a b s t r a c t

Optimal evidence-based management of patients with uncomplicated community-acquired pneumonia in the emergency department (ED) setting remains a topic of discussion. This discussion was recently revitalized by a 2014 study published in JAMA Internal Medicine by Makam et al showing an increase in the use of blood cultures for patients with community-acquired pneumonia during ED visits from 29.4% of patients in 2002 to 51.1% in 2010. As the authors acknowledge, one of the most likely explanations could be the former pneumonia core mea- sures required by the Centers for Medicaid & Medicare Services and the Joint Commission, potentially encourag- ing both ED and inpatient providers to reflexively order cultures. As these measures were the subject of fierce debate in the emergency medicine literature almost a decade ago, with recent Policy changes affecting practicing clinicians, we aimed to briefly revisit the developments and concerning guidelines and discuss some important potentials for research in this setting.

(C) 2015

Optimal evidence-based management of patients with uncomplicat- ed community-acquired pneumonia in the emergency depart- ment (ED) setting remains a topic of discussion. This discussion was revitalized in 2014, when Makam et al [1] published a study in JAMA Internal Medicine showing that use of blood cultures for patients with CAP during ED visits had jumped from 29.4% of patients in 2002 to 51.1% in 2010 (P = .03 for trend). As the authors acknowledge, one of the most likely explanations could be the former pneumonia core measures required by the Centers for Medicaid & Medicare Services (CMS) and the Joint Commission, potentially encouraging both ED and inpatient providers to reflexively order cultures. These measures were the subject of fierce debate in the emergency medicine literature [2-4] almost a decade ago. But given recent policy changes affecting practic- ing clinicians, it seems appropriate to briefly revisit developments and relevant guidelines and discuss some important potential avenues for research in this setting.

? Grant support: Dr Weerahandi is funded in part by a National Research Service Award T32 training grant. They played no role in the preparation of this manuscript.

?? Conflicts of interest: none.

* Corresponding author at: Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai. 1 Gustave L Levy Place, Box 1087, NY, NY 10029. Tel.:+1 212 824 7459.

E-mail addresses: [email protected] (H. Weerahandi), [email protected] (J. Poeran), [email protected] (D. Nassisi), [email protected] (M. Mazumdar).

Guidelines

Arguably the most influential and most cited guidelines on the topic of blood cultures in patients with CAP are from the Infectious Diseases Society of America (IDSA) and the American Thoracic Society. They state that blood cultures are optional for hospitalized patients and should be performed in the presence of certain indications, such as ad- mission to an intensive care unit, presence of cavitary infiltrates, leuko- penia, active alcohol abuse, chronic severe liver disease, asplenia, or pleural effusion [5]. Guidelines from the American College of Emergency Physicians, American Academy of family physicians, the National Insti- tute for Health, and Care Excellence and British Thoracic Society gener- ally concur with these recommendations [6-8].

The most current guidelines are supported by a broad evidence base. Appropriate use of blood cultures in the management of CAP is seen as important because blood cultures have limited utility in improving CAP outcomes [9-16]. Furthermore, they may cause harm from generating false-positive culture results [15,17] that lead to subsequent antibiotic overuse and mismanagement [18]. In a recent review by Afshar et al [19], they identified 13 studies that had examined the impact of blood cultures on management of CAP. Blood cultures were positive for a true pathogen in only 0% to 14% of cases and led to antibiotic narrowing in only 0% to 3% of patients. positive blood cultures led to identification of a resistant organism and antibiotic broadening in 0% to 1% of patients. These findings support the concept that obtaining blood cultures in pa- tients with uncomplicated CAP is a low-yield procedure and could po- tentially result in harm.

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Drivers of increased blood culture utilization

The initial 2002 CMS and Joint Commission measures stated that blood cultures in the ED setting should be collected before antibiotic ad- ministration (measure PN-3b). When it was written, this measure was backed by the former IDSA guidelines in 2000 [20], despite insufficient evidence for blood cultures in the management of CAP. After rigorous discussion in the emergency medicine literature [2-4,21-23], the IDSA/ American Thoracic Society guidelines changed in 2007 to reflect the ev- idence that routine blood cultures do not improve management of CAP [24]. Nonetheless, CMS and the Joint Commission did not adjust their quality guidelines until very recently. On January 1, 2014, CMS and the Joint Commission retired measure PN-3b. The CMS removed it from its Hospital Inpatient Quality Reporting program but the Joint Commission continuing to collect data on this measure only to retire the entire pneu- monia measure set on January 1, 2015.

Other guidelines, such as the Surviving sepsis campaign guidelines (initiated in 2002) [25], may have increased providers’ inclination to draw blood cultures in the setting of CAP. This campaign introduced sepsis care bundles, including an element to obtain blood cultures with- in the first 6 hours of presentation. In attempting to identify patients with sepsis and initiating treatment as early as possible, some patients with uncomplicated CAP (who do not need blood cultures) may have blood cultures performed anyway because of these other guidelines.

Given the very recent CMS and Joint Commission developments, the main limitation of the study by Makam et al [1] is that it analyzed data only up to 2010. In addition, because of the survey structure of their data, they lacked detailed clinical characteristics about these cases, in particular other indications for blood cultures (eg, history of liver dis- ease). An important piece of information provided-yet not mentioned in their discussion-is that obtaining blood cultures was not associated with either disease severity or risk for intensive care unit admission, adding to the discussion of the clinical utility of these tests.

Because the current guidelines mention specific clinical indications for blood cultures in patients with CAP, more detailed clinical data are needed to assess the appropriateness of blood culture utilization and the potential for overtreatment. Data on the effects of the recent policy changes would greatly benefit the ongoing discussion of optimal ED care in such patients. However, because of complex administrative and regulatory requirements with various conflicting guidelines, confu- sion may exist regarding changing clinical practice.

For example, consider a case where a treating physician in the ED ad- mitted a patient for uncomplicated CAP that did not require cultures based upon guidelines. If the physician then started the patient on ap- propriate antibiotics, only to have the admitting team order blood cul- tures later, this action would be flagged as noncompliant under the previous CMS/Joint Commission quality metrics because antibiotics were given before the blood culture. This situation likely resulted in pressures on ED providers to order blood cultures before initiating anti- biotic therapy, regardless of indication.

The potential high value of research in this area is illustrated by the current emphasis of policy makers on the potential for cost reduction associated with overtreatment, estimated to cost $226 billion in 2011 [26]. Often mentioned in this context is the choosing wisely initiative, which currently does not include blood culture utilization. Thus, an im- portant window of opportunity appears to be missed in modifying over- treatment and costs of ED care. This may be especially true for patients with CAP because pneumonia is among the top 10 most expensive treated conditions in the United States, costing more than $10 billion in 2011 [27].

There is a need to convert the current Evidence-based guidelines into clinical practice regarding the use of blood cultures in CAP patients. The Joint Commission/CMS pneumonia core measures have existed for over a decade; thus, it is important to highlight these new changes. There is also a need for more research in Clinical decision support and its effects on health care utilization. For example, a reminder in the

electronic health record that blood cultures are not recommended in uncomplicated CAP may aid in promoting best practices in this setting. In addition, the recent CMS and Joint Commission policy changes high- light an important research opportunity to evaluate the impact of these changes on clinical practice.

In conclusion, there has been a long-standing discussion on Optimal care for patients with CAP in the ED setting, where practice and policy guidelines have not always coincided. With recent policy changes, there are important and high-yield opportunities for research that will improve patient care and health care utilization and, thus, deserve high priority on the research agenda.

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