Pay for performance for antibiotic timing in pneumonia: caveat emptor.

BACKGROUND: Health care practitioners and hospital administrators have focused on a performance measure regarding antibiotic timing for patients with community-acquired pneumonia in anticipation of a pay-for-performance program through the Centers for Medicare & Medicaid Services (CMS) and private payers. ANTIBIOTIC TIMING AS A PERFORMANCE MEASURE: Early antibiotic administration is associated with improved outcomes, even after adjusting for severity. Yet although some patients may benefit through the early administration of antibiotics, there is a risk to other patients who are treated concurrently. Some patients' care may be delayed because they may not receive the same priority as patients with suspected pneumonia. Other patients may receive inappropriate antibiotics for suspected pneumonia to shorten the time to administration. POTENTIAL IMPACT OF PAY FOR PERFORMANCE: Attempts to address the performance measure are probably dependent on how well the emergency department functions and the level of crowding. Patients with a suspected pneumonia may be empirically covered with antibiotics before radiographic diagnosis, which should increase the rate of antibiotic administration for antibiotic-nonresponsive conditions and contribute to antibiotic resistance. The answer is to find measures of system throughput and/or work flow that are associated with improved patient care outcomes.