Abstract
BACKGROUND: Many low-risk patients with pneumonia are hospitalized despite recommendations to treat such patients in the outpatient setting.
OBJECTIVE: To identify the factors associated with the hospitalization of low-risk patients with pneumonia.
METHODS: We analyzed data collected by retrospective chart review for 1,889 low-risk patients (Pneumonia Severity Index [PSI] risk classes I to III without evidence of arterial oxygen desaturation) enrolled in a cluster-randomized trial conducted in 32 emergency departments.
RESULTS: Overall, 845 (44.7%) of all low-risk patients were treated as inpatients. Factors independently associated with an increased odds of hospitalization included PSI risk classes II and III, the presence of medical or psychosocial contraindications to outpatient treatment, comorbid conditions that were not contained in the PSI (cognitive impairment, history of coronary artery disease, diabetes mellitus, or pulmonary disease), multilobar radiographic infiltrates, and home therapy with oxygen, corticosteroids, or antibiotics before presentation. While 32.8% of low-risk inpatients had a contraindication to out-patient treatment and 47.1% had one or more preexisting treatments, comorbid conditions, or radiographic abnormalities not contained in the PSI, 20.1% had no identifiable risk factors for hospitalization other than PSI risk class II or III.
CONCLUSIONS: Hospital admission appears justified for one-third of low-risk inpatients based upon the presence of one or more contra-indications to outpatient treatment. At least one-fifth of low-risk inpatients did not have a contraindication to outpatient treatment or an identifiable risk factor for hospitalization, suggesting that treatment of a larger proportion of such low-risk patients in the outpatient setting could be achieved without adversely affecting patient outcomes.
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References
Defrances CJ, Hall MJ, Podgornik MN. 2003 National Hospital Discharge Survey. Advance Data from Vital and Health Statistics of the Centers for Disease Control and Prevention. 2005:1–20.
Lave JR, Lin CCJ, Fine MJ, Hughes-Cromwick P. The cost of treating patients with community-acquired pneumonia. Semin Respir Crit Care Med. 1999;20:189–97.
Fine MJ, Hough LJ, Medsger AR, et al. The hospital admission decision for patients with community-acquired pneumonia. Results from the pneumonia patient outcomes research team cohort study. Arch Intern Med. 1997;157:36–44.
Coley CM, Li YH, Medsger AR, et al. Preferences for home vs hospital care among low-risk patients with community-acquired pneumonia. Arch Intern Med. 1996;156:1565–71.
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;336:243–50.
Yealy DM, Auble TE, Stone RA, et al. Effect of increasing the intensity of implementing pneumonia guidelines: a randomized, controlled trial. Ann Intern Med. 2005;143:881–94.
Marrie TJ, Lau CY, Wheeler SL, Wong CJ, Vandervoort MK, Feagan BG. A controlled trial of a critical pathway for treatment of community-acquired pneumonia. CAPITAL study investigators. Community-acquired pneumonia intervention trial assessing Levofloxacin. JAMA. 2000;283:749–55.
Atlas SJ, Benzer TI, Borowsky LH, et al. Safely increasing the proportion of patients with community-acquired pneumonia treated as outpatients: an interventional trial. Arch Intern Med. 1998;158:1350–6.
Marrie TJ, Huang JQ. Low-risk patients admitted with community-acquired pneumonia. Am J Med. 2005;118:1357–63.
Halm EA, Atlas SJ, Borowsky LH, et al. Understanding physician adherence with a pneumonia practice guideline: effects of patient, system, and physician factors. Arch Intern Med. 2000;160:98–104.
Yealy DM, Auble TE, Stone RA, et al. The emergency department community-acquired pneumonia trial: methodology of a quality improvement intervention. Ann Emerg Med. 2004;43:770–82.
Rice N. Binomial regression. In: Leyland AH, Goldstein H, eds. Multilevel Modelling of Health Statistics. Hoboken, NJ: John Wiley & Sons Ltd; 2001:27–43.
Browne WJ. MCMC Estimation in MLwiN, Version 2.0. London, UK: Institute of Education, University of London; 2003.
Bartlett JG, Dowell SF, Mandell LA, File TM Jr, Musher DM, Fine MJ. Practice guidelines for the management of community-acquired pneumonia in adults. Infectious Diseases Society of America. Clin Infect Dis. 2000;31:347–82.
Mandell LA, Marrie TJ, Grossman RF, Chow AW, Hyland RH. Canadian guidelines for the initial management of community-acquired pneumonia: an evidence-based update by the Canadian Infectious Diseases Society and the Canadian Thoracic Society. The Canadian Community-Acquired Pneumonia Working Group. Clin Infect Dis. 2000;31:383–421.
Mandell LA, Bartlett JG, Dowell SF, File TM Jr, Musher DM, Whitney C. Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults. Clin Infect Dis. 2003;37:1405–33.
Goss CH, Rubenfeld GD, Park DR, Sherbin VL, Goodman MS, Root RK. Cost and incidence of social comorbidities in low-risk patients with community-acquired pneumonia admitted to a public hospital. Chest. 2003;124:2148–55.
Arnold FW, Ramirez JA, McDonald LC, Xia EL. Hospitalization for community-acquired pneumonia: the pneumonia severity index vs clinical judgment. Chest. 2003;124:121–4.
Marras TK, Gutierrez C, Chan CK. Applying a prediction rule to identify low-risk patients with community-acquired pneumonia. Chest. 2000;118:1339–43.
Stelianides S, Golmard JL, Carbon C, Fantin B. Influence of socioeconomic status on features and outcome of community-acquired pneumonia. Eur J Clin Microbiol Infect Dis. 1999;18:704–8.
Roson B, Carratala J, Dorca J, Casanova A, Manresa F, Gudiol F. Etiology, reasons for hospitalization, risk classes, and outcomes of community-acquired pneumonia in patients hospitalized on the basis of conventional admission criteria. Clin Infect Dis. 2001;33:158–65.
Metlay JP, Fine MJ. Testing strategies in the initial management of patients with community-acquired pneumonia. Ann Intern Med. 2003;138:109–18.
Fine MJ, Smith MA, Carson CA, et al. Prognosis and outcomes of patients with community-acquired pneumonia. A meta-analysis. JAMA. 1996;275:134–41.
Hasley PB, Albaum MN, Li YH, et al. Do pulmonary radiographic findings at presentation predict mortality in patients with community-acquired pneumonia? Arch Intern Med. 1996;156:2206–12.
Carratala J, Fernandez-Sabe N, Ortega L, et al. Outpatient care compared with hospitalization for community-acquired pneumonia: a randomized trial in low-risk patients. Ann Intern Med. 2005;142:165–72.
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This research was conducted as part of the project, Guideline to Improve Quality of Initial Pneumonia Care, funded by the Agency for Healthcare Research and Quality (grant number R01 HS10049). Dr. M. J. Fine was supported in part by a K-24 career development award from the National Institute of Allergy and Infectious Diseases (5K24 A101769). Dr. J. Labarere was supported by a grant from the Egide foundation, Paris, France (Programme Lavoisier), and by the Grenoble University Hospital (DRC, CHU Grenoble).
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Labarere, J., Stone, R.A., Obrosky, D.S. et al. Factors associated with the hospitalization of low-risk patients with community-acquired pneumonia in a cluster-randomized trial. J Gen Intern Med 21, 745–752 (2006). https://doi.org/10.1111/j.1525-1497.2006.00510.x
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DOI: https://doi.org/10.1111/j.1525-1497.2006.00510.x