Standardized treatment cuts pneumonia deaths
Guidelines also help lower admission rates
Death rates and hospital admissions for patients with community-acquired pneumonia were significantly reduced by using standardized treatment protocols developed in Utah. The results of the five-year study of more than 29,000 Utah pneumonia patients were published in the April 16, 2001 issue of the American Journal of Medicine.1
A multidisciplinary team at Intermountain Health Care (IHC) in Salt Lake City began establishing the treatment guidelines in 1994, notes Nathan Dean, MD, pulmonary medicine specialist at IHC’s LDS Hospital, also in Salt Lake City, and the study’s principal investigator. Dean chairs IHC’s lower respiratory tract infection team. "We had representatives from a number of different specialties, in both rural and urban facilities," he recalls. "They included emergency departments (ED), family practitioners, pharmacy, respiratory therapists, nursing, administration, and pulmonary and infectious disease physicians."
Establishing the guidelines
Prior to the establishment of the guidelines, treatment varied widely from facility to facility, where in some cases nearly 70 different oral and intravenous antibiotics were being used to treat pneumonia patients, with no correlation to optimal clinical outcomes. The key to the new clinical guidelines was a standardized risk assessment based on age, history, coexisting illnesses, and physical and lab abnormalities. Patients with fewer than two risk factors were recommended for outpatient oral antibiotic treatment. Those with two or more risk factors were evaluated for hospital admission or outpatient treatment with additional therapy.
At the time, the only existing published guidelines for the selection of antibiotics were those of the American Thoracic Society (ATS), Dean notes. "We simplified their guidelines and made them more operational, with bows to local practice," he says. For example, there was a common practice of using an injectible antibiotic, ceftriaxone, especially in rural facilities. "At the time, it was not recommended by the ATS," he recalls. "When we looked at it, it seemed to be a very good practice that was consistent with the guidelines, although not part of them." Interestingly, the new ATS guidelines do include ceftriaxone. "Some of our work helped validate certain treatments, and some have found their way back to the revised guidelines."
Antibiotic selection was organized according to those medications that cover common pathogens. In addition, it was determined to administer them as soon as possible after diagnosis. "Administration now is initiated in the ED, or the urgent care center, rather than admitting the patient and waiting several hours for the first dosage," Dean says. Admission decision support was based on objective risk stratification. "This gives an objective measure of what the patient’s risks of severe disease are," Dean explains. Routine preventive treatment against pulmonary embolism also is implemented.
Results are significant
The researchers observed the pneumonia patients over a five-year period. Thirty-day mortality was 13.4% among admitted patients and 6.3% overall, and was similar among patients affiliated with IHC and those not affiliated before the guideline was implemented. For patients admitted after guideline implementation, 30-day mortality was 11% among patients treated by IHC-affiliated physicians compared with 14.2% for other Utah physicians.
"That was a statistically significant finding," Dean says. "Another variable outcome we looked at was admission rates, where there was a pretty good odds ratio [.89] trend toward decrease. Length of stay also had a decrease statewide, although it was not statistically significant."
Dean notes that the guidelines have changed over time, as new literature about antibiotics is published and more information is gathered around the region. "They are also linked with contracting by our system," he adds. "If two medications are comparable by efficacy, the less expensive one is chosen."
Administration guidelines also have evolved. In 1997, it was determined that a patient with fewer than two risk factors would be recommended for outpatient oral therapy. That changed to three risk factors in 1998. "Doctors were not admitting patients with two risk factors, and they were treating them successfully as outpatients," Dean adds. "Since they were doing so well, there was no need for us to try and change the practice."
The relationship between outcomes and changed guidelines was covered in a paper in the May 2000 Chest,2 which Dean co-authored. "[Guideline] committees tend to be conservative," he adds. "It’s important as you put these guidelines out and get experience that you get feedback from the physicians in your system, look at your own data and make changes when appropriate. You don’t want to butt heads with docs, particularly when they’re right."
Benefits of standardization
The results of the study seem once again to underscore the importance of standardization in a medical setting, Dean says. "Everyone knows there is tremendous variation in medical practice, but some ways of doing things are clearly better than others. That’s particularly true with diseases like pneumonia, which is mostly treated by primary care doctors who may not be up on the latest information or developments," he points out.
"Recommended practice patterns can help guide them toward the most effective treatment. One of the problems with most national guidelines is that they are too long; we made them much more simple and more directive," Dean explains.
No set of guidelines should be seen as carved in stone, he adds. "We assume physicians will vary from the guidelines when they feel it is clinically appropriate. Compliance with our guidelines in the year 2000 was 85%, which is just about where we want it. Practices should vary, to some degree. It’s like a recipe; if you’re making stew, you need something to guide you, but you also need to be able to vary from the recipe," he explains.
References
1. Dean NC, Silver MP, Bateman KA, et al. Decreased mortality after implementation of a treatment guideline for community-acquired pneumonia. Am J Med 2001; 110.
2. Dean NC, Suchyta MR, Bateman KA, Aronsky D, et al. Implementation of admission decision support for community-acquired pneumonia. A pilot study. Chest 2000; 117: 1,368-1,377.
Need More Information?
For more on pneumonia guidelines, contact:
• Nathan Dean, MD, Intermountain Health Care, 333 S. Ninth E., Salt Lake City, UT 84102. Telephone: (801) 535-8202. E-mail: [email protected].
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