In reply

Abstract

Hospitalization for nursing home-acquired pneumonia (NHAP) is consistent with the financial interests of hospitals and most skilled nursing facilities. It is less clear that hospitalization for NHAP similarly serves the health interests of nursing home residents.1, 2 In our study of NHAP from general nursing home units (not subacute units) hospitalization was not associated with a survival benefit.3 Based on our studies in nursing homes in western New York State between November 1997 and April 1998 (manuscript submitted to the Journal of the American Geriatrics Society for publication), about 75% of nursing home residents with pneumonia are treated in the nursing home, and 25% are hospitalized for initial treatment. We believe that most (85–90%) residents with NHAP can be treated effectively in the nursing home. However, there is a need to evaluate community standards for treatment of NHAP. For example, the optimum frequency of physician or nurse practitioner assessment during treatment of NHAP is unclear. Based on our unpublished observations referred to above, residents treated for NHAP with an oral antibiotic are seen infrequently (if at all) by a physician or nurse practitioner. If intravenous therapy is being administered in the nursing home, daily assessment may be required initially, but this may not be necessary for more than 2 to 3 days since most residents could be switched to an oral regimen by Day 3 or Day 4. In fact, residents discharged from the hospital back to the nursing home to complete therapy with an oral antibiotic are not routinely examined by a physician during the completion of therapy. Although the concerns of Twersky et al. are appropriate, they beg the question about the hospital's role in the treatment of NHAP. Chest X-rays are readily available in the nursing home setting. Other diagnostic tests, such as a complete blood count, electrolytes, BUN, and serum creatinine, are also readily available. Serial chest X-rays are unnecessary in residents who respond to therapy, and follow-up blood tests can be done depending on the initial abnormalities. Treatment of residents with pneumonia in the nursing home is less costly and safer for residents than treatment in the hospital.1, 2 Our study is the result of a successful effort to provide an alternative to hospitalization for NHAP. We view it as a starting point for the critical assessment of acute disease management for nursing home residents in the nursing home.