To the Editor: The study of Hospital Compare quality performance measures by Drs Werner and Bradlow1 compared the mortality rates for Medicare patients cared for in hospitals classified as poor performing with the mortality rates of patients in high-performing hospitals; this was based on the performance measures that are used by the Joint Commission on Accreditation of Healthcare Organizations. The study found the differences in mortality to be very small and in some cases only marginally statistically significant.
The authors seek methodological explanations for this modest association. One problem may be their assumption that the performance measures have been tightly linked to patient outcomes in clinical trials. This is not true of at least 1 of the pneumonia standards. Houck et al,2 which is cited in support of that standard, is a retrospective analysis of Medicare data that showed a lower mortality rate for patients with pneumonia who received antibiotics within 4 hours of admission to an emergency department. That was not a clinical trial and should have been the basis for a prospective study to confirm this observation. Instead, it was used to support a national policy even though the authors acknowledged that patients treated in less than 2 hours or longer than 8 hours had the highest mortality. This raises the possibility that the different treatment groups were not comparable; there may have been clinical reasons not detected by the analysis (which was based on coded diagnoses) why some patients were treated more or less rapidly than others, and why those patients at the extremes had the worst outcomes.
Given the large interpatient variability in the interval between onset of illness and presentation to the emergency department for pneumonia, it is not clear that a difference of 1 to 2 hours in the timing of antibiotic administration would affect mortality. However, this performance measure may increase the likelihood that patients will not have a sputum culture obtained before antibiotics are administered. Prior administration of an antibiotic greatly reduces the ability of the laboratory to identify pneumococci in sputum samples.3 This may lead to an absence of etiological diagnosis and prolonged treatment with multiple broad-spectrum antibiotics, a practice that may contribute to the high rate of Clostridium difficile colitis that has been noted in some hospitals.4 This potentially serious complication could easily outweigh the small benefit associated with earlier treatment of pneumonia.
Financial Disclosures: None reported.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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