The Hospital Admission Decision for Patients With Community-Acquired Pneumonia: Results From the Pneumonia Patient Outcomes Research Team Cohort Study

doi:10.1001/archinte.1997.00440220040006

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Vol. 157 No. 1, 13 JANUARY 1997

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The Hospital Admission Decision for Patients With Community-Acquired Pneumonia

Results From the Pneumonia Patient Outcomes Research Team Cohort Study

Michael J. Fine, MD, MSc; Linda J. Hough, MPH; Anne R. Medsger, MSHyg; Yi-Hwei Li, PhD; Edmund M. Ricci, PhD; Daniel E. Singer, MD; Thomas J. Marrie, MD; Christopher M. Coley, MD; Mary B. Walsh, RN; Michael Karpf, MD; Karen C. Lahive, MD; Wishwa N. Kapoor, MD, MPH

Arch Intern Med. 1997;157(1):36-44.

Abstract

Background
The hospital admission decision directly influences the magnitudeof resource use in patients with community-acquired pneumonia,yet little information exists on how medical practitioners makethis decision.

Objectives
To determine which factors medical practitioners consider inmaking the hospital admission decision and which health careservices they believe would allow ambulatory treatment of low-riskhospitalized patients with community-acquired pneumonia.

Methods
Medical practitioners responsible for the hospital admissiondecision for low-risk patients with community-acquired pneumoniawere asked to describe patient characteristics at initial examinationthat influenced the hospitalization decision, and to identifythe health care services that would have allowed initial outpatienttreatment of hospitalized patients.

Results
A total of 292 medical practitioners completed questionnairesfor 472 (76%) of the 624 low-risk patients eligible for thisstudy. Although all patients had a predicted probability ofdeath of less than 4%, practitioners estimated that 5% of outpatientsand 41% of inpatients had an expected 30-day risk of death ofmore than 5%. Univariate analyses identified 3 practitionerratedfactors that were nearly universally associated with hospitalization:hypoxemia (odds ratio, 173.3; 95% confidence interval, 23.8-1265.0),inability to maintain oral intake (odds ratio, 53.3; 95% confidenceinterval, 12.8-222.5), and lack of patient home care support(odds ratio, 54.4; 95% confidence interval, 7.3-402.6). In patientswithout these 3 factors, logistic regression analysis demonstratedthat practitioner-estimated risk of death of more than 5% hada strong independent association with hospitalization (oddsratio, 18.4; 95% confidence interval, 6.1-55.7). Practitionersidentified home intravenous antibiotic therapy and home nursingobservation as services that would have allowed outpatient treatmentof more than half (68% and 59%, respectively) of the patientsinitially hospitalized for treatment.

Conclusions
Practitioners' survey responses suggest that the availabilityof outpatient intravenous antimicrobial therapy and home nursingcare would allow outpatient care for a large proportion of low-riskpatients who are hospitalized for community-acquired pneumonia.These data also suggest that methods to improve practitioners'identification of low-risk patients with community-acquiredpneumonia could decrease the hospitalization of such patients.Future studies are required to help physicians identify whichlow-risk patients could safely be treated in the outpatientsetting on the basis of clinical information readily availableat presentation.

Arch Intern Med. 1997;157:36-44

Footnotes

The affiliations of the authors appear in the acknowledgmentsection at the end of the article.

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