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Inappropriate diagnosis of community-acquired pneumonia (CAP) in hospitalized medical patients; Abbreviated form: Inappropriate diagnosis of CAP

CBE ID
3671
1.5 Project
Endorsement Status
1.0 New or Maintenance
1.1 Measure Structure
Previous Endorsement Cycle
Is Under Review
No
Next Maintenance Cycle
Spring 2026
1.6 Measure Description

The inappropriate diagnosis of CAP in hospitalized medical patients (or “Inappropriate Diagnosis of CAP”) measure is a process measure that evaluates the annual proportion of hospitalized adult medical patients treated for CAP who do not meet diagnostic criteria for pneumonia (thus are inappropriately diagnosed and treated).

    Measure Specs
      General Information
      1.7 Measure Type
      1.3 Electronic Clinical Quality Measure (eCQM)
      1.8 Level of Analysis
      1.9 Care Setting
      1.14 Numerator

      The outcome of this measure is the dichotomous answer of whether a patients was “over-diagnosed” with pneumonia or not. The numerator will consist of all patients “over-diagnosed” with pneumonia in the reporting quarter.

       

      Over-diagnosis is defined as patients treated for pneumonia who either do not have at least 2 signs/symptoms of pneumonia or who have radiographs inconsistent with pneumonia.

       

      Our measure is calculated quarterly (from 3 months of data) based on ~40 cases per hospital per quarter. Additional details are provided in S.5 Numerator Details

      1.15 Denominator

      The denominator includes all adult, general care, immunocompetent, medical patients hospitalized and treated for CAP who do not have a concomitant infection.

      Exclusions

      Patients are excluded from the denominator if they are/have: 

      • Left against medical advice or refused medical care
      • Admitted on hospice
      • Pregnant or breastfeeding
      • Cystic fibrosis
      • Pneumonia-related complication (e.g., empyema)
      Most Recent Endorsement Activity
      Endorsed Patient Safety Spring Cycle 2022
      Initial Endorsement
      Last Updated
      Steward Organization
      University of Michigan
      Steward POC email
      Steward Organization Copyright

      N/A

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