Comparison of Outcomes for Low-Risk Outpatients and Inpatients With Pneumonia: A Propensity-Adjusted Analysis

doi:10.1378/chest.06-1393

Chest

Volume 131, Issue 2, February 2007, Pages 480-488

https://doi.org/10.1378/chest.06-1393 Get rights and content

Abstract

Background:Low-risk patients with community-acquired pneumonia are often hospitalized despite guideline recommendations for outpatient treatment.

Methods:Using data from a randomized trial conducted in 32 emergency departments, we performed a propensity-adjusted analysis to compare 30-day mortality rates, time to the return to work and to usual activities, and patient satisfaction with care between 944 outpatients and 549 inpatients in pneumonia severity index risk classes I to III who did not have evidence of arterial oxygen desaturation, or medical or psychosocial contraindications to outpatient treatment.

Results:After adjusting for quintile of propensity score for outpatient treatment, which eliminated all significant differences for baseline characteristics, outpatients were more likely to return to work (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.5 to 2.6) or, for nonworkers, to usual activities (OR, 1.4; 95% CI, 1.1 to 1.8) than were inpatients. Satisfaction with the site-of-treatment decision (OR, 1.1; 95% CI, 0.7 to 1.8), with emergency department care (OR, 1.4; 95% CI, 0.9 to 1.9), and with overall medical care (OR, 1.1; 95% CI, 0.8 to 1.6) was not different between outpatients and inpatients. The overall mortality rate was higher for inpatients than outpatients (2.6% vs 0.1%, respectively; p < 0.01); the mortality rate was not different among the 242 outpatients and 242 inpatients matched by their propensity score (0.4% vs 0.8%, respectively; p = 0.99).

Conclusions:After adjusting for the propensity of site of treatment, outpatient treatment was associated with a more rapid return to usual activities and to work, and with no increased risk of mortality. The higher observed mortality rate among all low-risk inpatients suggests that physician judgment is an important complement to objective risk stratification in the site-of-treatment decision for patients with pneumonia.

Section snippets

Materials and Methods

We analyzed the data from low-risk patients without contraindications to outpatient treatment who were enrolled in a cluster randomized trial that was designed to assess the effectiveness and safety of using the PSI to guide the selection of the initial site of treatment for patients with pneumonia. Descriptions of the study design and the primary outcomes of this trial have been reported elsewhere.7, 12Institutional review boards at all sites approved the trial, and all enrolled patients

Results

Of the 3,201 patients who were enrolled in the original trial, 1,708 were excluded from this study (higher risk patients, 1,312; low-risk patients with one or more contraindications to outpatient treatment, 350; and low-risk patients with one or more missing baseline characteristics included in the propensity score, 46) [^{Fig 1}]. Our analytical sample consisted of 1,493 low-risk patients without a contraindication to outpatient treatment (outpatients, 944 [63%]; and inpatients, 549 [37%]).

The

Discussion

As found in the Pneumonia Patient Outcomes Research Team study,¹⁹our study showed that low-risk outpatients resumed normal activities 6 to 9 days sooner than low-risk inpatients. This difference persisted after propensity score adjustment for imbalances in baseline characteristics and was not explained by the hospital length of stay among low-risk inpatients. This finding may be explained by the deconditioning that results from hospitalization, whereas patients treated in the outpatient setting

Appendix

Medical and psychosocial contraindications to outpatient treatment included the following new conditions or exacerbations of chronic conditions that were documented as being present during the initial visit in the emergency department: (1) stupor or coma; (2) severe dementia, delirium, psychiatric illness, acute confusion, or disorientation that could affect compliance with prescribed oral antibiotics or other outpatient treatments; (3) intractable vomiting or the inability to take oral

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Cited by (46)

Oral 5-Day Lefamulin for Outpatient Management of Community-Acquired Bacterial Pneumonia: Post-hoc Analysis of the Lefamulin Evaluation Against Pneumonia (LEAP) 2 Trial
2021, Journal of Emergency Medicine
Safe and effective oral antibiotics are needed for outpatient management of moderate to severe community-acquired bacterial pneumonia (CABP).
We describe a post-hoc analysis of adults with CABP managed as outpatients from the Lefamulin Evaluation Against Pneumonia (LEAP) 2 double-blind, noninferiority, phase 3 clinical trial.
LEAP 2 compared the efficacy and safety of oral lefamulin 600 mg every 12 h (5 days) vs. oral moxifloxacin 400 mg every 24 h (7 days) in adults (inpatients and outpatients) with Pneumonia Outcomes Research Team (PORT) risk classes II‒IV.
Overall, 41% (151 of 368) of patients receiving lefamulin and 43% (159 of 368) of patients receiving moxifloxacin started treatment as outpatients—44% and 40%, respectively, were PORT risk class III/IV, and 21% in both groups had CURB-65 scores of 2‒3. Early clinical response (at 96 ± 24 h) and investigator assessment of clinical response success rates at test of cure (5‒10 days after last study drug dose) were high and similar in both groups among all (lefamulin, 91% vs. moxifloxacin, 89‒90%), PORT risk class III/IV (89‒91% vs. 88‒91%), and CURB-65 score 2‒3 (87‒90% vs. 82‒88%) outpatients. Few outpatients (lefamulin, 2.6%; moxifloxacin, 2.5%) discontinued the study drug because of treatment-emergent adverse events (TEAEs). No outpatient in the lefamulin group was hospitalized for a TEAE, compared with 5 patients (3%), including two deaths, in the moxifloxacin group.
These data suggest that 5 days of oral lefamulin can be given in lieu of fluoroquinolones for outpatient treatment of adults with CABP and PORT risk class III/IV or CURB-65 scores of 2‒3.
Soft tissue oxygen saturation to predict admission from the emergency department: A prospective observational study
2017, American Journal of Emergency Medicine
Citation Excerpt :
Our primary outcome of admission to the hospital reflects the decision of an individual healthcare provider rather than a physiologic outcome. To the extent that observational data supports higher mortality rates in admitted patients compared to non-admitted patients, the decision to admit may serve as a surrogate for more definitive outcome measures [28,29]. Nevertheless, we lack follow up data on the study population, so we are unable to establish the utility of Sto2 in predicting outcomes such as mortality.
We evaluated a soft tissue oxygen saturation (Sto2) measurement at triage for predicting admission to the hospital in adults presenting to the emergency department (ED) in addition to data routinely gathered at triage.
This was a prospective, observational, single center study of adults presenting to the ED for evaluation. Research assistants obtained thenar eminence Sto2 measurements on subjects in ED triage. ED providers not involved in the study then made all management and disposition decisions. We prospectively collected data on each subject's final ED disposition (admission versus discharge). We identified the optimal Sto2 cutoff value for predicting admission. We then used logistic regression modeling to describe the added predictive value of Sto2 beyond routinely collected triage data including Emergency Severity Index level, age, and vital signs.
We analyzed 2588 adult (> 17 years) subjects with 743 subjects (28.7%) admitted to the hospital. Sto2 < 76% was the optimal diagnostic cutoff for predicting admission. Of subjects with Sto2 < 76%, 158 of 384 (41.1%) underwent admission versus 585 of 2204 (26.5%) subjects with Sto2 ≥ 76. After controlling for age, vital signs, and ESI level in the logistic regression analysis, Sto2 < 76% had an odds ratio of 1.54 (95% confidence interval (CI), 1.19 to 1.98) for predicting admission.
Sto2 may provide additional prognostic data to routine triage assessment regarding the disposition for undifferentiated adult patients presenting to the ED.
Risk factors for the severity and mortality of pneumococcal pneumonia: Importance of premorbid patients' performance status
2016, Journal of Infection and Chemotherapy
Citation Excerpt :
We did not investigate the long-term prognosis of the patients. Several outcome studies have been conducted, and the mortality rate among the patients who survived the initial event of pneumonia was substantially higher than that in control subjects [32–35]. This is considered to be associated with the increased incidence of pulmonary or cardiovascular complications.
Comorbidity is known to be associated with the severity and mortality of pneumonia. The severity of each underlying disease varies, and performance status, which is known to be a prognostic factor of malignant diseases, reflects the overall patient condition as affected by his/her comorbidity and underlying diseases of various severity. We investigated whether premorbid patients' performance status is associated with the severity and mortality of pneumococcal pneumonia. This retrospective study assessed these factors in hospitalized patients suffering from pneumococcal pneumonia from 2002 to 2015. We included 424 patients aged 68.9 ± 14.1 years in the study, of which 68.9% were men. A multivariate analysis found that advanced age (≥65 years), diabetes mellitus, and poor performance status were independent factors associated with severity, whereas old pulmonary tuberculosis, poor performance status, pneumococcal bacteremia, and severe pneumonia were independent factors that were associated with non-survival. Poor performance status was associated with the severity and mortality of pneumococcal pneumonia.
Performance of pro-adrenomedullin for identifying adverse outcomes in community-acquired pneumonia
2015, Journal of Infection
We sought to evaluate the usefulness of biomarkers—procalcitonin (PCT), C-reactive protein (CRP) and proadrenomedullin (pro-ADM)—combined with prognostic scales (PSI, CURB-65 and SCAP score) for identifying adverse outcomes in patients with community-acquired pneumonia (CAP) attending at an Emergency Department (ED).
Prospective observational study in a teaching hospital among patients with CAP. In addition to collecting data for the prognostic scales, samples were taken at the ED for assessing PCT, CRP and pro-ADM levels. We compared the prognostic accuracy of these biomarkers with severity scores to predict pneumonia related complications, using the area under the receiver operating characteristics curves (AUC), which evaluates how well the model discriminate between patients who had a pneumonia related complication or not.
A total of 491 patients with CAP were enrolled, 256 being admitted to the hospital and 235 treated as outpatients. Admitted patients had higher biomarker levels than outpatients (p < 0.001). The SCAP score and pro-ADM level had the best AUCs for predicting pneumonia related complications (0.83 and 0.84, respectively). Considering SCAP score plus pro-ADM level, the AUC increased significantly to 0.88. SCAP score class 0 or 1 with a pro-ADM level <0.5 ng/mL was the best indicator for selecting patients for outpatient care.
A new risk score combining SCAP score with pro-ADM level is useful to classify severity risk in CAP patients and hence supporting decision-making on hospital admission.
Improved Management of Community-Acquired Pneumonia in the Emergency Department
2013, Archivos de Bronconeumologia
Citation Excerpt :
Routine implementation in an ED of a CPG which incorporates the PSI is known to reduce unjustified admissions, and lead to a better choice of place of treatment (outpatients or hospital) and the appropriateness and timeliness of antibiotic treatment.18,36 Variability in the percentage of admissions between different centers and different physicians is very wide3,4 when no CPG is followed, and even when adherence is high, if there are criteria present that are not covered by the PSI. In a study carried out in 12 EDs which closely followed a CPG with the PSI scale, Aujesky et al.20 found that 37.4% of the patients with PSI I-III were admitted and 3.2% of the PSI IV–V cases were discharged.
To determine the impact of implementing clinical practice guidelines (CPGs) in the treatment of community-acquired pneumonia (CAP) in the emergency department (ED) by analyzing case management decisions (admission or discharge, appropriateness and timeliness of antibiotic therapy, complementary tests) and the consequent results (clinical stabilization time, length of hospital stay, re-admission to ED and mortality).
A prospective, observational, descriptive, comparative study carried out from 1st January 2008 to 1st August 2009 in two phases: before and after the implementation of the “Management of CAP in ED” SEMES-SEPAR (Spanish Society of Emergency Medicine – Spanish Society of Pneumology and Thoracic Surgery) clinical practice guidelines from 2008. Two hundred adult patients treated in the ED with a diagnosis of CAP were included in the study, both in the pre-intervention and post-intervention groups.
The application of the guidelines increased the administration of early and appropriate antibiotic therapy (P<.001) and shortened both the total antibiotic therapy (P<.001) and the intravenous antibiotic therapy (P=.042) times. Time to clinical stabilization (P=.027), length of hospital stay (1.14 days, P=.01), intra-hospital mortality (P=.004) and total 30-day mortality (P=.044) were all reduced. Assessment with the Pneumonia Severity Index (PSI) and biomarkers aided in appropriate decision-making concerning admission/discharge (P<.001).
The implementation of the SEMES-SEPAR 2008 guidelines, along with the use of PSI and biomarkers, significantly improved the entire treatment process of CAP. This benefitted both patients and the system by reducing mortality and improving the results of other patient management factors.
Determinar el impacto de la implementación de una guía de práctica clínica (GPC) en el proceso asistencial de la neumonía adquirida en la comunidad (NAC) en un servicio de urgencias (SU), analizando los indicadores de manejo (decisión de alta o ingreso, adecuación y precocidad de la antibioterapia, solicitud de estudios complementarios) y de resultados (tiempo de estabilización clínica, tiempo de estancia hospitalaria, reconsultas en el SU y mortalidad).
Estudio prospectivo, observacional, descriptivo y comparativo realizado desde el 1 enero de 2008 al 1 agosto de 2009 en 2 fases, antes y después de la implantación de la GPC «Manejo de la NAC en los SU» SEMES-SEPAR 2008. Se incluyó a 200 pacientes adultos atendidos en el SU con el diagnóstico de NAC tanto en el grupo preintervención como en el postintervención.
El uso de la GPC consiguió aumentar la administración precoz adecuada del antibiótico (p < 0,001) y disminuir el tiempo de tratamiento antibiótico total (p < 0,001) e intravenoso (p = 0,042), así como reducir el tiempo hasta la estabilización clínica (p = 0,027), la estancia hospitalaria (1,14 días, p = 0,01) y la mortalidad intrahospitalaria (p = 0,004) y global a los 30 días (p = 0,044). El uso del Pneumonia Severity Index (PSI) y los biomarcadores ayudaron a mejorar la adecuación de la decisión: alta o ingreso (p < 0,001).
La implementación de la GPC SEMES-SEPAR 2008 con el uso del PSI y los biomarcadores mejoró de forma significativa todo el proceso asistencial de la NAC, siendo beneficiosa para los enfermos y para el sistema al lograr disminuir la mortalidad y el resto de indicadores de resultados y de manejo.
Can we use severity assessment tools to increase outpatient management of community-acquired pneumonia?
2012, European Journal of Internal Medicine
Citation Excerpt :
It categorises patients into five risk classes. Classes I–II are at low risk (0.1–0.7% risk of 30-day mortality) and are typically recommended for outpatient treatment, patients in class III are also at relatively low risk of death (0.9–2.8%) and it has been suggested that patients in class III without evidence of oxygen desaturation can also be managed as outpatients [23]. Patients in class IV have an increased risk of mortality (4–10%), and class V patients are at the highest risk of 30-day mortality (27%) [22].
Outpatient management of community-acquired pneumonia (CAP) has several potential advantages, including significant cost-savings, a reduction in hospital-acquired infections and increased patient satisfaction. Despite the benefits, it is often difficult to identify which patients may be managed in the community without compromising patient safety. CAP severity scores, such as the pneumonia severity index (PSI) and the British Thoracic Society CURB65/CRB65 scores are designed to identify groups of patients at low risk of mortality who may be suitable for outpatient care.
This review discusses the strengths and weaknesses of severity scores for use in determining site of care for patients with pneumonia.
Use of the PSI in emergency departments has been shown to increase the proportion of patients treated in the community without increasing patient mortality or hospital readmissions. The CURB65 and CRB65 scores are less complex alternatives to the PSI that have been shown to perform similarly for prediction of 30-day mortality.
All 3 scores identify populations at low risk of mortality who may be eligible for outpatient care. Nevertheless, a number of factors not included in severity scores may prevent discharge of these patients, including social factors, co-morbidities and severity markers not captured by severity scores. The limitations of severity scores are discussed along with recent attempts to improve predictive tools, with the development of new biomarkers and alternative scoring systems.

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This research was conducted as part of the project entitled “Guideline to Improve Quality of Initial Pneumonia Care,” funded by the Agency for Healthcare Research and Quality (grant No. 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 AI01769). Dr. Labarere was supported in part by a grant from the Egide foundation, Paris (Programme Lavoisier), France, and by a grant from the Délégation Régionale de la Recherche Clinique, Centre Hospitalier Universitaire de Grenoble, France.

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

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Chest

Original Research: Lung InfectionComparison of Outcomes for Low-Risk Outpatients and Inpatients With Pneumonia: A Propensity-Adjusted Analysis

Abstract

Section snippets

Materials and Methods

Results

Discussion

Appendix

Am J Med

Ann Emerg Med

Chest

Chest

Chest

Chest

Chest

Am J Med

The cost of treating patients with community-acquired pneumonia.

Semin Respir Crit Care Med

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

Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults.

Clin Infect Dis

Practice guidelines for the management of community-acquired pneumonia in adults: Infectious Diseases Society of America.

Clin Infect Dis

Effect of increasing the intensity of implementing pneumonia guidelines: a randomized, controlled trial.

Ann Intern Med

Original Research: Lung Infection
Comparison of Outcomes for Low-Risk Outpatients and Inpatients With Pneumonia: A Propensity-Adjusted Analysis