Brief observation
Effects of a practice guideline for community-acquired pneumonia in an outpatient setting

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Methods

A multidisciplinary team developed the practice guideline, which directed specific antibiotic choices and hospital admission based on severity assessment (11). Our guideline followed 1993 American Thoracic Society recommendations. The study sample included consecutive immunocompetent pneumonia patients ≥18 years old, treated at four Instacares, which are high-volume, urgent care clinics that are staffed to provide acute walk-in care 14 hours daily (no ambulance or long-term care facility

Results

Four hundred sixty-three patients were identified: 199 before guideline implementation (control period) and 264 after guideline implementation (intervention period). The practice guideline form was completed for 238 of 264 (90%) patients. Age, sex, smoking history, pneumonia severity index, pneumonia severity index risk class, and number of risk factors did not differ between the groups (Table 1).

The rate of hospital admission was twice as great during the control period (14% versus 6%, P =

Discussion

After implementation of a pneumonia guideline, the hospital admission rate for patients with community-acquired pneumonia seen at three urgent care clinics decreased without a detectable difference in baseline severity of illness. While the focus of the guideline was quality of care, it also resulted in substantial cost savings. Saving $45 per patient for antibiotic therapy amounts to $135 million if extrapolated to the estimated 3 million outpatients with pneumonia treated annually in the

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  • Guidelines and Quality Measures. Do They Improve Outcomes of Patients with Community-Acquired Pneumonia?

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    Threefold lower costs were found in those 60 years or younger without comorbidity given therapy consistent with the guidelines, but no significant differences in medical outcomes were found. A later study found that by following the ATS recommendations of 1993, hospital admission rates for CAP patients seen at urgent care clinics decreased.6,7 Table 1 lists references of relevant studies examining the effects of guidelines on various outcome measures.

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    Gleason and colleagues19 showed a good adherence to the ATS guidelines,20 with differences in costs but not in outcomes. Suchyta and colleagues21 found a decrease in admissions when there was higher adherence to a pneumonia guideline without reporting adverse effects. Concerning hospitalized patients with CAP, there is more information about the impact of compliance with antibiotic treatment on outcomes (Tables 1 and 2).

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Supported in part by an unrestricted educational grant from PfizerUSPG.

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