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Rapid Antibiotic Delivery and Appropriate Antibiotic Selection Reduce Length of Hospital Stay of Patients With Community-Acquired Pneumonia
Link Between Quality of Care and Resource Utilization
David S. Battleman, MD, MSc;
Mark Callahan, MD;
Howard T. Thaler, PhD
Arch Intern Med. 2002;162:682-688.
ABSTRACT
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Objectives To measure quality-of-care variables relevant to the treatment of community-acquired
pneumonia and to determine their relative contribution to variation in length
of hospital stay (LOS).
Methods One hundred cases of pneumonia requiring hospitalization from each of
7 institutions (2 community and 5 university teaching hospitals) were randomly
selected (total sample, 700 cases). Demographic and clinical variables were
abstracted using a standardized data instrument. Three quality-of-care measures
were analyzed: (1) site of initial antibiotic treatment (emergency department
vs floor), (2) door-to-needle time, and (3) appropriateness of antibiotic
selection. Appropriate antibiotic selection was defined by the 1998 Infectious
Disease Society of America guidelines for the treatment of hospitalized pneumonia
cases. Regression modeling was used to determine associations between LOS
and our quality-of-care (process) variables.
Results The mean ± SD LOS for this sample was 7.0 ± 4.1 days.
Prolonged LOS, defined as greater than or equal to the 75th percentile of
the LOS distribution, was the dependent variable in our regression analysis
and was greater than or equal to 9.0 days. After clinical and demographic
variables were adjusted for, logistic regression modeling revealed that all
3 quality-of-care measures were associated with prolonged LOS: (1) initial
antibiotic treatment in the emergency department (odds ratio [OR], 0.31; 95%
confidence interval [CI], 0.19-0.48); (2) appropriate antibiotic selection
(OR, 0.55; 95% CI, 0.35-0.88); and (3) door-to-needle time (OR, 1.75 per 8
hours; 95% CI, 1.34-2.29). In a secondary analysis, we examined the clinical
and demographic characteristics of the patients who were treated more rapidly
in the emergency department compared with those who were treated on the inpatient
floor. No clinically meaningful differences were observed between these groups.
Conclusions Unlike clinical and demographic variables, process-of-care variables
are modifiable and amenable to quality improvement. We observed that rapid
antibiotic initiation and appropriate antibiotic selection in the emergency
department have a statistically significant association with shorter LOS.
These findings suggest quality improvement targeted at these processes of
care may improve resource utilization and reduce LOS for patients with community-acquired
pneumonia.
INTRODUCTION
COMMUNITY-ACQUIRED pneumonia (CAP) is diagnosed in approximately 4 million
adults each year, 25% of whom require hospitalization.1-2
Pneumonia remains one of the most common reasons for adult hospitalization
in the United States, and the overall incidence is on the rise. Between 1984
and 1995, discharge rates for CAP increased by more than 30%.3-4
Mortality from pneumonia is also increasing. Community-acquired pneumonia
is the number 1 infectious cause of death,2
and between 1979 and 1994, the age-adjusted mortality rate for patients with
pneumonia increased by 22%.5 Also, the economic
burden of CAP is substantial, with annual direct costs exceeding $9.7 billion.4
Despite the availability of well-established treatment guidelines,6-8 many studies have documented
significant regional variation in length of hospital stay (LOS) among patients
hospitalized with pneumonia.9-13
Variation in LOS has been attributed to differences in patient, physician,
and hospital-based factors.10, 14
However, much of the observed LOS variation in CAP remains poorly understood.
These findings would suggest that LOS may be determined by other characteristics,
such as physician judgment or variation in processes of care.
Process-of-care variables are components of the medical encounter that
occur between the physician and the patient and often can serve as measures
of quality. In pneumonia, for example, appropriate adjustment of antibiotic
therapy in response to positive blood culture results is a process of care
that is essential to effective treatment and is also a relevant measure of
quality. Further, unlike patient or hospital characteristics, process-of-care
variables are frequently modifiable and can often serve as the basis for quality
improvement initiatives.
The purpose of this study was to examine quality-of-care process variables
that are relevant to the treatment of CAP and to determine their relative
contribution to variation in LOS. The quality-of-care measures that we analyzed
included (1) site of initial antibiotic administration (emergency department
[ED] vs floor); (2) door-to-needle time of antibiotic administration; and
(3) appropriateness of initial antibiotic selection. After adjusting for clinical
and demographic factors, we sought to determine the relative contribution
of these process measures to variation in LOS.
PATIENTS AND METHODS
SETTING
The setting for this study was the New York Presbyterian Healthcare
(NYPH) system, a developing integrated health care delivery system in the
New York metropolitan region. Patients for this study were identified from
among 7 hospital sites in the NYPH system. Hospital sites were chosen because
of a high annual incidence of pneumonia cases. Five institutions were university-based
teaching hospitals; 2 were community-based nonteaching hospitals. Cases were
identified between January 1998 through December 1998 using diagnosis related
group (DRG) billing codes for pneumonia (DRG codes 89 and 90).
STUDY DESIGN
We performed a retrospective chart review. One hundred cases were randomly
selected from each of 7 network institutions based on DRG discharge coding,
representing between 4.9% and 21.1% of the total CAP admissions for the participating
study sites. Adult cases of CAP were confirmed by physician record review
and then screened using the following inclusion/exclusion criteria: (1) the
patient had to be older than 18 years; (2) the admitting diagnosis by the
admitting ED physician had to be pneumonia; (3) the patient had to be admitted
from either his or her home or a nursing home; and (4) the patient had to
be admitted through the ED (direct-to-the-floor admissions were excluded).
Direct-to-the-floor admissions were excluded because accurate admission times
could not consistently be determined for these patients, thereby invalidating
the door-to-needle time calculation (see below).
Also, patients with known or suspected immunodeficiency (human immunodeficiency
virus, acquired immunodeficiency syndrome, or concurrent immunosuppressive
therapy) were excluded. Patients were also excluded if a diagnosis of Pneumocystis carnii pneumonia or tuberculosis was suspected
based on a physician's review of the medical record. Patients readmitted for
pneumonia within 30 days of discharge were excluded, as were patients who
had antibiotic therapy initiated prior to ED presentation. Finally, all in-hospital
deaths and patients who left against medical advice were excluded. Because
our primary outcome measure was LOS and because the combined death and against-medical-advice
rates were low (3.9%), we chose to exclude these patients from the analysis.
An institutional review board exemption was obtained for this study at each
participating institution because the data collection was limited to retrospective
chart review.
DATA INSTRUMENT
Each chart was reviewed and abstracted by a trained reviewer using a
structured data instrument. Length of hospital stay, our dependent variable,
was measured in days. Additionally, 13 independent variables were also collected.
Data elements included 5 demographic and 5 clinical variables, as well as
3 process-of-care measures. Demographic variables included (1) age; (2) sex;
(3) ethnicity (white vs nonwhite); (4) admission site (admitted from nursing
home vs private home); and (5) payer status (Medicaid/self-pay vs Medicare/commercial
insurance).
Clinical variables included (1) chronic obstructive pulmonary disease
(history of chronic obstructive pulmonary disease on admission); (2) comorbid
illness (history of active neoplastic disease, renal failure, cerebrovascular
disease, liver failure, congestive heart failure, or altered mental status
at admission); (3) white blood cell count (WBC) at admission; (4) respiratory
rate (RR) at admission; and (5) chest x-ray film at admission (chest x-ray
film consistent with pneumonia within 48 hours of admission). Comorbid illness
definitions were adopted from the pneumonia severity illness classification.15 Chest x-ray films were considered consistent with
pneumonia if the x-ray report contained any of the following terminology:
pneumonia, air bronchogram, air space disease, consolidation, infiltrate,
inflammation, opacity, or pneumonitis.
Process-of-care variables included (1) site of initial antibiotic administration
(ED vs floor); (2) door-to-needle time (hours); and (3) appropriateness of
antibiotic selection. The site of initial antibiotic administration (ED treatment
vs floor treatment) was measured as percent ED (the percentage of patients
who received their initial antibiotic therapy in the ED). Door-to-needle time
was measured in hours and represents the difference between the triage time
and the documented time of initial antibiotic administration. Appropriateness
of initial antibiotic selection was scored based on the 1998 Infectious Disease
Society of America (IDSA) guidelines, for the treatment of patients hospitalized
with pneumonia.8 Antibiotic selection within
the first 24 hours of admission was determined to be consistent or inconsistent
with published guidelines based on independent physician review of the medical
record and recorded as percent appropriate.
Ten percent of the records were randomly sampled and rescored. Reliability
testing indicated moderate to excellent interabstractor reliability with a 
statistic ranging from 0.68 to 0.98: for pneumonia confirmation ( =
0.98); exclusion criteria ( = 0.88); and abstraction of demographic
( = 0.94), clinical ( = 0.91), and process ( = 0.68)
variables.16
STATISTICAL METHODS
We used descriptive statistics (SPSS statistical software version 10.0;
SPSS Inc, Chicago, Ill) to characterize our study population. For this analysis,
our outcome of interest was prolonged LOS (pLOS). pLOS was defined as LOS
beyond the upper bounds of the interquartile range (>75th percentile), and
for our study sample it was 9.0 days. Univariate measures of association were
then tested between our primary outcome variable, pLOS, and each of the demographic,
clinical, and process variables listed above. Patients who died or left against
medical advice were excluded from the analysis (see above).
Univariate measures of association for categorical variables were calculated
using the Fisher exact test. Univariate measures of association for continuous
variables were tested using either the t test (parametric)
or the Wilcoxon rank sum test (nonparametric). We compared the unadjusted
mean LOS between ED-treated patients and floor-treated patients using a base-10
logarithmic transformation of LOS because of the skewed distribution of this
variable to aid in its statistical interpretation. All P values presented in the univariate analysis are 2-tailed.
A multivariate logistic regression model was then developed using pLOS
as our dependent variable. We selected the best model by applying stepwise
selection to any variable significant at P .2
from the univariate analyses. There was no interaction between the site of
initial antibiotic administration and appropriate antibiotic selection, nor
between any of the statistically significant variables from the univariate
analyses. Obviously correlated variables (site of antibiotic selection and
door-to-needle time) were not included together in models. We did not find
evidence of multicollinearity between other terms. Continuous variables were
rescaled as follows to maintain comparability of regression coefficients:
(1) age per 10-year increase; (2) WBC per 5-unit increase; (3) RR per 5-unit
increase; and (4) door-to-needle time per 8-hour period.
To improve the efficiency of the statistical model, we used a power
transformation to the process variable, door-to-needle time, to follow the
implicit statistical assumptions of normality. All P
values presented in the multivariate models are 2-tailed. We report the odds
ratios (ORs) with 95% confidence intervals (CIs) such that an OR greater than
1.0 is more highly associated with a prolonged LOS and an OR less than 1.0
is associated with a shorter, nonprolonged LOS.
RESULTS
Table 1 lists the demographic,
clinical, and process variables that describe our patient population. Our
initial sample consisted of 700 patients. Ninety-one patients, or 13% of the
original sample, were excluded from analysis based on the criteria outlined
above, resulting in a study sample of 609 patients. Eighteen patients were
not admitted through the ED. Twenty-four patients did not have an ED physician's
admitting diagnosis of pneumonia. Twelve patients had human immunodeficiency
virus, and another 8 patients had known or suspected immunodeficiency. Two
patients were excluded because of a prior 30-day admission. Twenty-three deaths
and 4 patients who were discharged against medical advice were also excluded.
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Table 1. Descriptive Statistics of the Study Population*
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Sixty-one (67%) of the 91 patients who were excluded were from university-based
teaching hospitals, averaging 12.2 cases excluded per teaching hospital. Thirty
(33%) of the 91 patients who were excluded were from the community-based nonteaching
hospitals, averaging 15.0 cases excluded per nonteaching hospital. The number
of patients who were excluded from the university-based teaching hospitals
and the community-based nonteaching hospitals was not significantly different.
The final patient population used in this analysis (N = 609) was primarily
an older population, with a mean age of 67 years. Forty-five percent were
men; 40% were white; 18% were admitted from a nursing home; and almost half
(49%) were receiving Medicaid or self-pay. The majority of patients (58%)
had significant comorbid illness. All patients included in this study received
a clinical diagnosis of pneumonia from the ED physician, and 92% had positive
results on the chest x-ray examination on admission.
Baseline measures of process-of-care variables revealed that 66% of
patients received their initial dose of antibiotics in the ED, and 34% did
not receive their first dose of antibiotics until transfer from the ED to
the inpatient floor. The appropriate initial antibiotic selection rate was
56%.
Figure 1 shows a box plot
distribution of the dependent variable for our analysis, LOS. The LOS for
this population was 7.0 ± 4.1 days. The LOS variable was then dichotomized
into prolonged LOS (LOS  9 days) and nonprolonged LOS (LOS <9 days)
subgroups, defined relative to the 75th percentile of the LOS distribution
for the study sample. Thus, 152 patients had an LOS greater than or equal
to 9.0 days.
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Figure 1. Box plot demonstrating the distribution
of the length of hospital stay (LOS) for the study sample (N = 609). 25% LOS
indicates the 25th percentile of the LOS distribution; 75% LOS, the 75th percentile
of the LOS distribution.
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LOS ANALYSIS
Univariate associations between pLOS and each of the independent demographic,
clinical, and process variables are presented in Table 2. Of the demographic variables analyzed, older age (OR =
1.28 per 10 years; 95% CI = 1.15-1.44) and white race (OR = 1.49; 95% CI =
1.02-2.19) were significant univariate predictors of pLOS. Of the clinical
variables analyzed, comorbid illness (OR = 2.39; 95% CI = 1.57-3.65) and RR
at admission (OR = 1.28 per 5 breaths/min; 95% CI = 1.11-1.48) demonstrated
significant associations with pLOS. Of the 2 process variables initially examined,
only site of initial antibiotic administration demonstrated a strong statistical
association with pLOS in the univariate analysis. In this population, the
process of administering the initial dose of antibiotics in the ED was protective
(OR = 0.42; 95%CI = 0.28-0.61), suggesting that initiating treatment in the
ED could lead to a shorter LOS. The clinical significance of this effect is
demonstrated in the mean difference in LOS between these 2 groups of patients.
The LOS for patients treated initially in the ED was 6.3 ± 3.5 days,
while the LOS for patients receiving antibiotic therapy that was started when
they reached the inpatient floor was 8.4 ± 4.7 days (P<.001).
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Table 2. Associations of Demographic, Clinical, and Process Variables
With Prolonged Length of Stay (pLOS)*
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Multivariate logistic regression analysis was used to assess the independent
associations between demographic, clinical, and process variables and the
outcome pLOS. The results from this regression model are also shown in Table 2. In this analysis, age (OR = 1.28
per 10 years; 95% CI = 1.12-1.46), RR at admission (OR = 1.23 per 5 breaths/min;
95% CI = 1.04-1.45), and comorbid illness (OR = 2.64; 95% CI = 1.55-4.49)
were the demographic and clinical variables that remained significant predictors
of pLOS after multivariate adjustment. In terms of process measures, both
initial antibiotic administration in the ED (OR = 0.31; 95% CI = 0.19-0.48)
and appropriate antibiotic selection (OR = 0.55; 95% CI = 0.35-0.88) were
significantly associated with pLOS. Both of these process-of-care variables
demonstrated a protective effect with respect to pLOS, suggesting that administering
antibiotics in the ED and selecting appropriate initial antibiotic therapy
were independent predictors of shorter LOS. It is of interest to note that
appropriate antibiotic selection was not associated with pLOS in the univariate
analysis but was strongly associated with pLOS in the multivariate analysis
(explained below).
DOOR-TO-NEEDLE TIME ANALYSIS
To further explore the relationship between site of initial antibiotic
selection and pLOS, we collected data on the door-to-needle time as a possible
root cause explanation for this association. The average door-to-needle time
for the entire sample was 5.5 ± 3.5 hours. Figure 2 is a clustered box plot depicting the distribution of the
ED door-to-needle times vs the floor door-to-needle times. On average, patients
who received their initial antibiotic treatment in the ED had a door-to-needle
time of 3.5 ± 1.4 hours, while patients who had their initial antibiotic
treatment on the inpatient floor had a door-to-needle time of 9.5 ±
3.0 hours (P<.001). Because door-to-needle time
and site of initial antibiotic therapy were strongly related to each other
(high degree of collinearity), a second regression model was constructed to
test the association between door-to-needle time and pLOS. In this second
multivariate model (data not shown), door-to-needle time demonstrated a significant
independent association with pLOS (OR = 1.75 per 8 hours; 95% CI = 1.34-2.29; P<.001). Longer door-to-needle time was strongly associated
with prolonged LOS.
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Figure 2. Clustered box plot demonstrating
the antibiotic delivery (door-to-needle) times among patients receiving their
first dose of antibiotics in the emergency department (ED) compared with those
patients who received their first dose of antibiotics on the inpatient service
(Floor). The 7 hospital sites are labeled A through G. The mean ± SD
door-to-needle time for ED-treated patients was 3.5 ± 1.4 hours. The
door-to-needle time for floor-treated patients was 9.5 ± 3.0 hours.
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APPROPRIATE ANTIBIOTIC SELECTION ANALYSIS
As mentioned above, appropriate antibiotic selection was not associated
with pLOS in the univariate analysis but was strongly associated with pLOS
in the multivariate analysis. This finding suggests that only after adjustment
for other covariates does the appropriate antibiotic selection variable become
significant. A correlation matrix was developed to identify potential suppressor
covariates. The comorbid illness variable had the strongest correlation with
appropriate antibiotic selection (R = 0.33) and was
selected for subgroup analysis. Table 3 demonstrates that within the subgroup of patients with significant
comorbid illness (n = 354), appropriate antibiotic selection is strongly associated
with pLOS in both the univariate (OR = 0.45; 95% CI = 0.27-0.74) and the multivariate
(OR = 0.42; 95% CI = 0.24-0.73) models. These data suggest that in patients
with significant comorbid illness, correct antibiotic selection may hasten
hospital discharge. The original univariate and multivariate associations
between pLOS and appropriate antibiotic selection for all 609 patients are
shown for comparison.
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Table 3. Subgroup Analysis: Relationship Between Appropriate Antibiotic
Selection and Prolonged Length of Stay
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PREDICTORS OF ED VS FLOOR ANTIBIOTIC THERAPY INITIATION
To determine the patient characteristics that predicted which patients
received antibiotics in the ED vs delayed antibiotic treatment on the inpatient
floor, we performed a final multivariate analysis (Table 4). All 609 patients in this study were admitted through the
ED; however, only 66% of the study population (406 patients) received antibiotic
treatment in the ED. Thirty-four percent (203 patients) received their first
dose of antibiotics on the inpatient floor. In this table, we compared demographic
and clinical variables between these 2 subgroups. As shown, only increased
WBC at admission (OR = 1.27 per 5 units; 95% CI = 1.08-1.49) and increased
RR at admission (OR = 1.20 per 5 breaths/min; 95% CI = 1.03-1.41) predicted
the rapid administration of antibiotics in the ED. However, the WBC was not
an independent predictor of pLOS (Table
2) and, though statistically significant, the magnitude of the differences
observed in both WBC and RR between these 2 groups is of little clinical significance.
All the other clinical and demographic variables were similar between the
2 groups, suggesting that these clinical and demographic variables were not
driving treatment decisions.
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Table 4. Predictors of Site of Initial Antibiotic Treatment*
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COMMENT
Variation in LOS has been well documented for many medical conditions,9, 14, 17-19
including CAP.9-10 In this study,
we examined the relationship between quality-of-care variables (process measures)
and LOS to further quantify determinants of variation in LOS.
We observed statistically significant and clinically important associations
between our process-of-care measures and our outcome of interest, pLOS (LOS 9.0
days). After clinical and demographic factors were adjusted for, initial antibiotic
therapy in the ED was shown to be associated with pLOS (multivariate OR =
0.31; 95% CI = 0.19-0.48). Subsequent analysis revealed that antibiotic treatment
in the ED was associated with nearly a 3-fold reduction in door-to-needle
time in comparison to initial treatment on the inpatient floor (3.5 ±
1.4 hours vs 9.5 ± 3.0 hours, respectively; P<.001).
Door-to-needle time was also shown to be associated with pLOS after patient
characteristics were adjusted for (multivariate OR = 1.75 per 8 hours; 95%
CI = 1.34-2.29; P<.001). We believe that this
relationship between door-to-needle time and pLOS exists because a more rapid
antibiotic delivery time may hasten the establishment of clinical stability,
resulting in earlier discharge. This is particularly true in high-risk elderly
populations that have significant comorbidity. In our study of hospitalized
patients, the mean age was nearly 70 years, and more than 60% of patients
had significant comorbid illness.
In 1998, the IDSA issued its current recommendations for the treatment
of patients hospitalized with pneumonia.8 We
found that after potential confounders were adjusted for, appropriate initial
antibiotic selection as defined by the IDSA guidelines was associated with
a shorter LOS (multivariate OR = 0.55; 95% CI = 0.35-0.88). Notably, in univariate
analysis, appropriate antibiotic selection did not demonstrate this protective
effect. Only after multivariate adjustment were we able to uncover this strong
association between antibiotic selection and pLOS. Subgroup analysis revealed
comorbid illness as a suppressor covariate (negative confounder) responsible
for this effect. Three hundred fifty-four patients had significant comorbid
illness as defined by the pneumonia severity illness classification.15 Within this subgroup, appropriate antibiotic selection
was associated with a shorter LOS in both the univariate and multivariate
models, suggesting that in this subgroup of sick patients, antibiotic selection
is an important independent driver of LOS variation.
Finally, we analyzed the clinical and demographic characteristic of
the patients who were treated initially in the ED (n = 406) vs those treated
initially on the inpatient floor (n = 203). All clinical and demographic variables
between these 2 groups were similar except for the initial WBC and the initial
RR. Although patients who were treated in the ED had statistically higher
WBCs (13 ± 6.2 x 103/µL vs 11 ± 5.3 x
103/µL; P<.01) and RRs (24 ±
6.5/min vs 22 ± 5.4/min; P<.05), the magnitude
of these differences was of little clinical significance. Furthermore, from
these data, one might infer that the ED-treated patients were more significantly
ill (higher initial WBCs and RRs) and would bias our results toward ED-treated
patients having a longer LOS. In fact, ED-treated patients had a shorter LOS,
demonstrating that these statistical differences were not clinically meaningful.
It is possible, however, that our data set did not capture other important
clinical differences between these 2 groups.
Our results build on those of previous studies by demonstrating the
impact of process-of-care measures in CAP. Previous studies have examined
the relationship between processes of care and 30-day mortality rates. In
a retrospective multicenter study of more than 14 000 Medicare beneficiaries,
Meehan et al20 demonstrated that antibiotic
delivery times of less than 8 hours were associated with a 15% lower odds
of 30-day mortality (95% CI = 0.75-0.96). Similar findings with respect to
timing of antibiotic administration and 30-day mortality rate have been found
by other investigators as well.21-22
Also, associations between initial antibiotic selection and 30-day mortality
rates have also been reported. Gleason et al23
reviewed the medication records of 12 945 Medicare inpatients with pneumonia.
Using a Cox proportional hazards model and after adjusting for baseline patient
characteristics, they found that 3 initial antibiotic regimens were independently
associated with a lower 30-day mortality. Initial treatment with a second-generation
cephalosporin plus a macrolide, a nonpseudomonal third-generation cephalosporin
plus a macrolide, or a fluoroquinolone alone was associated with 26%, 29%,
and 36% lower 30-day mortality rates, respectively. All these antibiotic regimens
are consistent with the IDSA recommendations for the treatment of hospitalized
patients with pneumonia.
McCormick et al24 recently analyzed differences
in LOS among 4 hospital sites. After adjusting for comorbid illness, severity
of disease, and sociodemographic variables, they found that a shorter LOS
was not associated with differences in an important clinical outcome, 30-day
mortality. The authors propose that one possible explanation for this observation
was that hospitals with a shorter LOS may have more effective processes of
care, permitting a faster resolution of the acute illness and earlier discharge.
Our data support this hypothesis.
These data must be interpreted within the context of the study design.
Medical record documentation and chart abstraction could have introduced errors;
however, our interrater reliability was measured and found to be moderate
to excellent. Our study was observational in design, and the association between
our measured quality-of-care variables and LOS may be subject to unmeasured
confounding factors, such as unmeasured patient, physician, or hospital characteristics.
Also, we did not examine subsequent in-hospital processes of care that may
also be important in determining LOS, such as the switch from parenteral to
oral antibiotic therapy. However, the fact that our data on timing and appropriateness
of antibiotic therapy are consistent with prior data suggests that the associations
reported herein are likely to be valid. Also, we must caution that the findings
in this study may not be generalizable because the study was conducted primarily
at urban hospital sites, 5 of which were teaching hospitals. Therefore, these
data may not be applicable to other settings. Finally, retrospective chart
review is inherently subject to selection bias. Although we analyzed a random
sample of medical records with DRG codes for CAP, it is possible that some
patients initially admitted with pneumonia were not coded as such because
of subsequent in-hospital events. To address this limitation, a prospective
analysis would need to be performed.
In conclusion, we found rapid delivery of appropriate antibiotics in
the ED was associated with a shorter LOS in patients with CAP. Given the clinical
and economic importance of pneumonia, there is substantial interest in understanding
and reducing the drivers of variation in LOS. Unlike clinical and demographic
variables, process-of-care variables, such as door-to-needle time and antibiotic
selection, are modifiable and lend themselves to quality improvement initiatives.
In our study, only 66% of patients were treated rapidly in the ED and only
56% of patients were treated with appropriate antibiotics as defined by the
IDSA, suggesting substantial opportunity for quality improvement. Future prospective
clinical trials will be needed to determine if improvements in these quality-of-care
measures can lead to improvements in the effectiveness of care of hospitalized
patients with CAP.
AUTHOR INFORMATION
Accepted for publication July 31, 2001.
We thank Arthur Klein, MD, and George Heinrich, MD, for their support
of this project. We also express our appreciation to the following medical
directors and emergency department directors of the New York Presbyterian
Healthcare Network who collaborated on this project: Jerry Balantine, DO;
Neil Flomenbaum, MD; James Giglio, MD; Lisandro Irizarry, MD; Paul Mendelowitz,
MD; Robert Rosadi, PhD; Steven Silber, DO; and Diane Sixsmith, MD.
This study was presented in part at the 23rd Annual Meeting of the Society
of General Internal Medicine, Boston, Mass, May 6, 2000.
Corresponding author and reprints: David S. Battleman, MD, MSc, Office
of Outcomes Research, New York Presbyterian Healthcare System, 411 E 69th
St, Suite 312, New York, NY 10021 (e-mail: dsbattle{at}med.cornell.edu).
From the Office of Outcomes Research and the Departments of Public
Health and Internal Medicine, New York Presbyterian Healthcare System, Weill
Medical College of Cornell University (Drs Battleman and Callahan), and the
Department of Biostatistics and Epidemiology, Memorial Sloan-Kettering Cancer
Center (Dr Thaler), New York, NY.
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