Pneumonia diagnosis? Maybe send them home
Pneumonia diagnosis? Maybe send them home
Pathway helps spot patients for home recovery
If certain criteria are met, younger patients with community-acquired pneumonia can be treated at home, saving everyone money. Researchers concluded recently that treating many low-risk patients at home not only makes clinical sense, but patients prefer it that way.1
More than $4 billion is spent annually in the United States for 600,000 hospital admissions for pneumonia. Hospitalization costs for this disease are estimated to be 10 to 15 times higher than outpatient therapy. Treating patients at home would obviously have a significant impact on the cost of treating pneumonia; it has the potential to improve quality of care as well.
"Getting patients to come in to get care early enough makes a big difference," says Sharon Baschon, a utilization management consultant in Durham, NC. "In addition, the concept really only applies to a patient population under 50. The majority of the pneumonias treated in the hospital are Medicare patients, and they would be eliminated from the low-risk population right off the bat because they’re over 50."
Reduced admissions and decreased lengths of stay save money, but how can you predict who is at low risk? A model for just that was developed recently by investigators from the University of Pittsburgh School of Medicine and elsewhere.2 The model predicts other important cost-effectiveness issues as well, such as length of stay, admission to the ICU for respiratory failure or hemodynamic compromise, and time to return to usual activities.
Risk is overestimated
There is a tendency to overestimate risk of death in patients with pneumonia. The prediction method could cut down on those admissions.
The algorithm begins with the patient’s age and proceeds to look at other factors, such as comorbidities and physical and mental conditions. (See algorithm on p. 48.) The prediction model stratifies patients into risk categories based on medical history, physical examination, and lab and X-ray findings.
The model’s developers analyzed data on 14,000 inpatients and concluded their prediction model accurately identifies pneumonia patients who are at low risk for death and other adverse outcomes.
There is considerable variability in hospitalization rates of patients with community-acquired pneumonia, due in part to physicians’ uncertainty about assessing the severity of the illness at presentation. In addition, most physicians don’t involve patients in site-of-care decisions. That’s unfortunate because most patients prefer outpatient-based therapy, regardless of whether they are treated initially at home or in the hospital.
Researchers caution that factors may exist that warrant consideration before assigning a patient to outpatient care, including ability to drink fluids and take meds by mouth, a history of substance abuse, cognitive impairment, the presence of a caregiver, and comorbidities.
Investigators doing related research have established that more expensive antimicrobial therapy and longer hospital stays don’t necessarily lead to better outcomes. Many patients hospitalized for pneumonia remain in the hospital beyond the time they reach clinical stability.
The study on pneumonia outcomes was part of the Pneumonia Patient Outcomes Research Team, a 5-year multicenter project sponsored by the Agency for Health Care Policy and Research aimed at improving quality, effectiveness, and cost-effectiveness of current therapies for some of the most common and costly medical conditions.
Earlier administration of the appropriate antibiotic, says an expert panel, could improve clinical outcomes, shorten length of stay, and reduce costs.3 The related study reports that only 27% of patients hospitalized for pneumonia receive preadmission antibiotics. Currently, the time between initial patient presentation and the first antibiotic dose can range from 2 to 8 hours. The panel concluded that empiric therapy should be started in the ambulatory setting or ED within three hours of initial assessment. While in most situations, the offending organism cannot be identified, the clinician must choose an agent most likely to be effective against the common pathogens.
Reference
1. Coley CM, Yi-Hwei L, Medsger AR, et al. Preferences for home vs. hospital care among low-risk patients with community-acquired pneumonia. Arch Int Med 1996; 156:1565-1571.
2. Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997; 336:243-250.
3. Bartlett JG, Hillman AL, Niederman MS, et al. Clinical and economic consensus on early intervention in community-acquired pneumonia. Infect Dis Clin Pract 1996; 5 (4 Suppl):S179-S184.
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