The Joint Commission on Accreditation of Healthcare Organizations and Center for Medicare and Medicaid Services Community-Acquired Pneumonia Initiative: What Went Wrong?

Abstract

During the past 4 decades, the focus for health care providers and systems has shifted from an anecdotal, experience-based practice toward the use of proven interventions with sound evidence of improved outcomes. In parallel, patients, insurers, and employers became increasingly sensitized to variability in the cost and quality of care, leading to a progressive increase in scrutiny and transparency in the health care system. Appropriately, the Center for Medicare and Medicaid Services, providing health insurance to more than 41,000,000 people, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) positioned themselves in the vanguard of the drive for increased uniformity and quality of care, initiating a series of national measures and a system of public reporting of hospital performance. Among the first of these National Hospital Quality Measures, initiated in 2002, are those related to acute myocardial infarction, heart failure, and community-acquired pneumonia. Emergency departments (EDs) bear a large measure of the responsibility for the acute myocardial infarction interventions, such as the administration of aspirin and b-blockers at hospital arrival and time to thrombolysis or percutaneous coronary intervention. The powerful evidence supporting these measures pre-empts any possible resistance, and individual departments work in earnest to meet or exceed national benchmarks and seek 100% compliance. The heart failure measures, also evidence based, relate primarily to inpatient care and do not directly affect ED operations. One small misstep in both the acute myocardial infarction and heart failure measures occurred, with failure to recognize the role of angiotensin receptor blocking agents as an alternative to the angiotensin-converting enzyme inhibitors that were specified in the guidelines, but this did not interfere with the process of care, and the definitions were subsequently modified to accept either class of agents. In sharp distinction, the community-acquired pneumonia measures include a requirement to obtain blood cultures before administering antibiotics, a measure that is opposed by an overwhelming weight of evidence and one that places an