Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients (NQF 0147)

eMeasure Name Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients eMeasure Id 0B501F4D-A268-4CF0-BDBD-813FEE0011EB
Version number 1 eMeasure Set Id Pending
Available Date No information Measurement Period January 1, 20xx through December 31, 20xx
Measure Steward Oklahoma Foundation for Medical Quality
Endorsed by National Quality Forum
Description Immunocompetent patients with Community-Acquired Pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines
Copyright
Measure scoring Proportion
Measure type Process
Stratification
None
Risk Adjustment
None
Data Aggregation
Data from Populations 1 and 2 should also be aggregated to report an aggregate of 'All patients compliant / All patients eligible'
			
The numerator includes: ALL ICU numerator 1 compliant + All Non-ICU numerator 2 compliant patients

The denominator includes: All patients who are ICU denominator 1 compliant (after excluding all in Denominator Exclusion(s) 1) and All Non-ICU denominator 2 compliant (after excluding all in Denominator Exclusion(s) 2)
Rationale
The current North American antibiotic guidelines for Community-Acquired Pneumonia in immunocompetent patients are from the Centers for Disease Control and Prevention (CDC), the Infectious Diseases Society of America (IDSA), the Canadian Infectious Disease Society / Canadian Thoracic Society (CIDS/CTS), and the American Thoracic Society (ATS). All four reflect that Streptococcus pneumoniae is the most common cause of CAP, that treatment that covers "atypical" pathogens (e.g., Legionella species, Chlamydia pneumoniae, Mycoplasma pneumoniae) can be associated with improved survival, and that the prevalence of antibiotic resistant S. pneumoniae is increasing. 
	
The CMS convened a conference of guideline authors, including Julie Gerberding, MD (CDC), John Bartlett, MD (IDSA), Ronald Grossman, MD (CIDS/CTS), and Michael Niederman, MD (ATS), to reach consensus on the antibiotic regimens that could be considered consistent with all four organizations' guidelines. These regimens are reflected in this measure, and in the Pneumonia Antibiotic Consensus Recommendation located directly behind the measure information form.
Clinical Recommendation Statement
Antibiotic guidelines reflect that Streptococcus pneumoniae is the most common cause of CAP, that treatment that covers "atypical" pathogens (e.g., Legionella species, Chlamydia pneumoniae, Mycoplasma pneumoniae) can be associated with improved survival.
Improvement notation
Higher score indicates better quality
Measurement duration
12 month(s)
Reference
Butler JC, Hofmann J, Cetron MS, et al. The continued emergence of drug-resistant Streptococcus pneumonia in the United States: an update from the Centers for Disease Control and Prevention's Pneumococcal Sentinel Surveillance System. J Infect Dis. 1996;174:986-993.
Reference
Fine MJ, Smith MA, Carson CA, et al. Prognosis and outcomes of patients with community-acquired pneumonia. JAMA. 1996;275:134-141.
Reference
Gleason PP, Meehan TP, Fine JM, et al. Associations between initial antimicrobial regimens and medical outcomes for elderly patients with pneumonia. Arch Intern Med. 1999;159:2562-2572.
Reference
Heffelfinger JD, Dowell SF, Jorgensen JH, Klugman KP, et al. Management of Community-Acquired Pneumonia in the era of pneumococcal resistance: A Report From the Drug-Resistant Streptococcus pneumoniae Therapeutic Working Group. Archives of Internal Medicine. 2000, 160:1399-1408.
Reference
Houck PM, MacLehose RF, Niederman MS, Lowery JK. Empiric antibiotic therapy and mortality among Medicare pneumonia inpatients in 10 western states, 1993, 1995, and 1997. Chest. 2001;119;1420-1426.
Reference
Mandell LA, Marrie TJ, Grossman RF, et al. Canadian guidelines for the initial management of community-acquired pneumonia: an evidence-based update by the Canadian Infectious Disease Society and the Canadian Thoracic Society. Clin Infect Dis. 2000;31:383-421.
Reference
Mandell LA, Wunderink RG, Anzueta A, Bartlett JG, Infectious Diseases Society of America; American Thoracic Society. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007 March 1;44 Suppl 2:S27-72.
Definition
Initial Patient Population(s): All hospital discharges for pneumonia with hospital stays <= 120 days during the measurement year for patients age 18 and older at the time of hospital .admission.  This measure is divided into patients admitted to the intensive care unit (ICU – population 1), and those admitted to non-ICU hospital locations (population 2).
Definition
Denominator(s): Pneumonia patients 18 years of age and older with An ICD-9-CM Hospital Measures-Principal Diagnosis Code of pneumonia, OR ICD-9-CM Hospital Measures-Principal Diagnosis Code of septicemia or respiratory failure (acute or chronic) and also a secondary ICD-9-CM Other Diagnosis Code of pneumonia, and abnormal findings on chest x-ray or CT scan of the chest within 24 hours prior to hospital arrival or during the hospitalization
Definition
Denominator Exclusion(s): 
Patients with Cystic Fibrosis.
Patients with Comfort Measures Only documented on day of or day after arrival.
Patients enrolled in clinical trials.
Patients received as a transfer from the emergency/observation department of another hospital.
Patients received as a transfer from an inpatient or outpatient department of another hospital.
Patients received as a transfer from an ambulatory surgery center.
Patients who have no diagnosis of pneumonia either as the ED final diagnosis/impression or direct admission diagnosis/impression.
Patients with Healthcare Associated pneumonia or are immunocompromised.
Patients transferred/admitted to the ICU within 24 hours after arrival to this hospital, with a beta-lactam allergy (population 1 only).
Patients who have duration of stay less than or equal to one day.
Pneumonia patients with Another Source of Infection who did not receive an antibiotic regimen recommended for pneumonia, but did receive antibiotics within the first 24 hours of hospitalization.
Definition
Numerator(s): Pneumonia patients who received an initial antibiotic regimen consistent with current guidelines during the first 24 hours of their hospitalization. Numerator 1 (in population 1) defines appropriate antibiotics for ICU patients. Numerator 2 (in population 2) defines appropriate antibiotics for non-ICU patients.
Definition
Denominator Exception(s): N/A
Guidance
General guidance:

The measure criteria indicate scenarios in which the patient is admitted to the hospital directly (to ICU or Non-ICU locations) or the patient is admitted to one of these locations from the Emergency Department (ED).  The calculation is to indicate the timing from arrival at the facility to the occurrence of an event. The arrival, therefore can be determined from the Emergency Department, the Non-ICU location, or the ICU location, whichever is the first location of contact between the patient and the facility.
	
Patients for whom there are missing or inaccurate data (e.g., arrival time, medication administration, etc.) are considered to have failed the measure; the total number of patients with missing or erroneous (e.g., a time of 03:69 or a date of 10/26/2035) data (i.e., measure failures) must be reported with the results of the measure.


Exclusion element guidance:

The exclusion for patients who are clinical trial participants is limited to patients participating in a clinical trial for pneumonia, the same condition as covered by the measure. Other clinical trials are not valid reasons for exclusions.

Transfers from another hospital or an Emergency Department that is not part of the hospital's organization are excluded since care may have been delivered in the other setting.  The measure as specified for abstraction allowed determination of other hospital or other hospital Emergency Departments by hospital billing number. Transfers within 1 day from those hospitals or Emergency Departments using the same facility number are not considered transfers for the exclusion section of this measure, those using other facility numbers are considered exclusions.

Any patient with a blood culture result available in the first 24 hours after patient arrival is excluded if:
a) The culture result identifies bacterial pathogens and susceptibilities that would require treatment with antibiotics, and
b) The culture is not considered a contaminant

The exclusion for absolute neutrophil count < 500 may require calculation. The absolute neutrophil count (ANC) = Total WBC x (% "Segs" + % "Bands"), OR WBC x ((Segs/100) + (Bands/100)).
Supplemental Data Elements
Report "Patient Characteristic: Gender" using "Gender HL7 Value Set (2.16.840.1.113883.1.11.1)"; Report "Patient Characteristic: Race" using "Race CDC Value Set (2.16.840.1.114222.4.11.836)"; Report "Patient Characteristic: Ethnicity" using "Ethnicity CDC Value Set (2.16.840.1.114222.4.11.837)"; Report "Patient Characteristic: Payer" using "Payer Source of Payment Typology Value Set (2.16.840.1.113883.3.221.5)".

Table of Contents


Population criteria

      ------ Population Criteria 1 ------

      ------ Population Criteria 2 ------

Data criteria (QDM Data Elements)

Supplemental Data Elements




Measure set CLINICAL QUALITY MEASURE SET 2011-2012