible. Knowing this, the CMS Technical Expert Panel (which makes recommendations to CMS regarding the pneumonia performance measures) had extensive discussions regarding the antibiotic timing measure. One suggestion was to revise the measure to assess the percentage of patients who received antibiotics in the ED. However, there was concern that in these days of crowded EDs and hospitals, when a patient may stay in the ED for 12-24 hours, this would not be a true measure of high quality care. A compromise was reached, specifying the performance measure for antibiotic timing as the percentage of patients who receive antibiotics within six hours (effective April 1, 2007). While it is clearly understood that there are no data to support six hours as opposed to four versus eight hours, it was felt that six hours represented a reasonable attempt to balance the desire for timely antibiotic delivery with the concern about unintended consequences of striving for 100% antibiotic delivery within four hours.

It is important to note that the National Quality Forum (NQF) tabled discussion of the antibiotic timing measure in October due to lack of consensus (in large part because of knowledge that the upcoming ATS-IDSA CAP guideline did not specify a specific antibiotic timing), so it is not clear if ANY timing measure will be endorsed by NQF. If no timing measure is endorsed by NQF, antibiotic timing may disappear as a CMS measure.

References

Torres, A. Serra-Batlles, J. Ferrer, A. Jimenez, P. Celis, R. Cobo, E. Rodriguez-Roisin, R. Severe community-acquired pneumonia. Epidemiology and prognostic factors. Am Rev Respir Dis 1991 144:312-8.
Meehan TP, Fine MJ, Krumholz HM, et al. Quality of care, process, and outcomes in elderly patients with pneumonia. JAMA 1997; 278:2080-2084.
Houck PM, Bratzler DW, Nsa W, Ma A, Bartlett JG. Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community-acquired pneumonia.
Arch Intern Med 2004;164:637-44.
Waterer GW. Kessler LA. Wunderink RG. Delayed administration of antibiotics and atypical presentation in community-acquired pneumonia.Chest 2006; 130:11-15.
Metersky ML, Sweeney TA, Getzow BM, Siddiqui F, Nsa W, Bratzler DW. Antibiotic timing and diagnostic uncertainty in Medicare patients with pneumonia: is it reasonable to expect all patients to receive antibiotics within 4 hours? Chest 2006; 130:16-21