eMeasure Title

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

eMeasure Identifier (Measure Authoring Tool) 188 eMeasure Version number 6.2.000
NQF Number 0147 GUID 8243eae0-bbd7-4107-920b-fc3db04b9584
Measurement Period January 1, 20XX through December 31, 20XX
Measure Steward Centers for Medicare & Medicaid Services (CMS)
Measure Developer Oklahoma Foundation for Medical Quality
Endorsed By National Quality Forum
Description
(PN-6) Immunocompetent patients with Community-Acquired Pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines 

(Population 1) Immunocompetent ICU patients with Community-Acquired Pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines

(Population 2) Immunocompetent non-Intensive Care Unit (ICU) patients with Community-Acquired Pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines
Copyright
Measure specifications are in the Public Domain  

CPT(R) is a trademark of the American Medical Association. Current Procedural Terminology. (CPT) is copyright 2015 American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.  

LOINC(R) is a registered trademark of the Regenstrief Institute.  

This material contains SNOMED Clinical Terms (R) (SNOMED CT(C)) copyright 2004-2015 International Health Terminology Standards Development Organization. All rights reserved.
Disclaimer
These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. The measures and specifications are provided without warranty. CMS has contracted with Mathematica Policy Research and its subcontractors, Lantana and Telligen, for the continued maintenance of this electronic measure.
Measure Scoring Proportion
Measure Type Process
Measure Item Count
Encounter, Performed: Encounter Inpatient
Stratification
None
Risk Adjustment
None
Rate 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 (eg 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 (eg Legionella species, Chlamydia pneumoniae, Mycoplasma pneumoniae) can be associated with improved survival
Improvement Notation
Improvement noted as an increase in rate
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.
Reference
File TM, Low DE, Eckburg PB, Talbot GH, Friedland D, Lee J, Llorens L, Critchley I, Thye D. Integrated analysis of FOCUS 1 and FOCUS 2 randomized, double blinded, multicenter phase 3 trials of the efficacy and safety of ceftaroline fosamil versus ceftriaxone in patients with community acquired pneumonia. CID. December 2010; 51 (12): 1395-1405.
Reference
Wunderlink RJ, Waterer GW, Rello J. Management of Community-acquired Pneumonia in Adults. Am J of Respir and Crit Care Med. August 2010: 2-41.
Reference
Tessmer, A., T. Welte, P. Martus, M. Schnoor, R. Marre, and N. Suttorp. Impact of intravenous beta-lactam/macrolide versus beta-lactam monotherapy on mortality in hospitalized patients with community-acquired pneumonia. J Antimicrob Chemother 2009; 63:1025-33.
Reference
Restrepo, M. I., E. M. Mortensen, J. Rello, J. Brody, and A. Anzueto. Late admission to the ICU in patients with community-acquired pneumonia is associated with higher mortality. Chest 2009.
Definition
None
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. 	 

Exclusion element guidance:  
Transfers from another hospital 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 hospitals by hospital billing number. 

Transfers within 1 day from those hospitals using the same facility number are not considered transfers for the exclusion section of this measure, those using other facility numbers are considered exclusions.  

Respiratory Infection exclusion- the logic indicates that the patient is included if they have a respiratory infection but excluded for any other infection unless the encounter ends <=24 hr after the start.

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)).
Transmission Format
TBD
Initial Population
Pneumonia patients 18 years of age and older at the time of admission to inpatient care with a discharge principal diagnosis of pneumonia, OR Principal Diagnosis of septicemia or respiratory failure (acute or chronic) AND also a secondary other diagnosis code of pneumonia. Patient with a LOS <=120 days and discharged during the measurement period.

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).
For both populations, arrival at the hospital means either arrival at the ED or arrival as a direct admit to the inpatient setting.
Denominator
ICU population:  
Patients who meet the Initial Population and:
* Arrival at hospital is either arrival in ED or arrival to floor as direct admit
* Admitted to ICU within 24 hours after arrival at hospital with reasons for admission due to pneumonia
* Pneumonia related reasons for admission to ICU include:
        * Septic shock
        * Respiratory distress or failure
        * Hypotension
        * Tachypnea
        * Hypoxemia
        * Need for a ventilator
        * Tachycardia
* Diagnosis of pneumonia documented within 24 hours after arrival; if seen in ED diagnosis must be documented in ED
* Antibiotics received within 24 hours of arrival or within 1 day prior to hospital arrival and during hospital stay.

Non-ICU population:
Patient who meet the Initial Population and:
* Arrival at hospital is either arrival in ED or arrival to floor as direct admit
* Diagnosis of pneumonia documented within 24 hours after arrival; if seen in ED diagnosis must be documented in ED
* Antibiotics received within 24 hours after arrival
Denominator Exclusions
ICU Population only:
Patients transferred/admitted to the ICU within 24 hours after arrival to this hospital, with a beta-lactam allergy (population 1 only).
For patients in both ICU and non-ICU the rest of the denominator exclusions are the same:
* Patients with either a normal Chest X-ray or a normal CT scan which includes the chest within 1 day prior to arrival at the hospital or during the hospitalization
* Patients who have "Comfort Measures" documented as performed or ordered on the day of or the day after arrival at the hospital or after arrival in the ED
* Patients who are transferred from one of the following within 24 hours before the start of the ED encounter or the hospital encounter:
        * An acute care hospital
        * An ambulatory surgical center
        * A transfer from an emergency department of an outside hospital       
        * A transfer from an outpatient department of an outside hospital 
* Patients who were an inpatient less than or equal to 1 day.

The following exclusions are "reasons for alternative empiric antibiotic therapy":
*Patients who have a diagnosis of a "prolonged QT interval" documented within 24 hours after arrival at the ED or the hospital
* Patients who have a diagnosis of an immunocompromised condition within the last 90 days before arrival at the ED or arrival at the hospital or during the hospitalization
* Patients who have significant neutropenia, which is defined as a Neutrophil count of <500 per mm3 within the last 90 days before arrival at the ED or arrival at the hospital or during the hospitalization
* Patients who have any of the following within 30 days before arrival at the ED or arrival at the hospital:
        * Hemodialysis or peritoneal dialysis
        * Wound care
        * Tracheostomy care
        * Ventilator care
        * Diagnosis of healthcare associated pneumonia
* Patients who have any of the following which starts before the end of the inpatient hospitalization:
        * Immunodeficient conditions
        * Cystic Fibrosis
        * History of an organ transplant
* Patients who have any of the following within 90 days before the start of either the ED or the direct admit:
        * Immunocompromised Therapies (radiation treatments, for instance)
        * Systemic Immunosuppressive therapy (chemotherapy, for instance)
        * A patient in a nursing home or an extended care facility
        * A patient in another acute care hospital
Numerator
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.
Non-ICU patients are evaluated for pseudomonal risk. 

Pseudomonal risk requires certain antibiotics per clinical guidelines.
Pseudomonal risk includes:
* Bronchiectasis
* Structural lung disease which includes the following:
        * "Diagnosis: COPD"
        * "Diagnosis: Chronic bronchitis"
        * "Diagnosis: Emphysema"
        * "Diagnosis: Interstitial lung disease"
        * "Diagnosis: Restrictive lung disease"
        * "Diagnosis: Structural lung disease"
Numerator Exclusions
Not Applicable
Denominator Exceptions
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.  Pneumonia patients who have been on systemic corticosteroid/prednisone therapy within the last 90 days prior to arrival to the hospital.
Supplemental Data Elements
For every patient evaluated by this measure also identify payer, race, ethnicity and sex

Table of Contents


Population Criteria

Data Criteria (QDM Variables)

Data Criteria (QDM Data Elements)

Supplemental Data Elements

Risk Adjustment Variables


Measure Set
Not Applicable