An estimated 5 million pneumonia cases are diagnosed each year in U.S. physician offices and hospital emergency rooms, accounting for 86 million days of restricted activity for those affected and more than $9 billion in health care costs. Despite its prevalence, physicians frequently overestimate the probability of death in many pneumonia patients, leading to potentially unnecessary and costly hospitalizations.
"Pneumonia is common, costly and serious, but for patients at lower risk it often can be treated successfully at home, which is what many low-risk patients prefer at 1/20th the cost of hospitalization," said Michael Fine, M.D., professor of medicine at the University of Pittsburgh, author of the study and a noted expert in the treatment of pneumonia.
The year-long, multi-center randomized trial conducted by investigators from the University of Pittsburgh School of Medicine and the Pittsburgh VA Healthcare System involved 32 hospital emergency departments in Connecticut and southwestern Pennsylvania and more than 3,200 patients, all of whom were diagnosed with pneumonia but who posed varying risks of adverse outcomes from the disease.
"A unique aspect to this study was the use of one of three different interventions at sites, each of varying intensity, allowing us not only to alter care, but also to determine the amount of effort needed to create change," noted lead author Donald M. Yealy, M.D., professor and vice chair of emergency medicine at the University of Pittsburgh. "Similar efforts in the past have employed a singular 'one size fits all' approach," he observed.
For the purposes of this study, participating emergency departments were randomly assigned as low-intensity, moderate-intensity or high-intensity sites – designations reflecting the level and intensity of feedback, reinforcement and continuous quality improvement activities that each emergency department would carry out relevant to its pneumonia patients. All emergency departments agreed to follow uniform practice guidelines, which were based on expert consensus of national experts in pneumonia care.
In the low-intensity sites, practitioners also were asked to voluntarily develop quality improvement strategies for pneumonia care and received supportive literature. Moderate-intensity sites received the supportive literature and reminders and were mandated to develop quality improvement strategies for pneumonia care. Additionally, the moderate-intensity sites received on-site educational training sessions, which reinforced practice guidelines and offered in-depth training in pneumonia assessment. High-intensity sites received all low-intensity and moderate-intensity strategies and received real-time reminders, medical provider audits and feedback, and participated in site-specific ongoing quality improvement activities.
Study results showed that the moderate- and high-intensity strategies safely increased the proportion of low-risk patients who were successfully treated as outpatients. Additionally, the high-intensity strategy effectively increased the proportion of practitioners who implemented guideline recommendations in clinical practice.
"On the national level, the quality of care is far from ideal, leaving considerable opportunity for improvements. This study helps define that which is needed to achieve better outcomes for patients with pneumonia," noted Dr. Fine.
The study was funded by the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.
Journal
Annals of Internal Medicine