Improved clinical outcomes with utilization of a community-acquired pneumonia guideline.
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 > or = 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.


CONCLUSIONS
Improved clinical outcomes were associated with pneumonia guideline utilization.
Dean
Nathan C
NC
Division of Pulmonary and Critical Care Medicine, LDS Hospital, University of Utah School of Medicine, Salt Lake City, UT, USA. Nathan.Dean@Intermountainmail.org
Bateman
Kim A
KA
Donnelly
Steven M
SM
Silver
Michael P
MP
Snow
Greg L
GL
Hale
David
D
D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D000925:Anticoagulants / Q000627:therapeutic use; D017963:Azithromycin / Q000627:therapeutic use; D017714:Community-Acquired Infections / Q000188:drug therapy* / Q000401:mortality; D017984:Enoxaparin / Q000627:therapeutic use; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008484:Medicaid / Q000706:statistics & numerical data; D006278:Medicare / Q000706:statistics & numerical data; D010359:Patient Readmission / Q000706:statistics & numerical data; D018410:Pneumonia, Bacterial / Q000188:drug therapy* / Q000401:mortality; D017410:Practice Guidelines as Topic; D015996:Survival Rate / Q000639:trends; D016896:Treatment Outcome; D014589:Utah
D000900:Anti-Bacterial Agents; D000925:Anticoagulants; D017984:Enoxaparin; D017963:Azithromycin