Clinical pathway care improves outcomes among patients hospitalized for community-acquired pneumonia

Abstract

Purpose

To examine the impact of a unique evidence-based clinical pathway on six outcomes of care in patients hospitalized for community-acquired pneumonia (CAP).

Methods

A retrospective cohort study of CAP patients discharged between January 1999 and December 2001, from 31 Adventist Health System institutions nationwide. A total of 22,196 records were available for multivariate analyses. Odds ratios (OR) for the outcomes were calculated and stratified by a unique severity score. The severity score ranged from 1 to 5, where 5 indicated the most severe condition.

Results

Pathway patients were significantly less likely to die in-hospital compared with non-pathway patients in four of the five severity strata (OR in severity level 1 = 0.37; 95% confidence interval [CI], 0.20–0.70). In all severity strata, pathway patients were approximately twice as likely as non-pathway patients to receive blood cultures and appropriate antibiotic therapy. Among patients who were classified as severity level 1, pathway patients experienced an 80% reduction in the odds of respiratory failure requiring mechanical ventilation (OR = 0.20; 95% CI, 0.12–0.33).

Conclusions

Patients who were placed on pneumonia clinical pathway care were much more likely than non-pathway patients to have favorable outcomes of care.

Introduction

Community-acquired pneumonia (CAP) is a common and potentially lethal disease. It remains so in spite of the availability of potent antimicrobial agents and effective vaccines. Pneumonia (together with influenza) is the seventh leading cause of death in the US (1) and the major cause of death due to infectious diseases. In the United States annually there are over 65,000 deaths due to pneumonia and influenza, which is 2.7% of all deaths in this country (1).

According to year 2000 vital statistics, pneumonia is the third most common cause of hospital discharge in the US following heart disease and baby delivery (2). Pneumonia accounts for 1.3 million hospital discharges annually (2). The national average length of stay (LOS) for CAP patients is 5.9 days for all patients and 6.5 days for Medicare patients (2). The total estimated treatment cost for an episode of CAP managed in the hospital is over $7500 (US dollars) (3). Although mortality has ranged from 2% to 30% among CAP patients in a variety of studies (for patients whose disease is severe enough to warrant treatment in the hospital setting), the average is approximately 14% 4., 5..

Several international organizations have developed guidelines for the diagnosis and management of CAP 5., 6., 7., 8.. They provide evidence-based and consensus derived statements of optimum care for patients with CAP. The challenge for physicians and hospitals is how to transform the evidence from paper to practice. This can be accomplished by converting the knowledge contained in these international guidelines into clinical pathways, protocols, and order sets that are utilized by physicians and hospital staff to guide CAP patient management. The goals are to reduce process variation and improve patient outcomes in both quality and the cost-effectiveness. There is a growing body of literature that demonstrates that this strategy helps hospitals improve the quality and cost-effectiveness of CAP patient care 9., 10., 11.. This was the course chosen by Adventist Health System (AHS). AHS created an evidence-based, standardized approach for the care of CAP patients across a national healthcare system. This was accomplished in community, non-academic hospitals with private practicing physicians. The study included patients admitted to 31 geographically dispersed hospitals. A retrospective review in a large cohort of CAP patients examined the effect of the AHS pneumonia clinical pathway on six measures that involved process, clinical, and financial outcomes.