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Processes of Care, Illness Severity, and Outcomes in the Management of Community-Acquired Pneumonia at Academic Hospitals
Julien Dedier, MD, MPH;
Daniel E. Singer, MD;
Yuchiao Chang, PhD;
Maria Moore, MPH;
Steven J. Atlas, MD, MPH
Arch Intern Med. 2001;161:2099-2104.
Background Prompt antibiotic administration, oxygenation measurement, and blood
cultures are generally considered markers of high-quality care in the inpatient
management of community-acquired pneumonia (CAP). However, few studies have
examined the relationship between prompt achievement of process-of-care markers
and outcomes for patients with CAP. We examined whether antibiotic administration
within 8 hours of hospital arrival, a blood culture within 24 hours, an oxygenation
measurement within 24 hours, or performing blood cultures before giving antibiotics
was associated with the following: (1) reaching clinical stability within
48 hours of hospital admission, (2) a decreased length of hospital stay, or
(3) fewer inpatient deaths.
Methods A retrospective medical record review identified 1062 eligible patients
discharged from the hospital with a diagnosis of CAP between December 1, 1997,
and February 28, 1998, among 38 US academic hospitals. We assessed the independent
relationship between each process marker and the 3 clinical outcomes, controlling
for the Pneumonia Severity Index on admission. We also examined the relationship
of pneumonia severity on admission to process marker achievement and clinical
outcomes.
Results Overall, there was no consistent or statistically significant relationship
between achieving process markers and better clinical outcomes (P>.40 for all). We did observe that performing blood cultures within
24 hours was related to not achieving clinical stability within 48 hours (odds
ratio, 1.62; 95% confidence interval, 1.13-2.33). However, this finding likely
reflects residual confounding by severity of illness, since increasing pneumonia
severity on admission was associated with blood culture performance (P = .009) and with shorter times to antibiotic administration
(P = .04).
Conclusions Achieving process-of-care markers was not associated with improved outcomes,
but was related to the severity of pneumonia as assessed on admission. Our
results highlight the difficulty in demonstrating a link between process-of-care
markers and outcomes in observational studies of CAP. Randomized studies are
needed to objectively evaluate the impact of process-of-care markers on CAP
outcomes.
From the Section of General Internal Medicine Research Unit, Department
of Medicine, Boston Medical Center, Boston, Mass (Dr Dedier); the Clinical
Epidemiology Unit, General Medicine Division, Department of Medicine, Massachusetts
General Hospital, Harvard Medical School, Boston (Drs Singer, Chang, and Atlas);
and the University HealthSystem Consortium, Oak Brook, Ill (Ms Moore).
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