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Patient and Hospital Characteristics Associated With Recommended Processes of Care for Elderly Patients Hospitalized With Pneumonia
Results From the Medicare Quality Indicator System Pneumonia Module
Jonathan M. Fine, MD;
Michael J. Fine, MD, MSc;
Deron Galusha, MS;
Marcia Petrillo, MA;
Thomas P. Meehan, MD, MPH
Arch Intern Med. 2002;162:827-833.
Background Unexplained wide variability exists in the performance of key initial
processes of care associated with improved survival of elderly patients (those  65
years) hospitalized with pneumonia. The objective of this study was to assess
which patient and hospital characteristics are associated with performance
of these key initial processes of care for hospitalized elderly patients with
pneumonia.
Methods A retrospective cohort analysis was performed using data from the Medicare
Quality Indicator System Pneumonia Module for 14 069 patients 65 years
or older hospitalized with pneumonia throughout the United States. Associations
were calculated using multivariate logistic regression analysis between specific
patient and hospital characteristics and 2 processes of care associated with
improved 30-day survival: administration of antibiotics within 8 hours of
hospital arrival and blood culture collection within 24 hours of arrival.
Results Timely antibiotic administration was negatively associated with nonwhite
race (African American: odds ratio [OR], 0.71; 95% confidence interval [CI],
0.60-0.85; and other racial minorities: OR, 0.79; 95% CI, 0.68-0.92), major
hospital teaching status (OR, 0.79; 95% CI, 0.67-0.93), and larger hospital
size (250 beds vs <100 beds: OR, 0.68; 95% CI, 0.59-0.80). Timely blood
culture collection was positively associated with larger hospital size (OR,
1.61; 95% CI, 1.39-1.87). Performance of both processes of care were positively
associated with registered nurse–bed ratios of 1.25 or higher (for antibiotic
administration: OR, 1.23; 95% CI, 1.10-1.38; and for blood culture collection:
OR, 1.43; 95% CI, 1.26-1.61) and fever (for antibiotic administration: OR,
1.35; 95% CI, 1.23-1.49; and for blood culture collection: OR, 3.07; 95% CI,
2.81-3.34) and were negatively associated with hospital location in the South
(for antibiotic administration: OR, 0.77; 95% CI, 0.69-0.86; and for blood
culture collection: OR, 0.85; 95% CI, 0.77-0.93).
Conclusions Minority race, fever, nurse-bed ratio, hospital size and teaching status,
and southern location are among the major patient and hospital characteristics
associated, either negatively or positively, with the timeliness of performance
of initial antibiotic administration and blood culture collection for patients
hospitalized with pneumonia. Because performance of these processes of care
is associated with improved likelihood of survival, medical providers should
seek to eliminate the variations in care associated with these patient and
hospital characteristics. In addition, the impact of nurse staffing changes
on performance of key time-sensitive processes of care should be weighed carefully.
From the Section of Pulmonary and Critical Care Medicine, Norwalk Hospital,
Norwalk, Conn (Dr J. M. Fine); Qualidigm, Middletown, Conn (Drs J. M. Fine
and Meehan, Mr Galusha, and Ms Petrillo); the Division of General Internal
Medicine, Department of Medicine, and the Center for Research on Health Care,
University of Pittsburgh, Pittsburgh, Pa (Dr M. J. Fine); and the Department
of Medicine, Yale University School of Medicine, New Haven, Conn (Dr Meehan).
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