Chest
Volume 130, Issue 3, September 2006, Pages 794-799
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Original Research: Pneumonia
Improved Clinical Outcomes With Utilization of a Community-Acquired Pneumonia Guideline

https://doi.org/10.1378/chest.130.3.794Get rights and content

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.

Section snippets

MATERIALS AND METHODS

A pneumonia guideline was introduced in Intermountain Healthcare hospitals and outpatient facilities between January 1995 and January 1998. We have reviewed the methods of guideline development and implementation.11 Briefly, clinicians developed the guideline in conjunction with administrative and data support personnel by combining local practices with American Thoracic Society and Infectious Disease Society of America recommendations for treating community-acquired pneumonia. Guideline

RESULTS

The Utah Medicare fee-for-service population ≥ 65 years of age averaged 185,310 beneficiaries during the study years, ranging from 133,130 in 1994 to 223,846 in 2003. Altogether, the 10 years comprise 1,853,097 patient-years and 32,888 pneumonia hospital admissions. The hospital admission rate was therefore 17.7 per 1,000 patient years, ranging from 17.0 in 1998 to 22.4 in 1995. After the exclusions enumerated in Table 2, 17,728 pneumonia admissions remained for analysis. Mean (± SD) age of the

DISCUSSION

The Intermountain Healthcare pneumonia guideline was associated with decreased all-cause 30-day mortality in this 10-year analysis. Lower mortality was linked with administration of specific guideline-recommended antibiotics, a marker for use of other guideline elements in our view. Intermountain Healthcare hospitals demonstrate lower mortality compared with other Utah hospitals. These results confirm our earlier study28 while using better adjustment for comorbidities, a longer period of study,

CONCLUSION

We have validated the Intermountain Healthcare pneumonia guideline and in turn the specialty society recommendations from which it was derived. This study only included patients ≥ 66 years old, but the principles of care likely apply equally to younger pneumonia patients, saving additional lives. Implementing a guideline that standardizes treatment for most patients according to literature-based, current recommendations appears beneficial.

ACKNOWLEDGEMENT

We thank the nurses, respiratory therapists, pharmacists, administrators, and physicians of Intermountain Healthcare for collaborating to improve pneumonia care.

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  • Cited by (0)

    The authors have no relevant conflicts of interest to report.

    This study was funded by the Deseret Foundation and HealthInsight, Salt Lake City.

    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 organizationsimply endorsement by the US government. The authors assume full responsibility for the accuracy and completeness of the ideas presented.

    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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