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    ABSTRACT: BACKGROUND: Pneumonia antibiotic timing performance measures can result in unnecessary antibiotic administration to patients in whom a diagnosis of pneumonia remains possible but has not been confirmed. OBJECTIVE: Our objective was to determine if unnecessary antibiotic administration to admissions with Emergency Department (ED) congestive heart failure (CHF) diagnoses increased as institutional attention to pneumonia antibiotic timing intensified. METHODS: We performed a cross-sectional study in an academic ED with 39,000 annual visits. Our subjects included adult admissions with ED CHF diagnoses between October and March of 2004-2005, 2005-2006, and 2006-2007. We excluded patients with any concomitant infectious diagnosis from primary analysis. We obtained patient age, sex, triage acuity, vital signs, ED diagnoses, and admitting service from electronic databases. Trained abstractors confirmed infectious diagnosis presence and noted if antibiotics were administered. Inter-observer agreement was assessed. Multivariate logistic regression determined association of time period with antibiotic administration. We assessed trends in concomitant infectious diagnoses. RESULTS: Of 778 CHF admissions, 125 had infectious diagnoses, leaving 653 for primary analysis. Inter-observer agreement was good to excellent (κ = 0.71-0.83). Demographic and presenting characteristics did not vary by period. Antibiotics were administered to 18.4% (95% confidence interval [CI] 12.7-23.3), 15.0% (95% CI 9.6-18.5), and 15.1% (95% CI 10.2-19.8), per period, respectively. Time period was not associated with antibiotics, odds ratios were 0.8 (95% CI 0.5-1.4) and 0.9 (95% CI 0.5-1.6) for periods 2 and 3, respectively. Concomitant infectious diagnoses did not increase significantly (from 15.5% to 19.4%). Pneumonia antibiotic timing compliance remained low (50-70%). CONCLUSIONS: Unnecessary antibiotic administration to ED CHF admissions did not increase as institutional scrutiny of pneumonia antibiotic timing intensified, although neither did compliance with pneumonia antibiotic timing.
    Journal of Emergency Medicine 10/2012; · 1.18 Impact Factor
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    ABSTRACT: Significant controversy exists regarding the Centers for Medicare & Medicaid Services (CMS) "time to first antibiotics dose" (TFAD) quality measure. The objective of this study was to determine whether hospital performance on the TFAD measure for patients admitted from the emergency department (ED) for pneumonia is associated with decreased mortality. This was a cross-sectional analysis of 95,704 adult ED admissions with a principal diagnosis of pneumonia from 530 hospitals in the 2007 Nationwide Inpatient Sample. The sample was merged with 2007 CMS Hospital Compare data, and hospitals were categorized into TFAD performance quartiles. Univariate association of TFAD performance with inpatient mortality was evaluated by chi-square test. A population-averaged logistic regression model was created with an exchangeable working correlation matrix of inpatient mortality adjusted for age, sex, comorbid conditions, weekend admission, payer status, income level, hospital size, hospital location, teaching status, and TFAD performance. Patients had a mean age of 69.3 years. In the adjusted analysis, increasing age was associated with increased mortality with odds ratios (ORs) of >2.3. Unadjusted inpatient mortality was 4.1% (95% confidence interval [CI] = 3.9% to 4.2%). Median time to death was 5 days (25th-75th interquartile range = 2-11). Mean TFAD quality performance was 77.7% across all hospitals (95% CI = 77.6% to 77.8%). The risk-adjusted OR of mortality was 0.89 (95% CI = 0.77 to 1.02) in the highest performing TFAD quartile, compared to the lowest performing TFAD quartile. The second highest performing quartile OR was 0.94 (95% CI = 0.82 to 1.08), and third highest performing quartile was 0.91 (95% CI = 0.79 to 1.05). In this nationwide heterogeneous 2007 sample, there was no association between the publicly reported TFAD quality measure performance and pneumonia inpatient mortality.
    Academic Emergency Medicine 05/2011; 18(5):496-503. · 2.20 Impact Factor
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    ABSTRACT: The study aimed to determine if emergency department (ED)-administered antibiotics for patients discharged home with nonpneumonia acute respiratory tract infections (ARIs) have increased since national pneumonia performance measure implementation, including antibiotic administration within 4 hours of arrival. Design: Time series analysis. Setting: Six university and 7 Veterans Administration EDs participating in the Improving Antibiotic Use for Acute Care Treatment (IMPAACT) trial (randomized educational intervention to reduce antibiotics for bronchitis). Participants: Randomly selected adult (age >18 years) ED visits for acute cough, diagnosed with nonpneumonia ARIs, discharged home during winters (November-February) of 2003 to 2007. Main outcome: Time trend in ED-administered antibiotics, adjusted for patient demographics, comorbidities, vital signs, ED length of stay, IMPAACT intervention status, geographic region, Veterans Administration/university setting, and site and provider level clustering. Six thousand four hundred seventy-six met study criteria. Three hundred ninety-four (6.1%) received ED-administered antibiotics. Emergency department-administered antibiotics did not increase across the study period among all IMPAACT sites (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.76-1.01) after adjusting for age, congestive heart failure history, temperature higher than 100 degrees F, heart rate more than 100, blood cultures obtained, diagnoses, and ED length of stay. The ED-administered antibiotic rate decreased at IMPAACT intervention (OR, 0.80; 95% CI, 0.69-0.93) but not nonintervention sites (OR, 1.04; 95% CI, 0.91-1.19). Adjusted proportions receiving ED-administered antibiotics were 6.1% (95% CI, 2.7%-13.2%) for 2003 to 2004; 4.8% (95% CI, 2.2%-10.0%) for 2004 to 2005; 4.6% (95% CI, 2.7%-7.8%) for 2005 to 2006; and 4.2% (95% CI, 2.2%-8.0%) for 2006 to 2007. Emergency department-administered antibiotics did not increase for patients with acute cough discharged home with nonpneumonia ARIs since pneumonia antibiotic timing performance measure implementation in these academic EDs.
    The American journal of emergency medicine 01/2010; 28(1):23-31. · 1.15 Impact Factor