Improved Clinical Outcomes With Utilization of a Community-Acquired Pneumonia Guideline*
- Nathan C. Dean, MD, FCCP,
- Kim A. Bateman, MD,
- Steven M. Donnelly, PhD,
- Michael P. Silver, MPH,
- Greg L. Snow, PhD, and
- David Hale, PharmD, MHA
Abstract
Background: We previously reported decreased mortality following implementation of a community-acquired pneumonia guideline derived from specialty society recommendations. However, patients with respiratory failure and sepsis from pneumonia were not included, adjustment for comorbidities was limited, and no guideline compliance data were available. We also questioned whether decreased mortality continued after 1997.
Methods: We utilized Utah data from the Centers for Medicare and Medicaid from 1993 to 2003 to determine if pneumonia guideline implementation was associated with 30-day all-cause mortality, length of hospital stay, and readmission rate. We adjusted outcomes by age, gender, Deyo comorbidity score, prior hospitalizations, and race. Guideline compliance was measured by initial default guideline antibiotic administration. We included patients ≥ 66 years old with primary International Classification of Diseases, Ninth Revision, Clinical Modification codes 480.0–483.9, 485.0–486.9, 487.0, 507.0 or 518.81, and 038.x with secondary code pneumonia. We excluded patients with prior hospitalization within 10 days, patients with HIV infection or transplant recipients, and patients not treated by physicians closely affiliated with study hospitals.
Results: Mean (± SD) age of 17,728 pneumonia patients admitted to the hospital was 72.3 ± 12.0 years, 55.2% were female, and 96.0% were white. Within Intermountain Healthcare hospitals, a 1-SD increase (10%) in guideline compliance (range, 61 to 100%) was associated with mortality odds ratio (OR) of 0.92 (95% confidence interval[CI], 0.87 to 0.98; p = 0.007). Mortality OR at 16 Intermountain Healthcare hospitals was 0.89 (95% CI, 0.82 to 0.97; p = 0.007) compared with 19 other Utah hospitals. This mortality difference corresponds to approximately 20 lives saved yearly. The readmission rate was also lower.
Conclusion: Improved clinical outcomes were associated with pneumonia guideline utilization.
Footnotes
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Abbreviations: CI = confidence interval; CURB-65 = confusion, elevated blood urea nitrogen, elevated respiratory rate, low systolic or diastolic BP, and age > 65 years; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; OR = odds ratio
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The authors have no relevant conflicts of interest to report.
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This study was funded by the Deseret Foundation and HealthInsight, Salt Lake City.
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The analyses upon which this publication is based were performed under contract No. 500–02-UT01, funded by the Centers for Medicare and Medicaid Services, an agency of the US Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US government. The authors assume full responsibility for the accuracy and completeness of the ideas presented.
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- Accepted February 25, 2006.
- Received December 1, 2005.
