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An Interventional Trial

Steven J. Atlas, MD, MPH; Theodore I. Benzer, MD, PhD; Leila H. Borowsky, MPH; YuChiao Chang, PhD; Diann C. Burnham, RN; Joshua P. Metlay, MD, PhD; Ethan A. Halm, MD; Daniel E. Singer, MD

Arch Intern Med. 1998;158:1350-1356.

Background  Patients with community-acquired pneumonia who are at low risk for short-term mortality can be identified using a validated prediction rule, the Pneumonia Severity Index. Such patients should be candidates for outpatient treatment, yet many are hospitalized.

Objective  To assess a program to safely increase the proportion of low-risk patients with pneumonia treated at home.

Methods  The intervention provided physicians with the Pneumonia Severity Index score and corresponding mortality risk for eligible patients and offered enhanced visiting nurse services and the antibiotic clarithromycin. Prospectively enrolled, consecutive low-risk patients with pneumonia presenting to an emergency department during the intervention period (n = 166) were compared with consecutive retrospective controls (n = 147) identified during the prior year. A second group of 208 patients from the study hospital who participated in the Pneumonia Patient Outcomes Research Team cohort study served as controls for patient-reported measures of recovery.

Results  There were no significant baseline differences between patients in the intervention and control groups. The percentage initially treated as outpatients increased from 42% in the control period to 57% in the intervention period (36% relative increase; 95% confidence interval, 8%-72%; P=.01). However, more outpatients during the intervention period were subsequently admitted to the study hospital (9% vs 0%). When any admission to the study hospital within 4 weeks of presentation was considered, there was a trend toward more patients receiving all their care as outpatients in the intervention group (42% vs 52%; 25% relative increase; 95% confidence interval -2% to 59%; P=.07). No patient in the intervention group died in the 4-week follow-up period. Symptom resolution and functional status were not diminished. Satisfaction with overall care was similar, but patients treated in the outpatient setting during the intervention were less frequently satisfied with the initial treatment location than comparable control patients (71% vs 90%; P=.04).

Conclusions  Use of a risk-based algorithm coupled with enhanced outpatient services effectively identified low-risk patients with community-acquired pneumonia in the emergency department and safely increased the proportion initially treated as outpatients. Outpatients in the intervention group were more likely to be subsequently admitted than were controls, lessening the net impact of the intervention.

From the Medical Practices Evaluation Center and the General Medicine Division, Medical Services (Drs Atlas, Chang, Metlay, Halm, and Singer and Mss Borowsky and Burnham), and the Department of Emergency Medicine (Dr Benzer), Massachusetts General Hospital, Harvard Medical School, Boston, Mass.

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