How should these findings guide performance measurement? First, skepticism and reexamination must be encouraged, as they promote improved measures. However, new studies must have adequate power and populations comparable to those of the studies being challenged. The methods should reflect previous findings such as the importance of prior treatment. Randomized trials of TFAD would be ideal, but ethical concerns limit us to observational studies such as that of Meehan et al.8 Unfortunately, the CMS has stopped producing large, very clinically rich databases. Second, a performance measure used in public reporting or PFP should be applied only to the population from which it was derived, unless supporting evidence is clearly generalizable. A 4-h TFAD measure should thus be limited to persons aged ≥ 65 years with radiographic evidence of pneumonia and no antibiotic pretreatment. Third, as suggested by Metersky et al,4 public reporting and PFP should apply measures in ways that minimize consequences such as antibiotic therapy misuse. The application of inclusion criteria is one approach. For example, CMS will soon require a pneumonia diagnosis in the emergency department and radiographic evidence of pneumonia before the timing measure is applied, reducing the pressure to administer antibiotics prior to the confirmation of pneumonia (Dale Bratzler, DD; personal communication; January 16, 2006). However, this approach adds to the data abstraction burden. Another approach avoids the public reporting of the actual rates in hospitals and the use of percentile-based ranking in PFP. Reporting and rewarding hospitals by rate “band” (eg, 70 to 84% and 85 to 100%) would reduce indiscriminant antibiotic administration by eliminating the pressure to “look the very best” or be in the highest percentile of hospitals. Targeting a submaximal benchmark (eg, 80% or 85%) would allow for diagnostic uncertainty and unusual situations without defining specific exclusions. A variation would be to use a longer time (eg, 6 h) and a higher benchmark (eg, 90%).