Fine et al in Pittsburgh, Boston, and Halifax have published three new articles that shed additional light on appropriate decision making in community-acquired pneumonia. The first article examines factors used to decide on admission of 472 patients. From 1991 to 1994, 292 practitioners were polled about low-risk patients (< 4% mortality rate according to prior Fine parameters). Factors found to be most important in deciding to admit a patient were hypoxia, poor oral intake, and lack of home care support. They also asked the clinicians if there were factors that would have allowed outpatient care for those who were hospitalized and found that the ready availability of an outpatient intravenous antibiotics therapy program would likely have avoided admission in 68% of patients. Home nursing visits could have avoided admission in 59%.
The second article examined hospital discharge decisions by 168 physicians involved in the care of 332 patients with community-acquired pneumonia. These studies were conducted in 1993 and 1994. According to the clinicians, 22% of patients could have been discharged earlier; the delay was due primarily to diagnostic studies or treatment of co-morbid conditions (56%), completion of a standard course of intravenous therapy (15%), or delay in arrangements for long-term care (14%). Outpatient parenteral antibiotic therapy (OPAT) would have allowed earlier discharge in 26% and home visiting nurses in 20%.
The third article (reviewed in Infect Dis Alert 1997;16:109-110) describes a prediction rule to identify risk factors in patients with community-acquired pneumonia. Data were analyzed in more than 14,000 adult inpatients. The risk of death within 30 days was used to stratify patients. The prediction rule assigned points based on age, coexisting disease, and physical as well as laboratory findings. The mortality rate ranged from approximately 0.1% in Class I to 27% in Class V, with good consistency within each group. The low-risk groups were considered to be I-III, which had a 0.9% mortality rate. These low-risk categories found seven deaths (only 4 were pneumonia-related) among 1575 patients. The information was further validated from data on more than 38,000 patients and more than 2200 outpatients from the pneumonia patient outcomes research team (PORT) cohort study. The authors propose a prediction rule that may be a useful one in deciding whether or not the patient needs to be admitted to the hospital.
COMMENT BY ALAN D. TICE, MD, FACP
Fine and coworkers provide a useful insight and careful analysis of a huge amount of clinical data. It is obvious that significant moneys can be saved by avoiding hospitalization, but the risks in terms of mortality and morbidity are not clear. These studies help considerably in that regard and provide a useful and practical insight into admission decision. Although the prediction rule is somewhat cumbersome it appears to be a useful one. This is the type of study that needs to be done to help in regard to quality assurance and understanding how soon patients can truly be treated outside the hospital with little risk.
While these rules must be considered in every individual, they are not absolute. Considerations such as the home situation and family support are obviously critical in making decisions about an admission and early discharge, yet these are not addressed. Hopefully, these types of decisions can be analyzed better in the future. There are also problems considering unusual factors such as HIV, neurologic disease, or others. It certainly does not take away the need for or necessarily undermine the value of the physician in overseeing patient care and making appropriate decisions.
We need more studies like these to help us better understand how to make decisions in regard to quality as well as cost. This will be increasingly important with managed care.
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