Reducing door-to-antibiotic time in community-acquired pneumonia: Controlled before-and-after evaluation and cost-effectiveness analysis.
BACKGROUND
Practice guidelines suggest that all patients hospitalised with community-acquired pneumonia (CAP) should receive antibiotics within 4 h of admission. An audit at our hospital during 1999-2000 showed that this target was achieved in less than two thirds of patients with severe CAP.


METHODS
An experienced multidisciplinary steering group designed a management pathway to improve the early delivery of appropriate antibiotics to patients with CAP. This was implemented using a multifaceted strategy. The effect of implementation was evaluated using a controlled before-and-after study design over two winter seasons (November-April 2001-2 and 2002-3). Cost-effectiveness analyses were performed from the hospital's perspective.


RESULTS
The proportion of patients receiving appropriate antibiotics within 4 h of admission to hospital increased from 33% to 56% at the intervention site, and from 32% to 36% at the control site (absolute change adjusted for differences in severity of illness 17%, p = 0.035). The cost per additional patient receiving appropriate antibiotics within 4 h was 132 pound with no post-implementation evaluation, and 456 pound for a limited post-implementation evaluation. Simple modelling from the results of a large observational study suggests that the cost per death prevented could be 3003 pound with no post-implementation evaluation, or 16,632 pound with a limited post-implementation evaluation.


CONCLUSIONS
The intervention markedly improved door-to-antibiotic time, albeit at considerable cost. It might still be a cost-effective strategy, however, to reduce mortality in CAP. Uncertainty about the cost effectiveness of such interventions is likely to be resolved only by a well-designed, cluster randomised trial.
Barlow
Gavin
G
Ninewells Hospital and Medical School, Dundee, Scotland, UK. gavin.barlow@hey.nhs.uk
Nathwani
Dilip
D
Williams
Fiona
F
Ogston
Simon
S
Winter
John
J
Jones
Michael
M
Slane
Peter
P
Myers
Elizabeth
E
Sullivan
Frank
F
Stevens
Nicola
N
Duffey
Rebecca
R
Lowden
Karen
K
Davey
Peter
P
D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage* / Q000191:economics; D017714:Community-Acquired Infections / Q000188:drug therapy / Q000191:economics; D003362:Cost-Benefit Analysis; D005260:Female; D019983:Guideline Adherence; D006760:Hospitalization; D006801:Humans; D007902:Length of Stay; D008485:Medical Audit; D008875:Middle Aged; D011014:Pneumonia / Q000188:drug therapy* / Q000191:economics; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome
D000900:Anti-Bacterial Agents