Is pay-for-performance leading to antibiotic overuse?

I’m not surprised about this:

Elderly patients hospitalized for suspected pneumonia may be getting antibiotics before their doctor is certain about the diagnosis, a new study suggests.

Among health-care professionals, the practice is known as “shoot first and ask questions later.” And the premature use of antibiotics for elderly patients with suspected pneumonia is often done to meet federal performance standards that dictate giving the drugs within four hours of arrival at a hospital.

“Some patients are probably getting antibiotics inappropriately in an attempt to deliver antibiotics quickly to meet externally mandated standards,” said lead study author Dr. Mark L. Metersky, a professor of medicine at the University of Connecticut School of Medicine. . .

. . . For hospital officials and those who establish standards of care, the message is that “100 percent [antibiotic adherence within four hours] is not an appropriate goal, because it leads to inappropriate care,” Metersky said.

“Seventy-five or 80 percent is probably more appropriate,” he said.

This will happen when you use a blunt instrument, like global performance measures, to improve quality.

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  • Anonymous

    Kevin, I’ve noticed you’ve criticized every effort to improve quality or set different pay schedules for physicians. What would you suggest? Realistically?

  • Kevin

    Not at all. I actually think that pay-for-performance is a step in the right direction.

    I am simply pointing out that global quality measures are not black and white, all or nothing. There will be cases where some global measures are not in the best interest of individual patients.

    Thanks,
    Kevin

  • Anonymous

    Medicine is not a cookbook practice. What works for one patient will not necessarily apply to another. The “pay for performance” guidelines should not be applied to all patients and physicians should be allowed some room to maneuver. Many physicians will do the knee-jerk response to stay within the guidelines, as Kevin blogs above, so that they can get reimbursed the paltry amount that the government allows, but is that the right treatment for the patient? Medicine is multifactorial – a patient may present with shortness of breath but this may be due to a cardiac condition and not pneumonia. However, a first read on a chest xray may be equivocal and therefore prior to obtaining an echocardiogram or some such test, a patient may be empirically started on antibiotics. Then what if the patient develops an anaphylactic reaction to the antibiotic, though the indications to given it were present – as stated by “pay for performance” guidelines? If there was a cut and dried practice to medicine, don’t you think computer programs would already be implemented in the emergency rooms to help triage patients? Should a patient be denied a CT scan just because his/her blood test is normal and he/she has had pain for less than 2 hours? Actually, a lot of these guidelines are already implemented. It’s called pre-certification from the insurance company. Try to get an MRI scan for a patient and you will realize that you have to fill out reams of paperwork. “Pay for performance” just adds on that much more administrative duties to the already over-burdened physician with paperwork.

  • Dr. Steve

    I will go futher than Kevin.

    Managed care “pay for performance” systems are nothing more than an excuse to pay doctors less. Insurers would not do this unless there was a return on investment (for them).

    Then again I am not opposed to some measures of quality – but the present sytem for collecting data are at best a pain and at worst totally nonsensical.

  • Anonymous

    Yep, pay for performance really is the practice of medicine by the payers. Many decisions of medical care are somewhat grey to the physician. Now along comes the payer or JCAHO with mandates, and and one shade of grey is tinted with red ink and the other is tinted green and perhaps too there will be a ‘report card’ of compliance to be later available to the hospital, insurers and patients. I’m so glad that the blue blazers of health care have clarified all areas of uncertainty in practice.

  • Anonymous

    Our ER is a crazy busy hectic environment often with long waits and physically no room to see patients. Administration is always over out ass about these measures. In the case of antibiotics within 4 hours there is not much literature that actually supports it, but what the hell it is something that some bean counters want to measure and think is important. So we stock levaquin 750mg at triage. Any old geezer that comes up to the triage window with a fever, cough, chest pain, SOB gets an anibiotic just in fucking case someone ever wants to mention pneumonia on the chart and we have met this “core” measure. I am sure there is more and more bullshit to come.

  • Anonymous

    It is probably a made-up deadline. It used to be a QA hit if a patient was neither discharged nor admitted to the ward within 4 hours of ER admission. That is now a hopeless and laughably quaint expectation, so they now are fixing time limits to administration of hospital-essential therapies, like IV antibiotics, as something of a half-measure.

  • Anonymous

    What is wrong with all of you?The guidelines are evidence based. Tons of time, money and clinical practice goes into these decisions. If you all spent more time on actually trying to meet the guideliens then you might actually ,God forbid, lower the mortality/morbity rates for CAP. Instead of “dwelling” on the few patients that might fall out, how about trying to get into the 90% for the rest? Besides, do you actually think all your bitching will actually change the guideline writers minds? I think not. It’s time to cut all this crap out and be proactive. Fix it before P4P startes for real and it will. Not only for Hospitals but for physicians too.