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The Unintended, Negative Consequences of the Door-to-Antibiotic Measure for Pneumonia
- Robert M. Wachter, MD;
- Christopher Fee, MD; and
- Scott A. Flanders, MD
- From University of California, San Francisco, San Francisco, CA 94143, and University of Michigan, Ann Arbor, MI 48109.
IN RESPONSE:
We appreciate the letters, which endorse our main premise while adding new data and insights. Although we agree with most of the authors' points, we worry that the experience of a flawed measure, such as door-to-antibiotics for pneumonia, will lead some to throw out the baby (quality measurement and transparency) with the bathwater (the bad measure).
For example, Dr. Dean argues that the imposition of a national standard for pneumonia care undermined his organization's homegrown pneumonia strategy. We agree that national guidelines should provide enough flexibility to allow for individual institutional choice based on local factors, such as cost, resistance, and ease of administration, as long as the choices are compatible with the best evidence. In fact, Intermountain's preferred antibiotics were on the list of recommended antibiotics.
That said, we are concerned about the generalizability of Dr. Dean's example. Intermountain Healthcare is a large, highly evolved system with a strong infrastructure, including world-class information technology (1). Most institutions around the country don't look like that. Substantial evidence supports the value of widespread adherence to evidence-based standards (2, 3). We believe it would be a mistake to eschew thoughtful, evidence-based national guidelines because some organizations with the capacity to develop and study local guidelines might need to subsume their work to these national standards. Organizations with such capacity should become learning laboratories, testing existing guidelines and standards for effectiveness and engaging in the process of developing future evidence-based national guidelines.
Dr. Gogol states that he was skeptical of the value of the door-to-antibiotic measure because antibiotic timing had no impact on outcomes in his hospital's 44 patients with pneumonia. Here, too, individual institutions may not be able to generate the statistical power to identify even significant effects of practice changes. That should not be cause to shun national measures. But it is yet another reason to be sure that national standards are based on strong evidence, have been field-tested, and are reviewed frequently for unintended consequences.
Luckily, in part because of the door-to-antibiotic experience, both the National Quality Forum and the CMS have begun to change their processes to ensure that future measures are less likely to lead to unintended negative consequences (4). This is particularly important because, as Dr. Srouji correctly observes, there is no question that the public reporting of quality measures does have the intended effect: to change clinical practice, for better or worse.
Robert M. Wachter, MD
Christopher Fee, MD
University of California, San Francisco
San Francisco, CA 94143
Article and Author Information
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Potential Financial Conflicts of Interest: None disclosed.
