Percent of Hospitalized Pneumonia Patients with Chest Imaging Confirmation

The chest imaging-confirmed measure of pneumonia diagnosis is a process measure of inpatient hospitalizations that identifies the proportion of adult patients hospitalized patients with a discharge diagnosis of pneumonia and who received systemic or oral antimicrobials at any time during admission who received chest imaging that supported the diagnosis of pneumonia, as recommended by clinical practice guidelines. The measure applies to a target population of adult hospitalized patients.

None

None

None

None

None

As the leading infectious cause death in the United States, the leading source of sepsis, and one of the most common reasons for adult hospitalizations, pneumonia is an important target for quality measurement and improvement. Prior measures of quality in pneumonia have driven important improvements for timely treatment and improved outcomes. However, past measures have also been challenged by difficulties in ensuring a consistent target population due to the subjectivity of diagnosis and the burden of manual chart review. Clinical practice guidelines strongly recommend verification of a pneumonia diagnosis with chest imaging. The availability of chest imaging is universal in US hospitals and are increasingly integrated into modern EHR's in searchable formats, but 10-30% of patients diagnosed with pneumonia lack chest imaging confirmation. With advances in the EHR and technology, an electronic Clinical Quality Measure that identifies chest imaging confirmation of diagnoses of pneumonia would 1) improve diagnostic accuracy in pneumonia, and 2) serve as a eCQM foundation for all quality measures in pneumonia. 

The use of an eCQM for diagnostic quality in pneumonia also balances with other current quality efforts, including reducing costs and improving 30-day mortality for pneumonia hospitalizations, reducing inappropriate antibiotics for bronchitis, and improving timely treatment and outcomes for sepsis. All of these measures could promote over-diagnosis of pneumonia, since patients without radiographic abnormalities generally have lower illness severity, and clinicians are increasingly required to provide justification for antibiotic use. Reporting the proposed eCQM in conjunction with the existing quality measures would promote meaningful quality improvement by ensuring accurate target populations and reporting.

Joint ATS/IDSA clinical guidelines recommend obtaining chest imaging to confirm the diagnosis of pneumonia among hospitalized patients.

Increased score (e.g., higher score) indicates better quality and is the preferred result.

Reference Type: CITATION

Reference Text: 'Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. Mar 01 2007;44 Suppl 2(Suppl 2):S27-72. doi:10.1086/511159'

Reference Type: CITATION

Reference Text: 'Metlay JP, Waterer GW, Long AC, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. Oct 1 2019;200(7):e45-e67. doi:10.1164/rccm.201908-1581ST'

Reference Type: CITATION

Reference Text: 'Bartlett JG, Dowell SF, Mandell LA, File TM, Musher DM, Fine MJ. Practice guidelines for the management of community-acquired pneumonia in adults. Infectious Diseases Society of America. Clin Infect Dis. Aug 2000;31(2):347-82. doi:10.1086/313954'

Reference Type: CITATION

Reference Text: '(NICE) NIfHaCE. Pneumonia in adults, quality standard [QS110]: Quality statement 3-- Chest x-ray and diagnosis within 4 hours of hospital presentation. https://www.nice.org.uk/guidance/qs110/chapter/quality-statement-3-chest-xray-and-diagnosis-within-4-hours-of-hospital-presentation'

Reference Type: CITATION

Reference Text: '(NICE) NIfHaCE. Pneumonia in adults: diagnosis and management. NICE Guideline, No 191. London2023.'

Reference Type: CITATION

Reference Text: 'Kalil AC, Metersky ML, Klompas M, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. Sep 01 2016;63(5):e61-e111. doi:10.1093/cid/ciw353'

Reference Type: CITATION

Reference Text: 'Watkins RR, Lemonovich TL. Diagnosis and management of community-acquired pneumonia in adults. Am Fam Physician. Jun 1 2011;83(11):1299-306.'

Reference Type: CITATION

Reference Text: 'Woodhead M, Blasi F, Ewig S, et al. Guidelines for the management of adult lower respiratory tract infections--full version. Clin Microbiol Infect. Nov 2011;17 Suppl 6(Suppl 6):E1-59. doi:10.1111/j.1469-0691.2011.03672.x'

Reference Type: CITATION

Reference Text: 'Excellence. NNIfHaC. Pneumonia (including community acquired pneumonia). 2014. http://www.nice.org.uk/guidance/cg191'

Reference Type: CITATION

Reference Text: 'Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. Oct 2011;53(7):e25-76. doi:10.1093/cid/cir531'

Reference Type: CITATION

Reference Text: 'Singh H, Giardina TD, Meyer AN, Forjuoh SN, Reis MD, Thomas EJ. Types and origins of diagnostic errors in primary care settings. JAMA Intern Med. Mar 25 2013;173(6):418-25. doi:10.1001/jamainternmed.2013.2777'

Reference Type: CITATION

Reference Text: 'Morgan DJ, Pineles L, Owczarzak J, et al. Accuracy of Practitioner Estimates of Probability of Diagnosis Before and After Testing. JAMA Intern Med. Jun 01 2021;181(6):747-755. doi:10.1001/jamainternmed.2021.0269'

Reference Type: CITATION

Reference Text: 'Klompas M. Clinical evaluation and diagnostic testing for community-acquired pneumonia in adults. In: Eds., Ramirez J, Bond S, Dieffenbach P, editors. UpToDate: Wolters Kluwer; 2023.'

Reference Type: CITATION

Reference Text: 'Chandra A, Nicks B, Maniago E, Nouh A, Limkakeng A. A multicenter analysis of the ED diagnosis of pneumonia. Am J Emerg Med. Oct 2010;28(8):862-5. doi:10.1016/j.ajem.2009.04.014'

Reference Type: CITATION

Reference Text: 'Marrie TJ, Huang JQ. Low-risk patients admitted with community-acquired pneumonia. Am J Med. Dec 2005;118(12):1357-63. doi:10.1016/j.amjmed.2005.06.035'

Reference Type: CITATION

Reference Text: 'Atamna A, Shiber S, Yassin M, Drescher MJ, Bishara J. The accuracy of a diagnosis of pneumonia in the emergency department. Int J Infect Dis. Dec 2019;89:62-65. doi:10.1016/j.ijid.2019.08.027'

Reference Type: CITATION

Reference Text: 'Kanwar M, Brar N, Khatib R, Fakih MG. Misdiagnosis of community-acquired pneumonia and inappropriate utilization of antibiotics: side effects of the 4-h antibiotic administration rule. Chest. Jun 2007;131(6):1865-9. doi:10.1378/chest.07-0164'

Reference Type: CITATION

Reference Text: 'Welker JA, Huston M, McCue JD. Antibiotic timing and errors in diagnosing pneumonia. Arch Intern Med. Feb 25 2008;168(4):351-6. doi:10.1001/archinternmed.2007.84'

Reference Type: CITATION

Reference Text: 'Ang CS, Kelvin Beh KM, Yeang LJ, et al. Misdiagnosis of community-acquired pneumonia in patients admitted to respiratory wards, Penang General Hospital. Med J Malaysia. Jul 2020;75(4):385-390.'

Reference Type: CITATION

Reference Text: 'Gupta AB, Flanders SA, Petty LA, et al. Inappropriate Diagnosis of Pneumonia Among Hospitalized Adults. JAMA Intern Med. Mar 25 2024;doi:10.1001/jamainternmed.2024.0077'

Reference Type: CITATION

Reference Text: 'Fee C, Weber EJ. Identification of 90% of patients ultimately diagnosed with community-acquired pneumonia within four hours of emergency department arrival may not be feasible. Ann Emerg Med. May 2007;49(5):553-9. doi:10.1016/j.annemergmed.2006.11.008'

Reference Type: CITATION

Reference Text: 'Metersky ML, Ma A, Bratzler DW, Houck PM. Predicting bacteremia in patients with community-acquired pneumonia. Am J Respir Crit Care Med. Feb 1 2004;169(3):342-7.'

Reference Type: CITATION

Reference Text: 'Novosad SA, Sapiano MR, Grigg C, et al. Vital Signs: Epidemiology of Sepsis: Prevalence of Health Care Factors and Opportunities for Prevention. MMWR Morb Mortal Wkly Rep. Aug 26 2016;65(33):864-9. doi:10.15585/mmwr.mm6533e1'

Reference Type: CITATION

Reference Text: 'McDermott K, Roemer M. Most frequent principal diagnoses for inpatient stays in U.S. hospitals, 2018. In: Quality AfHRa, editor. Statistical Brief #277   Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet] Rockville (MD): Agency for Healthcare Research and Quality (US)2021.'

Reference Type: CITATION

Reference Text: 'Hayes BH, Haberling DL, Kennedy JL, Varma JK, Fry AM, Vora NM. Burden of Pneumonia-Associated Hospitalizations: United States, 2001-2014. Chest. Feb 2018;153(2):427-437. doi:10.1016/j.chest.2017.09.041'

Reference Type: CITATION

Reference Text: 'Heron M. Deaths: Leading Causes for 2018. Natl Vital Stat Rep. May 2021;70(4):1-115. '

Reference Type: CITATION

Reference Text: 'Ramirez JA, Wiemken TL, Peyrani P, et al. Adults Hospitalized With Pneumonia in the United States: Incidence, Epidemiology, and Mortality. Clin Infect Dis. Nov 13 2017;65(11):1806-1812. doi:10.1093/cid/cix647'

Reference Type: CITATION

Reference Text: 'Magill SS, Edwards JR, Bamberg W, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med. Mar 27 2014;370(13):1198-208. doi:10.1056/NEJMoa1306801'

Reference Type: CITATION

Reference Text: 'Jones BE, Sarvet AL, Ying J, et al. Incidence and Outcomes of Non-Ventilator-Associated Hospital-Acquired Pneumonia in 284 US Hospitals Using Electronic Surveillance Criteria. JAMA Netw Open. May 01 2023;6(5):e2314185. doi:10.1001/jamanetworkopen.2023.14185'

Reference Type: CITATION

Reference Text: 'Papazian L, Klompas M, Luyt CE. Ventilator-associated pneumonia in adults: a narrative review. Intensive Care Med. May 2020;46(5):888-906. doi:10.1007/s00134-020-05980-0'

Reference Type: CITATION

Reference Text: 'Niederman MS, McCombs JS, Unger AN, Kumar A, Popovian R. The cost of treating community-acquired pneumonia. Clin Ther. Jul-Aug 1998;20(4):820-37. doi:10.1016/s0149-2918(98)80144-6'

Reference Type: CITATION

Reference Text: 'Tong S, Amand C, Kieffer A, Kyaw MH. Trends in healthcare utilization and costs associated with pneumonia in the United States during 2008-2014. BMC Health Serv Res. Sep 14 2018;18(1):715. doi:10.1186/s12913-018-3529-4'

Reference Type: CITATION

Reference Text: 'Jain S, Self WH, Wunderink RG, et al. Community-Acquired Pneumonia Requiring Hospitalization among U.S. Adults. N Engl J Med. Jul 30 2015;373(5):415-27. doi:10.1056/NEJMoa1500245'

Reference Type: CITATION

Reference Text: 'File TM, Ramirez JA. Community-Acquired Pneumonia. N Engl J Med. Aug 17 2023;389(7):632-641. doi:10.1056/NEJMcp2303286'

None

The "Chest Imaging for Pneumonia Grouping Definition" value set intends to capture all types of imaging that could result in a pneumonia diagnosis. This was developed with the intention to potentially include ultrasound or other imaging types as the research and national governing boards recommend.
 
The "Qualifying Pneumonia Encounter" definition intends to reflect the diagnosis of pneumonia that was relevant at the time of discharge and encoded within the encounter when it was finalized.
 
The denominator population includes patients with inpatient hospitalizations who have a discharge diagnosis of pneumonia who received systemic or oral antimicrobials during the admission. The numerator includes patients with chest imaging results consistent with pneumonia. The measure reports percent of diagnostic concordance.
 
This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.
 
This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

TBD

Inpatient hospitalizations for patients age 18 and older with a discharge diagnosis code for pneumonia at any coding position who were treated with systemic or oral antimicrobials at any time during the index hospitalization (24 hours preceding hospitalization through hospital discharge).

Number of inpatient admissions with a discharge diagnosis code at any position for pneumonia and administered systemic antimicrobials at any time during hospitalization or within 24 hours preceding admission.

None

Number of adult patients identified in the denominator (inpatient admission with a discharge diagnosis code at any position for pneumonia and administered systemic antimicrobials at any time during hospitalization) with evidence of a chest image consistent with pneumonia during their hospital admission or within 48 hours preceding the inpatient admission.

None

None

For every patient evaluated by this measure also identify payer, race, ethnicity and sex.

None