TFAD and JCAHO: What the Data Shows
Here’s a familiar scenario: an elderly patient comes to the ER with symptoms that include a cough, abdominal pain, and confusion. It could be pneumonia, but the attending doctor's unsure; other symptoms suggest chronic obstructive pulmonary disease, or even heart failure. Meanwhile, the clock is ticking—the Centers for Medicare and Medicaid Services (CMS) measure how many pneumonia patients get antibiotics within four hours of hospital admission. And low CMS scores can influence the hospital’s reputation, not to mention looming pay-for-performance allocations under Medicare.
Faced with that situation, many doctors simply “shoot first and ask later,” meaning they give antibiotics for pneumonia before confirming the diagnosis. But while that might boost CMS performance measures, it's not necessarily good medicine. “It's inappropriate to give antibiotics if you don't know what you're giving them for,” says Mark Metersky, MD, a professor of medicine at the University of Connecticut School of Medicine. Not only does that accelerate antibiotic resistance, he explains, but it can also complicate treatment. Some patients have allergic reactions to antibiotics, while one in five develop antibiotic-induced diarrhea; a potentially serious condition. Read More...
The Scientific Rationale
Pressure to shrink the TFAD stems back to the early 1990s. At that time, mounting evidence was showing that Medicare patients with pneumonia had better survival if antibiotics were given as soon as possible. Peter Houck, MD, a former director of the CMS' National Pneumonia Project (NPP), says the most convincing evidence came from large cohorts of patients aged 65 years or more. For instance, Thomas Mehan, et al. studied 14,069 hospitalized Medicare patients, and identified a 15% reduction in 30-day mortality with a TFAD of 8 hours. Those results were published in the December 17, 1997 issue of the Journal of the American Medical Association.
Other studies linked improved survival to even shorter TFAD. Khan et al., reported in JAMA on October 17, 1990, that survival among Medicare pneumonia patients improved if they were treated with antibiotics within four hours of admission.
These cumulative findings led Houck's group to recommend that hospitals treat the elderly for pneumonia with antibiotics faster. Taking that cue, CMS and JCAHO in 2001 both recommended a TFAD of eight hours. JCAHO incorporated compliance with the measure into its hospital accreditation processes, while CMS applied it to its own quality reporting procedures. Read More...