Low-risk Community-acquired Pneumonia Research Articles

Acute management of pneumonia in adult patients.

Acute management of pneumonia in adult patients.

Antimicrobial prescribing and outcomes of community-acquired pneumonia in Australian hospitalized patients: a cross-sectional study.

ObjectiveWe aimed to assess prescribing practices, compliance with guidelines, and outcomes for patients who were admitted to the authors’ institution with community-acquired pneumonia (CAP).MethodsWe performed a single-center retrospective cross-sectional study of adults with CAP presenting during the 2019 influenza season. CAP severity was assessed using the CURB-65 risk score. The effect of CURB-65 risk score use on the rate of appropriate antimicrobial prescribing was assessed using the chi-square test and reported as odds ratio (OR). Fisher’s exact test was used to assess the relationship between prescribing appropriateness and patient outcomes.ResultsPatients with low-risk CAP were most likely to be inappropriately prescribed antimicrobials (OR: 4.77; 95% confidence interval: 2.44–10.47). In low-risk CAP, the most common prescribing error was overuse of ceftriaxone. In high-risk CAP, the most common errors were ceftriaxone underdosing and missed atypical coverage with azithromycin. Overall, 80% of patients were considered to have been inappropriately prescribed antimicrobials. No effect on mortality was observed.ConclusionsIn this study, we found low use of CAP risk scores and low adherence to antimicrobial prescribing guidelines for CAP at the authors’ institution.

Two new inflammatory markers related to the CURB-65 score for disease severity in patients with community-acquired pneumonia: The hypersensitive C-reactive protein to albumin ratio and fibrinogen to albumin ratio

BackgroundThe objective of this study was to investigate the relationship among hypersensitive C-reactive protein to albumin ratio (CAR), fibrinogen to albumin ratio (FAR), and the CURB-65 score for community-acquired pneumonia (CAP) severity.MethodsClinical data and laboratory indicators of 82 patients with CAP and 40 healthy subjects were retrospectively analysed. The relationship among CAR, FAR, and the severity of CAP was then analysed.ResultsCAR and FAR in patients with low-risk CAP were significantly higher than those in the normal control group (P < 0.05). CAR and FAR in patients with medium–high-risk CAP were further increased compared with those in patients with low-risk CAP (P < 0.05). CAR and FAR were positively correlated with hypersensitive C-reactive protein, neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and CURB-65 scores (P < 0.05). In the receiver operating characteristic curve for predicting severe CAP, the area under the curve of combining four biomarkers (CAR + FAR + NLR + PLR) was the largest. CAR was also an independent risk factor for severe CAP (OR = 8.789, 95% CI: 1.543–50.064, P = 0.014).ConclusionsCAR and FAR may be used as the inflammatory markers for CAP severity evaluation.

Development and Implementation of a Clinical Pathway to Reduce Inappropriate Admissions Among Patients with Community-Acquired Pneumonia in a Private Health System in Brazil: An Observational Cohort Study and a Promising Tool for Efficiency Improvement.

PurposePatients with community-acquired pneumonia (CAP) at low risk of death by CURB-65 scoring system are usually unnecessarily treated as inpatients generating additional economic and clinical burden. We aimed to implement an evidence-based clinical pathway to reduce hospital admissions of low-risk CAP and investigate factors related to mortality and readmissions within 30 days.Patients and MethodsFrom November 2015 to August 2017, a clinical pathway was implemented at 20 hospitals. We included patients aged >18 years, with a diagnosis of CAP by the attendant physician. The main outcome was the monthly proportion of low-risk CURB-65 admission after the implementation of the clinical pathway. Logistic regression models were performed to assess variables associated with mortality and readmission in the admitted population within 30 days.ResultsWe included 10,909 participants with suspected CAP. The proportion of low-risk CAP admitted decreased from 22.1% to 12.8% in the period. Among participants with low risk, there has been no perceptible increase in deaths (0.80%) or readmissions (6.92%). Regression analysis identified that CURB-65 variables, presence of pleural effusion (OR= 1.74; 95%CI=1.08–2.8; p=0.02) and leucopenia (OR= 2.47; 95%CI=1.11–5.48; p=0.02) were independently associated with 30-day mortality, whereas a prolonged hospital stay (OR= 2.09; 95%CI=1.14–3.83; p=0.01) was associated with 30-day readmission in the low-risk population.ConclusionThe implementations of a clinical pathway diminished the proportion of low-risk CAP admissions with no apparent increase in clinical outcomes within 30 days. Nonetheless, additional factors influence the clinical decision about the site of care management in low-risk CAP.

Neumonía adquirida en la comunidad de bajo riesgo: Consecuencias evolutivas de los determinantes de internación no contemplados por los scores

ObjectivesThe decision to admit patients with community-acquired pneumonia (CAP) to hospital are based on stratification scales. This classification into risk groups is not perfect. In low-risk community-acquired pneumonia (LR-CAP), physicians often depend on their subjective impressions to decide the need for hospitalisation, which suggests the existence of conditions not considered by the scores. The aim of this article was to describe the determining factors for admission in LR-CAP, and to analyse the relationship between these causes and clinical outcome. Material and methodsA descriptive, observational, retrospective study, based on the review of medical records during a 2 year-period. It included patients over 18 years, who were hospitalised in a third level hospital in Argentina due to LR-CAP. ResultsA total of 80 cases were identified. The causes that led to hospitalisation were: comorbidities not included in the scores, development of pleural effusion and sepsis, lack of response to ambulatory antibiotic treatment, oral intolerance, and social causes. HIV infection was associated with an unfavourable clinical progress during hospital admission (p=.03), as well as the lack of response to outpatient treatment (p=.03) and the development of pleural effusion (p=.03). Social causes were associated with a need for longer intravenous treatment. ConclusionsHIV infection, social causes, and lack of response to ambulatory treatment were related to unfavourable clinical progress.

Discordance of physician clinical judgment vs. pneumonia severity index (PSI) score to admit patients with low risk community-acquired pneumonia: a prospective multicenter study.

The relationship between clinical judgment and the pneumonia severity index (PSI) score in deciding the site of care for patients with community-acquired pneumonia (CAP) has not been well investigated. The objective of the study was to determine the clinical factors that influence decision-making to hospitalize low-risk patients (PSI ≤2) with CAP. An observational, prospective, multicenter study of consecutive CAP patients was performed at five hospitals in Spain. Patients admitted with CAP and a PSI ≤2 were identified. Admitting physicians completed a patient-specific survey to identify the clinical factors influencing the decision to admit a patient. The reason for admission was categorized into 1 of 6 categories. We also assessed whether the reason for admission was associated with poorer clinical outcomes [intensive care unit (ICU) admission, 30-day mortality or readmission]. One hundred and fifty-five hospitalized patients were enrolled. Two or more reasons for admission were seen in 94 patients (60.6%), including abnormal clinical test results (60%), signs of clinical deterioration (43.2%), comorbid conditions (28.4%), psychosocial factors (28.4%), suspected H1N1 pneumonia (20.6%), and recent visit to the emergency department (ED) in the past 2 weeks (7.7%). Signs of clinical deterioration and abnormal clinical test results were associated with poorer clinical outcomes (P<0.005). Low-risk patients with CAP and a PSI ≤2 are admitted to the hospital for multiple reasons. Abnormal clinical test results and signs of clinical deterioration are two specific reasons for admission that are associated with poorer clinical outcomes in low risk CAP patients.

LO068: Physician adherence to Antimicrobial Guidelines for Community Acquired Pneumonia in the St. Michael’s Hospital Emergency Department

Introduction: The Toronto Central Local Health Integration Network released new antimicrobial guidelines for the treatment of community acquired pneumonia (CAP) in August 2013. These deemphasized antimicrobial coverage for atypical organisms and use amoxicillin-clavulanic acid (AMC) as first-line for low risk CAP. The purpose of this study was to assess physician adherence to these guidelines in St. Michael’s Hospital (SMH) Emergency Department (ED). Methods: A retrospective chart review was conducted from April 1 to May 31 in 2013, 2014 and 2015. All adult patients who were discharged home from the ED with a diagnosis of pneumonia were included. Severity of pneumonia was graded based on the CRB-65 score as per the CAP guidelines. Primary outcome was type of antibiotic prescribed by the ED physician. Data was analyzed using simple descriptive statistics. Results: There were a total of 141 patients analyzed during the study period (N=46 in 2013, N=59 in 2014, N=36 in 2015). Demographics and relevant comorbidities were similar across the years: age (2013: median=53 years, range 20-92 years; 2014: 56, 21-83; 2015: 54, 20-81); preexisting lung disease (30%, 27%, 25% respectively); HIV positive status (9%, 7%, 17%). CRB-65 score was: low risk (0 points)=70% in 2013, 66% in 2014, 75% in 2015; intermediate risk (1-2 points)=30%, 34%, 25%; high risk (3-4 points)=0% in all years. Percentage of patients discharged home with a documented prescription was 83%, 85%, and 94% respectively. In 2013, patients received azithromycin (AZM) (n=17, 43% of antibiotic prescriptions that year); levofloxacin (LVX) (n=10, 25%); AMC (n=5, 13%); clarithromycin (CLR) (n=5, 13%); trimethoprim-sulfamethoxazole (SXT) (n=2, 5%); doxycycline (DOX) (n=1, 3%). In 2014: AMC (n=26, 51%); AZM (n=12, 24%); LVX (n=9, 18%); CLR (n=2, 4%); DOX (n=1, 2%); erythromycin (ERY) (n=1, 2%). In 2015: AMC (n=17, 47%); AZM (n=12, 33%); LVX (n=4, 11%); CLR (n=1, 3%); SXT (n=1, 3%); DOX (n=1, 3%). Number of return ED visits within 2 weeks were: n=16 (35%); n=11 (19%); and n=10 (28%) respectively. Conclusion: The results of this study show that there has been a change in antibiotic prescribing practices in the SMH ED since dissemination of the CAP guidelines, with AMC accounting for nearly half of antibiotic prescriptions. Further antimicrobial stewardship efforts will focus on evaluating factors influencing prescribing practices.

Causes of Hospital Admission in Low Risk Community-Acquired Pneumonia (CAP): A Prospective Multicenter Study

Causes of Hospital Admission in Low Risk Community-Acquired Pneumonia (CAP): A Prospective Multicenter Study

Adecuación de los ingresos y de la asistencia facilitada a los pacientes con neumonía adquirida en la comunidad

Background The purpose of this study has been to know the adequacy of the hospital admissions of patients with community-acquired pneumonia (CAP), applying the Fine Modified Forecast Classification Rule and if patient care is performed in accordance with the indicators for quality by the Infectious Diseases Society of America (IDSA) recommendations. Patients and methods A cross-sectional and retrospective study analyzing the appropriateness of hospital admissions of all patients treated for CAP at the Hospital Clínico Universitario de Valladolid during 2006. All patients were interviewed with the classification rules for Fine Modified Forecasting to evaluate the adequacy of hospital admissions through the analysis of associated comorbidity, severity parameters and quality indicators. Results We detected 23 cases (6.07%) of CAP inadequately admitted, 5 of whom were Class I (21.7%), 10 Class II (43.4%) and 8 Class III (34.7%). COPD (32.5%) and hypoxemia (36%) were the comorbidities and risk factors most involved in the admission of low-risk CAP. A total of 25 (32.89%) inadequate discharges were observed from the Emergency Service and the following was found in regard to their Pneumonia Severity Index (PSI): Class I: 2 (8%), Class II: 10 (40%) Class III: 7 (28%), Class IV: 4 (16%), Class V: 0; Fine Unknown: 2. The most important comorbidity in inadequate discharges was 10 for COPD (40%). The following were performed: blood cultures in 160 cases (42.2%), chest x-ray in 379 (100%), gas and/or pulse measurement in 379 (100%), and measurement of Ag S. pneumoniae and Legionella in urine in 14 (87.5%) of the 16 cases of CAP that required admission to the ICU. Conclusion The Fine Modified Forecasting Classification Rule can be very useful in assessing adequacy of admissions and to decide the need for hospital admission due to CAP. Adequate care for patients with CAP according to the quality indications established by the IDSA stands out.

Physician judgement is a crucial adjunct to pneumonia severity scores in low-risk patients

This study investigates the reasons for hospitalisation in patients with low-risk (CURB-65 score 0-1) community-acquired pneumonia (CAP), with a view to identifying the potential for improving outpatient management. As part of a prospective observational study of CAP, we evaluated reasons for hospitalisation in these low-risk patients. 565 patients had low-risk CAP and 420 of these were admitted (for >12 h). 39.3% had additional markers of severity justifying admission, 29.5% of the admissions were required for further management that could not be provided rapidly in the community, 11.9% had unsafe social circumstances and 19.3% had no clinical reason justifying hospitalisation. 30-day mortality was increased in patients with additional severity markers (6.7%), which was significantly higher compared with 0% for patients awaiting investigations (p=0.009) and 0% without a clear indication for hospitalisation (p=0.04). In a logistic regression analysis, parameters associated with 30-day mortality were chronic cardiac comorbidity (adjusted odds ratio (aOR) 5.73, 95% CI 1.52-21.6; p=0.01), acidosis (aOR 5.14, 95% CI 1.44-18.3; p=0.01), hypoxia (aOR 9.86, 95% CI 2.39-40.7; p=0.002) and multilobar chest radiograph shadowing (aOR 4.54, 95% CI 1.21-17.1; p=0.03). This study supports recommendations from international guidelines that pneumonia severity scores should be used as an adjunct to clinical judgement, when deciding on hospitalisation.

The Effects of Incorporating a Pneumonia Severity Index into the Admission Protocol for Community-Acquired Pneumonia

Background: Community-acquired pneumonia (CAP) is a common reason for admissions in the emergency department (ED). However, patient disposition is not always standardized. Objective: To evaluate the effect of incorporating a pneumonia severity index (PSI) on admission rates and medical costs in CAP patients presenting to the ED. Methods: From April 2008 to March 2009, CAP patients presenting to the ED were prospectively screened and low-risk CAP patients (PSI I, II, or III) were enrolled (after group). Discharge and outpatient care were recommended for this group in the absence of other medical conditions requiring hospitalization. Data from low-risk CAP patients from May 2003 to October 2006 were also collected for comparative analysis (before group). Results: There were 365 and 174 patients in the before and after groups, respectively. The admission rate of the after group was significantly lower than that of the before group (30.4% vs. 68.2%, p < 0.01). The subsequent admission rates after ED discharge due to CAP were similar (3.2% vs. 7.7%, p = 0.10). The ultimate admission rate in the after group was significantly lower than that in the before group (32.5% vs. 70.7%, p < 0.01). Direct medical costs per patient for the before and after groups were $US 1532 and $US 1186, respectively (p = 0.03). Conclusions: Incorporation of the PSI into the admission protocol for ED patients with CAP significantly reduced the admission rates and medical costs.

Potential for Cost-Savings in the Care of Hospitalized Low-Risk Community-Acquired Pneumonia Patients in China

Background The cost of treating community-acquired pneumonia (CAP) in China is a heavy economic burden for the society. Objective To investigate the costs of hospitalization of low-risk CAP patients and how hospitalization costs can be reduced through proper usage of hospital resources. Methods Two hundred thirty-six patients with low-risk CAP who were hospitalized between January 2000 and December 2005 in a 1161-bed tertiary care teaching hospital were included in a retrospective cohort study. Their hospitalization costs and antibiotic therapy were analyzed. General linear model was utilized to determine correlative variables associated with total hospital costs. Results The median length of hospital stay was 12 days and the median duration of intravenous (IV) antibiotic therapy was 10 days, they were correlated significantly ( P = 0.000, r = 0.81). The median total hospital cost was $556.50 (mean $705.60), of which 48.9% was for drugs, 21.9% for laboratory tests, 8.6% for radiology, 6.5% for medical staff, 6.3% for hospital beds, and 5.3% for examination. General linear model analysis determined that duration of IV antibiotic therapy, Pneumonia Severity Index class, age, and initial empirical antibiotic therapy failure were correlative factors of total hospital costs. Pathogens were identified in 106 patients (44.9%), Mycoplasma pneumoniae was the most common pathogen (19.9%), followed by Streptococcus pneumoniae (8.5%), and Haemophilus influenza (5.5%). The majority of patients accepted initial empirical β-lactam (37.3%) or fluoroquinolone (30.9%) monotherapy, the empirical treatment failure rates were 20.5% and 5.5%, respectively. Conclusions Efforts to reduce duration of IV antibiotic therapy will have the most profound effect on reducing total hospital costs of low-risk CAP. The atypical pathogens should be considered for initial empirical antibiotics in low-risk CAP therapy in China.

Limited role for outpatient parenteral antibiotic therapy for community‐acquired pneumonia

This study examined the potential utility of outpatient parenteral antibiotic therapy (OPAT) as a means of reducing the excessive number of patients hospitalized with low-risk community-acquired pneumonia (CAP). A prospective feasibility study was conducted, in which a selection algorithm was applied to a cohort of patients admitted with suspected CAP, to identify a group in whom admission may have been prevented by the use of OPAT. Numbers of potentially suitable patients, inpatient bed days saved and frequency of adverse events that may have led to readmission were measured. There were 118 inpatients treated with confirmed CAP during the study period, of whom 27 had low-risk disease (Pneumonia Severity Index grades I-III). Application of the selection algorithm identified eight (30% of those with low-risk disease) patients who were potentially suitable for OPAT, and this group commonly experienced adverse events during follow up which may have resulted in readmission to hospital. In many hospitalized patients with CAP, outpatient therapy is precluded by either disease severity or active medical and psychosocial factors. This limits the role of OPAT as a tool for reducing the inpatient burden of CAP.

The information and support needs of patients discharged after a short hospital stay for treatment of low-risk Community Acquired Pneumonia: implications for treatment without admission.

BackgroundThere is increasing evidence that patients with low-risk community acquired pneumonia (CAP) can be effectively treated as outpatients. This study aimed to explore patients' experiences of having pneumonia and seeking health care; their perceptions of the information provided by health professionals; how they self managed at home; their information and support needs; and their beliefs and preferences regarding site of care.MethodsWe conducted qualitative, semi-structured interviews with 15 patients who had a confirmed diagnosis of low-risk CAP and had received fewer than 3 days hospital care. Interviews were audio recorded and transcribed, and data were analysed thematically.ResultsMost patients left hospital with no clear understanding of pneumonia, its treatment or follow-up and most identified additional-other specific information needs when they got home. Some were unable to independently address their activities of daily living in their first days at home.Main concerns after discharge related to the cause and implications of pneumonia, symptom trajectory and prevention of transmission. Most sought advice from their GP in their first days at home, and indicated they would have appreciated a follow-up phone call or visit to discuss their concerns.Patients' preferences for site of care varied and appeared to be influenced by beliefs about safety (fear of rapid deterioration at home or acquiring an infection in hospital), family burden, access to support, or confidence in home-care services. Those who received intravenous (IV) medication were more likely to state a preference for hospital care.ConclusionTrends to support community-based treatment of CAP should be accompanied by increased attention to the information and support needs of patients who go home to self-manage. Although some information needs can be anticipated and addressed on diagnosis, specific needs often do not become apparent until patients return home, so some access to information and support in the community is likely to be necessary. Our finding that patients who received IV treatment for low-risk CAP were concerned about the relative safety of home-based care highlights the potential importance of the inferences patients make from treatment modalities, and also the need to ensure that patients' expectations and understandings are managed effectively.

Cost and Incidence of Social Comorbidities in Low-Risk Patients With Community-Acquired Pneumonia Admitted to a Public Hospital

There are up to 1 million patients treated in acute-care hospitals for community-acquired pneumonia (CAP), with an estimated annual cost > 8 billion dollars. A newly validated CAP outcomes prediction rule developed by Fine and colleagues has been advocated as a guide to hospitalization decisions. To evaluate the clinical characteristics, costs of care, and resource utilization of patients with low-risk CAP at an urban public hospital serving an indigent population. Prospective cohort study from June 1, 1994 to May 31, 1996. Clinical characteristics and costs of care of patients with low-risk CAP and features associated with low-risk CAP in this population. A total of 522 patients were identified at the time of hospital admission as having CAP; 97 patients (19%) were HIV positive on hospital admission and excluded. Of the remaining 425 patients, 253 patients (60%) were classified as pneumonia severity index (PSI) class I-III (low risk). Of the patients with low-risk CAP, only four patients (1.6%; 95% confidence interval, 0.4 to 4.0%) died during hospitalization. Low-risk CAP was both costly and accounted for significant resource use (35.4% of total CAP costs, and 45% of all CAP bed days). Of the patients with low-risk CAP, there were 138 patients (55%) who could potentially have been treated as outpatients (absence of altered mental status, hypotension, hypoxia on hospital admission, or direct ICU admission). However, 49% of these patients had a history of alcoholism, 20% had a blood alcohol level > 50 mg/dL, and 44% were homeless. A significant proportion of the patients admitted with CAP to a public hospital had low-risk CAP and accounted for a significant proportion of the CAP bed days and costs. The use of the PSI accurately predicted which patients would be at low risk for death; however, the utility of using the PSI to reduce low-risk CAP hospital admissions would have been of limited benefit. High rates of homelessness, substance abuse, and medical needs not captured in the PSI would preclude many of these patients from unsupervised outpatient treatment.

Determinants for hospitalization in " low-risk" community acquired pneumonia.

BackgroundA variable decision in managing community acquired pneumonia (CAP) is the initial site of care; in-patient versus outpatient. These variations persist despite comprehensive practice guidelines. Patients with a Pneumonia Severity Index (PSI) score lower than seventy have low risk for complications and outpatient antibiotic management is recommended in this group. These patients are generally below the age of fifty years, non-nursing home residents, HIV negative and have no major cardiac, hepatic, renal or malignant diseases.MethodsA retrospective analysis of 296 low-risk CAP patients evaluated within a year one period at St. Agnes Hospital, Baltimore, Maryland was undertaken. All patients were assigned a PSI score. 208 (70%) were evaluated and discharged from the emergency department (E.D.) to complete outpatient antibiotic therapy, while 88 (30%) were hospitalized. Patients were sub-stratified into classes I-V according to PSI. A comparison of demographic, clinical, social and financial parameters was made between the E.D. discharged and hospitalized groups.ResultsStatistically significant differences in favor of the hospitalized group were noted for female gender (CI: 1.46-5.89, p= 0.0018), African Americans (CI: 0.31-0.73, p= 0.004), insurance coverage (CI: 0.19-0.63, p= 0.0034), temperature (CI: 0.04-0.09, p= 0.0001) and pulse rate (CI: 0.03-0.14, p= 0.0001). No statistically significant differences were observed between the two groups for altered mental status, hypotension, tachypnea, laboratory/radiological parameters and social indicators (p>0.05). The average length of stay for in-patients was 3.5 days at about eight time's higher cost than outpatient management. There was no difference in mortality or treatment failures between the two groups. The documentation rate and justifications for hospitalizing low risk CAP patients by admitting physicians was less than optimal.ConclusionsHigh fever, tachycardia, female gender, African- American race and medical insurance coverage are determinants for hospitalization among low risk CAP patients in our study. The average length of stay for in-patients was 3.5 days (3 to 5 days). The cost of in-patient care was about eight times higher than outpatient management. This study supports the recommendation of using the PSI for E.D evaluation of patients in appropriate social settings.

Hemochromatosis as a Risk Factor for Fulminant Staphylococcus aureus Pneumonia*

Hemochromatosis as a Risk Factor for Fulminant Staphylococcus aureus Pneumonia*

Hospitalized low-risk community-acquired pneumonia: outcome and potential for cost-savings.

In the USA, a group of low-risk patients with community-acquired pneumonia (CAP) with a low risk of mortality were identified and it was suggested that they may be treated as outpatients to save costs. We evaluated the outcome of these low-risk CAP patients that were hospitalized in our local setting, and gauged the number of such patients in order to estimate the potential cost-savings by treating them as out-patients, as well as the safety of such an approach. All patients with CAP admitted to the National University Hospital, Singapore, from 1 April to 1 November 1997 were enrolled into a prospective cohort study. Low-risk patients were identified, and their hospital outcomes were compared with the other patients. Hospitalization charges were obtained from the Finance Department. There were 155 CAP patients (69 females and 86 males). The age was 56.6 +/- 22.2 years, ranging from 12 to 93 years old. The average hospital stay was 8.4 +/- 11 days. Mortality was 12.9%. There were 37 (24%) low-risk CAP patients, and there was no mortality in this group. No low-risk patient required mechanical ventilation. They had a significantly shorter hospital stay compared with high-risk patients. An identifiable organism was found in 27% of the low-risk CAP with only one patient having a positive blood culture. The average hospitalization charge for low-risk CAP patients was, as expected, significantly lower than for the high-risk patients, and was 11.9% of the total cost for hospitalized CAP patients. Nearly one-quarter of our CAP admissions consisted of low-risk patients that had no mortality, and required a significantly shorter hospitalization period. The management of such patients who are young (< or = 50 years), and had no serious coexisting conditions in an out-patient setting, may lead to significant cost-savings as the average hospitalization charge was US$1295 and 11.9% of total hospitalization charges for CAP.

¿Cuál es el coste de las neumonías que ingresamos inadecuadamente?

The number of patients admitted with community-acquired pneumonia (CAP) varies greatly from one hospital to another. Prognostic models for CAP can help physicians decide which cases to treat on an outpatient basis. Our aims were: a) to validate a model for predicting low-risk CAP, and b) to estimate savings that would have resulted if the low-risk patients identified by the model had been treated at home rather than in hospital. All CAP cases diagnosed by the emergency room physicians of a hospital in northwestern Spain (Ferrol) were enrolled prospectively over a period of 19 months. The prediction rule of Fine et al was used to classify all patients. Mortality in each category was compared with the mortality predicted by Fine's system. Patients in the lowest risk categories (I and II) were considered to have been inappropriately admitted unless they were hypoxemic or had significant comorbidity. Costs were figured based on data provided by our accounting department. Of 192 CAP patients enrolled, 131 were admitted and 61 were treated as outpatients. Ten patients died, none of whom was in classes I or II. The costs of the apparently unnecessary hospital stays of the 34 patients in these classes was 6,979,756 pesetas. The estimated savings that would have derived from treating these patients out-of-hospital was 6,133,292 pesetas (36,862 euros; 322,804 pesetas/month). a) The predictive model used has been found useful for identifying patients at very low risk of dying from CAP; b) Using this model can improve CAP admission criteria, and c) Application of the model can lead to savings.

Preferences for Home vs Hospital Care Among Low-Risk Patients With Community-Acquired Pneumonia

To measure preferences for initial outpatient vs hospital care among low-risk patients who were being actively treated for community-acquired pneumonia (CAP). Study patients included 159 patients with CAP, 57 (36%) initially hospitalized, who were identified as being at low risk for early mortality using a validated prediction model. Subjects were enrolled from university and community health care facilities located in Boston, Mass, Halifax, Nova Scotia, and Pittsburgh, Pa, participating in the Pneumonia Patient Outcome Research Team prospective cohort study of CAP. Three utility assessment techniques (category scaling, standard gamble, and willingness to pay) were used to measure the strength of patient preferences for the site of care for low-risk CAP. At the time of initial therapy or during the early recuperative period, patient preferences were assessed across a spectrum of potential clinical outcomes using 7 standardized pneumonia clinical vignettes. Responses to the 7 pneumonia scenarios indicated that most patients consistently preferred outpatient-based therapy. This pattern was observed regardless of whether patients had actually been treated initially at home or in a hospital. Patients (74%) who stated that they generally preferred home care for low-risk CAP were willing to pay a mean of 24% of 1 month's household income to be assured of this preference. Preference for home care, as measured by the category scaling and the willingness to pay, persisted after adjustment for sociodemographic and baseline health status covariates. Sixty nine percent of interviewed patients said that their physician alone determined whether they would be treated in the hospital or at home. Only 11% recalled being asked if they had a preference for either site of care. Most patients, even those treated initially in a hospital, who were at low risk for mortality from CAP prefer outpatient treatment. However, most physicians appear not to involve patients in the site-of-care decision. More explicit discussion of patient preferences for the location of care would likely yield more highly valued care by patients as well as less costly treatment for CAP.