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Inappropriately Broad Empiric Antibiotic Selection for Adult Hospitalized Patients with Uncomplicated Community-Acquired Pneumonia

CBE ID
4545e
Endorsement Status
E&M Committee Rationale/Justification

When the measure returns for maintenance (3 years), the measure developer should have:

  • Continued to explore the exclusion list to determine if changes are needed (e.g., empirical analyses with broader testing across entities) and to further clarify the conditions and justify them based on burden; and
  • Conducted additional validity testing (data element in additional EHR).
1.0 New or Maintenance
1.1 Measure Structure
Previous Endorsement Cycle
Is Under Review
No
Next Maintenance Cycle
Fall 2027
1.6 Measure Description

The Inappropriately Broad Empiric Antibiotic Selection for Adult Hospitalized Patients with Uncomplicated Pneumonia measure is a process measure representing the annual percentage of hospitalized adults with uncomplicated community-acquired pneumonia. Here, we defined “inappropriately broad” as any antibiotic therapy targeting methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa in patients without risk factors for one of those organisms. The measure will be calculated using electronic health record (EHR) data and is intended for use at the facility level for both quality improvement and pay-for-performance.

Measure Specs
General Information
1.7 Measure Type
1.7 Composite Measure
No
1.3 Electronic Clinical Quality Measure (eCQM)
1.8 Level of Analysis
1.10 Measure Rationale

The overall objective of this electronic clinical quality measure is to quantify inappropriately broad empiric antibiotic use in hospitalized adults with uncomplicated community-acquired pneumonia (CAP). Here, we defined “inappropriately broad” as any antibiotic therapy targeting methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa in patients without risk factors for one of those organisms.

 

Antibiotic overuse is a national and international public health emergency with antibiotic resistant infections estimated to directly cause 1.27 million deaths globally and indirectly contribute to 4.95 million deaths.1 National studies by the Centers for Disease Control and Prevention (CDC) estimate that up to 50% of hospitalized patients receive antibiotic therapy, most commonly for pneumonia, and that up to 40% of antibiotic prescribing could be improved.2 

 

Pneumonia is not only the most common reason for inpatient antibiotic use but also the most common infectious cause of mortality in the US resulting in approximately 1.4 million emergency department visits, 740 000 hospitalizations, 41 000 deaths, and $7.7 billion in inpatient costs each year in the US.3-6 Adverse consequences of unnecessarily broad empiric therapy include an increased adjusted risk of death, kidney injury, and serious secondary infections.7-9 

 

How will this measure improve quality of care? By establishing a standardized process to assess inappropriately broad empiric antibiotic use for CAP, a larger proportion of patients will potentially receive appropriate care consistent with the 2019 American Thoracic Society/Infectious Disease Society of America (ATS/IDSA) CAP national guidelines.10 Appropriateness of antibiotic therapy for pneumonia is a priority for numerous federal and accreditation organizations–including CDC, The Joint Commission, and Centers for Medicare and Medicaid Services–and is not currently captured in typical quality improvement measures. For example, the National Healthcare Safety Network (NHSN) antimicrobial use (AU) measures focus on quantifying antibiotic use and comparing to expected values, with no assessment of appropriateness of empiric therapy. Notably, the NHSN AU initiative could be augmented with an eCQM to assess appropriateness of empiric antibiotics for CAP, the most common indication for inpatient antibiotic use.

 

What are the benefits or improvements in quality envisioned by this measure? Inappropriately broad empiric therapy for CAP is common. A recent report on 8,286 non-intensive care unit (ICU) hospitalized CAP patients from 67 Michigan hospitals (assessed using the chart review measure from which our eCQM was adapted) showed that 2,215 (26.7%) received inappropriately broad empiric treatment (i.e., anti-MRSA or anti-Pseudomonal coverage in patients eligible for standard CAP coverage per ATS/IDSA guidelines).11 Compared to patients who received standard CAP antibiotic treatment, patients receiving inappropriately broad antibiotics had higher 30-day readmissions, more transfers to ICU and antibiotic-associated adverse events, and longer hospitalizations.11 Similarly, a retrospective analysis of 88,605 patients with CAP across the Veterans Health Administration health care system found that adding empirical anti-MRSA therapy to standard CAP therapy) was associated with an increased adjusted risk of death, kidney injury, and secondary infections (C. difficile, vancomycin-resistant Enterococcus infection, and resistant gram-negative rod infections).8 Given that up to 90% of empiric anti-MRSA or anti-Pseudomonal antibiotic therapy is non-guideline concordant,8,11 there is substantial potential benefit to patients and the US by reducing inappropriately broad empiric antibiotic selection. National surveillance of drug-related adverse events estimated that even a small reduction in unnecessary antibiotic use could significantly decrease the direct risks of drug-related adverse event in individual patients.12 Thus, our guideline-based measure has the potential to improve patient care for a large number of patients hospitalized with CAP across the US.

 

The full reference list can be found in Section 2.2.

1.20 Types of Data Sources
1.25 Data Source Details

The anticipated data source for the measure is electronic health record (EHR) data from inpatient hospital admissions, including discharge diagnosis codes, pharmacy and medication administration, and imaging records. These data are all collected routinely during usual clinical care through the process of inpatient hospitalizations.