Improved Clinical Outcomes With Utilization of a Community-Acquired Pneumonia Guideline.
Nathan C. Dean, MD, FCCP; Kim A. Bateman, MD; Steven M. Donnelly, PhD; Michael P. Silver, MPH; Greg L. Snow, PhD and David Hale, PharmD, MHA.
From the Division of Pulmonary and Critical Care Medicine (Dr. Dean), LDS Hospital, University of Utah School of Medicine; HealthInsight (Dr. Bateman, Dr. Donnelly, and Mr. Silver); and Intermountain Healthcare (Drs. Snow and Hale), Salt Lake City, UT.
Correspondence to: Nathan C. Dean, MD, FCCP, Intermountain Healthcare, 333 South Ninth East, Salt Lake City, UT 84102; e-mail [email protected]
Chest. 2006;130:794-799.
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.
Key Words: mortality • patient admission • pneumonia • practice guidelines • therapy
COMENTARIO:
Este estudio demuestra, como un gemelo suyo publicado por Frei et al (Am J Med. 2006 Oct;119(10):865-71), que el seguimiento de las guías para el tratamiento de la neumonía adquirida en la comunidad puede salvar vidas.
En el estudio de Frei, realizado de forma retrospectiva sobre una cohorte de pacientes ingresados en 5 hospitales diferentes a lo largo de 6 meses, se demostró que las guías clínicas (en este caso la de la ATS) eran seguidas en el 57% de los casos, y que ello se asociaba de forma significativa con una menor mortalidad, menor estancia media y un inicio más temprano de la terapia secuencial.
El presente estudio trata de demostrar que la adherencia a la Intermountain Healthcare Pneumonia Guideline es beneficiosa y puede disminuir mortalidad y el riesgo de reingreso. Básicamente, esta guía se apoya en:
Los principales aspectos son:
- el empleo del CURB-65 para decidir si un paciente debe ingresar.
- el tratamiento de la neumonía con una cefalosporina de tercera generación y azitromicina para pacientes con formas moderadas o graves de la enfermedad.
La SEPAR ha publicado en el 2005 una guía sobre el diagnóstico y tratamiento de la neumonía adquirida en la comunidad (www.separ.es; Publicaciones; Normativas y Procedimientos) con similares recomendaciones. Persisten dudas razonables acerca de las dosis de antibióticos que deben ser empleadas y también acerca de la duración total del tratamiento.