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. 2024 Jun 14;78(6):1403-1411.
doi: 10.1093/cid/ciae044.

Development of Patient Safety Measures to Identify Inappropriate Diagnosis of Common Infections

Andrea T White  1 , Valerie M Vaughn  1   2   3 , Lindsay A Petty  4 , Tejal N Gandhi  4 , Jennifer K Horowitz  3 , Scott A Flanders  3 , Steven J Bernstein  5   6   7 , Timothy P Hofer  5   6   7 , David Ratz  5 , Elizabeth S McLaughlin  3 , Daniel Nielsen  3 , Tawny Czilok  3 , Jennifer Minock  3 , Ashwin Gupta  3   6
Affiliations

Development of Patient Safety Measures to Identify Inappropriate Diagnosis of Common Infections

Andrea T White et al. Clin Infect Dis. .

Abstract

Background: Inappropriate diagnosis of infections results in antibiotic overuse and may delay diagnosis of underlying conditions. Here we describe the development and characteristics of 2 safety measures of inappropriate diagnosis of urinary tract infection (UTI) and community-acquired pneumonia (CAP), the most common inpatient infections on general medicine services.

Methods: Measures were developed from guidelines and literature and adapted based on data from patients hospitalized with UTI and CAP in 49 Michigan hospitals and feedback from end-users, a technical expert panel (TEP), and a patient focus group. Each measure was assessed for reliability, validity, feasibility, and usability.

Results: Two measures, now endorsed by the National Quality Forum (NQF), were developed. Measure reliability (derived from 24 483 patients) was excellent (0.90 for UTI; 0.91 for CAP). Both measures had strong validity demonstrated through (a) face validity by hospital users, the TEPs, and patient focus group, (b) implicit case review (ĸ 0.72 for UTI; ĸ 0.72 for CAP), and (c) rare case misclassification (4% for UTI; 0% for CAP) due to data errors (<2% for UTI; 6.3% for CAP). Measure implementation through hospital peer comparison in Michigan hospitals (2017 to 2020) demonstrated significant decreases in inappropriate diagnosis of UTI and CAP (37% and 32%, respectively, P < .001), supporting usability.

Conclusions: We developed highly reliable, valid, and usable measures of inappropriate diagnosis of UTI and CAP for hospitalized patients. Hospitals seeking to improve diagnostic safety, antibiotic use, and patient care should consider using these measures to reduce inappropriate diagnosis of CAP and UTI.

Keywords: asymptomatic bacteriuria; community-acquired pneumonia; diagnostic stewardship; quality of care; urinary tract infection.

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Conflict of interest statement

Potential conflicts of interest. T. C., D. R., J. K. H., and L. A. P. report grants or contracts paid to institution from Blue Cross Blue Shield of Michigan (BCBSM). E. S. M. reports salary support from BCBSM. T. N. G. reports grants or contracts paid to institution from BCBSM and AHRQ. V. V. reports grants or contracts paid to institution from AHRQ, Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), BCBSM. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

Figures

Figure 1.
Figure 1.
Median percent of cases inappropriately diagnosed with UTI (A) and CAP (B) by performance decile from 2017 to 2019 (n = 49 hospitals). Data are from 1 July 2017 to 31 March 2020 across 49 acute care hospitals in the state of Michigan. This includes 13 805 patients treated for UTI, of whon 23.2% (3197) were inappropriately diagnosed (A) and 18 625 patients treated for CAP, of whom 12.3% (2299) were inappropriately diagnosed (B). Data from 2020 are not included, as only first quarter data were available (prior to the Covid-19 pandemic). Abbreviations: CAP, community-acquired pneumonia; UTI, urinary tract infection.
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