Clinical pathway care improves outcomes among patients hospitalized for community-acquired pneumonia

PURPOSE: To examine the impact of a unique evidence-based clinical pathway on six outcomes of care in patients hospitalized for community-acquired pneumonia (CAP). METHODS: A retrospective cohort study of CAP patients discharged between January 1999 and December 2001, from 31 Adventist Health System institutions nationwide. A total of 22,196 records were available for multivariate analyses. Odds ratios (OR) for the outcomes were calculated and stratified by a unique severity score. The severity score ranged from 1 to 5, where 5 indicated the most severe condition. RESULTS: Pathway patients were significantly less likely to die in-hospital compared with non-pathway patients in four of the five severity strata (OR in severity level 1=0.37; 95% confidence interval [CI], 0.20-0.70). In all severity strata, pathway patients were approximately twice as likely as non-pathway patients to receive blood cultures and appropriate antibiotic therapy. Among patients who were classified as severity level 1, pathway patients experienced an 80% reduction in the odds of respiratory failure requiring mechanical ventilation (OR=0.20; 95% CI, 0.12-0.33). CONCLUSIONS: Patients who were placed on pneumonia clinical pathway care were much more likely than non-pathway patients to have favorable outcomes of care.     

Racial variations in processes of care for patients with community-acquired pneumonia

Background

Patients hospitalized with community acquired pneumonia (CAP) have a substantial risk of death, but there is evidence that adherence to certain processes of care, including antibiotic administration within 8 hours, can decrease this risk. Although national mortality data shows blacks have a substantially increased odds of death due to pneumonia as compared to whites previous studies of short-term mortality have found decreased mortality for blacks. Therefore we examined pneumonia-related processes of care and short-term mortality in a population of patients hospitalized with CAP.

Methods

We reviewed the records of all identified Medicare beneficiaries hospitalized for pneumonia between 10/1/1998 and 9/30/1999 at one of 101 Pennsylvania hospitals, and randomly selected 60 patients at each hospital for inclusion. We reviewed the medical records to gather process measures of quality, pneumonia severity and demographics. We used Medicare administrative data to identify 30-day mortality. Because only a small proportion of the study population was black, we included all 240 black patients and randomly selected 720 white patients matched on age and gender. We performed a resampling of the white patients 10 times.

Results

Males were 43% of the cohort, and the median age was 76 years. After controlling for potential confounders, blacks were less likely to receive antibiotics within 8 hours (odds ratio with 95% confidence interval 0.6, 0.4–0.97), but were as likely as whites to have blood cultures obtained prior to receiving antibiotics (0.7, 0.3–1.5), to have oxygenation assessed within 24 hours of presentation (1.6, 0.9–3.0), and to receive guideline concordant antibiotics (OR 0.9, 0.6–1.7). Black patients had a trend towards decreased 30-day mortality (0.4, 0.2 to 1.0).

Conclusion

Although blacks were less likely to receive optimal care, our findings are consistent with other studies that suggest better risk-adjusted survival among blacks than among whites. Further study is needed to determine why this is the case.     

Severe Pneumonia Associated with Pandemic (H1N1) 2009 Outbreak, San Luis Potos��, Mexico

We describe the clinical characteristics and outcomes of adults hospitalized with pneumonia during the pandemic (H1N1) 2009 outbreak. Patients admitted to a general hospital in San Luis Potosí, Mexico, from April 10 through May 11, 2009, suspected to have influenza virus–associated pneumonia were evaluated. We identified 50 patients with suspected influenza pneumonia; the presence of influenza virus was confirmed in 18: 11 with pandemic (H1N1) 2009 virus, 5 with unsubtypeable influenza A virus, 1 with seasonal influenza A virus (H3N2), and 1 in whom assay results for seasonal and pandemic (H1N1) 2009 viruses were positive. Eighteen patients were treated in the intensive care unit, and 10 died. During the pandemic (H1N1) 2009 outbreak, severe pneumonia developed in young adults who had no identifiable risk factors; early diagnosis and treatment of influenza virus infections may have a determinant role in outcome.     

The case for comprehensive quality indicator reliability assessment.

To demonstrate the importance of evaluating overall quality indicator reliability, in addition to component or variable level reliability, a comparison of interrater agreement on four chart-abstracted pneumonia-related processes of care was conducted. The hospital medical records of 356 Medicare patients' recent discharges for pneumonia were independently abstracted by different abstractors. Kappa, prevalence and bias-adjusted kappa, P(pos), P(neg), and the Bias Index were used to assess reliability of composite quality indicators and their components. The adjusted kappas for the data elements used to determine eligibility to receive as well as to derive the pneumonia-related processes of care ranged from 0.68 to 1.0. The adjusted kappa associated with overall eligibility to receive the pneumonia-related processes of care was 0.63. The kappa statistics for determining if processes of care were provided ranged from 0.56 to 0.83 and increased to 0.65 and 0.85 upon adjustment for the prevalence effect. Kappas for the composite quality indicators were lower, but improved with adjustment for the prevalence effect. The composite quality indicator with the highest adjusted kappa value was oxygenation assessment (0.93); the composite quality indicator with the lowest adjusted kappa value was antibiotic administration within 8 hours of hospital arrival (0.74). This study establishes the reliability of pneumonia indicators and underscores the need for reliability assessment at the quality indicator level, as well as at the component level.     

National hospital antibiotic timing measures for pneumonia and antibiotic overuse

The development of drug-resistant bacteria from the overuse of antibiotics is a serious problem, with overutilization threatening to disarm caregivers and their patients even as together they face increasingly virulent strains of microbes. On the other hand, the speedy treatment of pneumonia with antibiotics is a firmly established, evidence-based practice, enshrined in Joint Commission on Accreditation for Healthcare Organizations Core Measures used in hospital accrediting and public reporting, and in Centers for Medicare and Medicaid Services (CMS) public-reporting and pay-for-performance hospital measures. This sets the stage for a potential conflict between (a) not doing the wrong thing by overprescribing antibiotics and (b) prescribing antibiotics on time for pneumonia. In November 2005, pneumonia antibiotic timing results were announced for the 133 top-performing hospitals in the first year of the 3-year CMS Hospital Quality Incentive Demonstration (HQID) pay-for-performance project, conducted in collaboration with Premier Inc, a hospital purchasing and informatics alliance. Premier client hospitals participating in the HQID also submit drug utilization and other comparative data to Premier for client access for benchmarking purposes; this makes it possible to see how the antibiotics specified for pneumonia are used by Premier hospitals for other conditions. In this study we look at where increased success in meeting the HQID pneumonia antibiotic timing measure is tied to an increase in antibiotic use for conditions where antibiotics are unwarranted--with the potential for promoting antibiotic resistance.     

Clinical microsystems, part 2. Learning from micro practices about providing patients the care they want and need

BACKGROUND: Usual medical care in the United States is frequently not a satisfying experience for either patients or primary care physicians. Whether primary care can be saved and its quality improved is a subject of national concern. An increasing number of physicians are using microsystem principles to radically redesign their practices. Small, independent practices-micro practices-are often able to incorporate into a few people the frontline attributes of successful microsystems such as clear leadership, patient focus, process improvement, performance patterns, and information technology. PATIENT FOCUS, PROCESS IMPROVEMENT, AND PERFORMANCE PATTERNS: An exemplary microsystem will (1) have as its primary purpose a focus on the patient-a commitment to meet all patient needs; (2) make fundamental to its work the study, measurement, and improvement ofcare-a commitment to process improvement; and (3) routinely measure its patterns of performance, "feed back" the data, and make changes based on the data. LESSONS FROM MICRO PRACTICES: The literature and experience with micro practices suggest that they (1) constitute an important group in which to demonstrate the value of microsystem thinking; (2) can become very effective clinical microsystems; (3) can reduce their overhead costs to half that of larger freestanding practices, enabling them to spend more time working with their patients; (4) can develop new tools and approaches without going through layers of clearance; and (5) need not reinvent the wheel. CONCLUSIONS: Patient-reported data demonstrate how micro practices are using patient focus, process improvement, performance patterns, and information technology to improve performance. Pati ents should be able to report that they receive "exactly the care they want and need exactly when and how they want and need it."     

Evaluation of a preoperative team briefing: a new communication routine results in improved clinical practice

BACKGROUND Suboptimal communication within healthcare teams can lead to adverse patient outcomes. Team briefings were previously associated with improved communication patterns, and we assessed the impact of briefings on clinical practice. To quantify the impact of the preoperative team briefing on direct patient care, we studied the timing of preoperative antibiotic administration as compared to accepted treatment guidelines. STUDY DESIGN A retrospective pre-intervention/post-intervention study design assessed the impact of a checklist-guided preoperative team briefing on prophylactic antibiotic administration timing in surgical cases (N=340 pre-intervention and N=340 post-intervention) across three institutions. χ(2) Analyses were performed to determine whether there was a significant difference in timely antibiotic administration between the study phases. RESULTS The process of collecting and analysing these data proved to be more complicated than expected due to great variability in documentation practices, both between study sites and between individual practitioners. In cases where the timing of antibiotics administration was documented unambiguously in the chart (n=259 pre-intervention and n=283 post-intervention), antibiotic prophylaxis was on time for 77.6% of cases in the pre-intervention phase of the study, and for 87.6% of cases in the post-intervention phase (p<0.01). CONCLUSIONS Use of a preoperative team checklist briefing was associated with improved physician compliance with antibiotic administration guidelines. Based on the results, recommendations to enhance timely antibiotic therapy are provided.     

Implementing a guideline for the treatment of type 2 diabetics: results of a Cluster- Randomized Controlled Trial (C-RCT)

Background:

Lower respiratory tract infections like acute bronchitis, exacerbated chronic obstructive pulmonary disease and community-acquired pneumonia are often unnecessarily treated with antibiotics, mainly because of physicians' difficulties to distinguish viral from bacterial cause and to estimate disease-severity. The goal of this trial is to compare medical outcomes, use of antibiotics and hospital resources in a strategy based on enforced evidence-based guidelines versus procalcitonin guided antibiotic therapy in patients with lower respiratory tract infections.

Methods and design:

We describe a prospective randomized controlled non-inferiority trial with an open intervention. We aim to randomize over a fixed recruitment period of 18 months a minimal number of 1002 patients from 6 hospitals in Switzerland. Patients must be >18 years of age with a lower respiratory tract infections <28 days of duration. Patients with no informed consent, not fluent in German, a previous hospital stay within 14 days, severe immunosuppression or chronic infection, intravenous drug use or a terminal condition are excluded. Randomization to either guidelines-enforced management or procalcitonin-guided antibiotic therapy is stratified by centre and type of lower respiratory tract infections. During hospitalization, all patients are reassessed at days 3, 5, 7 and at the day of discharge. After 30 and 180 days, structured phone interviews by blinded medical students are conducted. Depending on the randomization allocation, initiation and discontinuation of antibiotics is encouraged or discouraged based on evidence-based guidelines or procalcitonin cut off ranges, respectively. The primary endpoint is the risk of combined disease-specific failure after 30 days. Secondary outcomes are antibiotic exposure, side effects from antibiotics, rate and duration of hospitalization, time to clinical stability, disease activity scores and cost effectiveness. The study hypothesis is that procalcitonin-guidance is non-inferior (i.e., at worst a 7.5% higher combined failure rate) to the management with enforced guidelines, but is associated with a reduced total antibiotic use and length of hospital stay.

Discussion:

Use of and prolonged exposure to antibiotics in lower respiratory tract infections is high. The proposed trial investigates whether procalcitonin-guidance may safely reduce antibiotic consumption along with reductions in hospitalization costs and antibiotic resistance. It will additionally generate insights for improved prognostic assessment of patients with lower respiratory tract infections.

Trial registration:

ISRCTN95122877     

Fatal pneumonia in an adolescent due to community-acquired methicillin-resistant Staphylococcus aureus positive for Panton-Valentine-leukocidin

A 15-year-old girl developed a severe Staphylococcus aureus pneumonia following an influenza virus infection. The patient was admitted to a paediatric intensive-care facility because of respiratory and circulatory failure. Despite aggressive therapy, she died on the third day following admission to the intensive care unit due to secondary hypoxic-ischaemic encephalopathy. Blood and respiratory aspirate cultures showed community-acquired methicillin-resistant S. aureus (CA-MRSA) with a normal antibiotic sensitivity except for betalactam antibiotics. PCR-based methods demonstrated that the isolate possessed the Panton-Valentine-leukocidin (PVL) gene, encoding an S. aureus exotoxin that is associated with fulminant necrotising pneumonia. This case shows that clinicians in the Netherlands should also be aware of the possibility of CA-MRSA in patients without risk factors for MRSA carriage. Especially in children and adolescents with an influenza virus infection, pneumonia due to PVL-positive S. aureus strains may be life-threatening.     

An early switch from intravenous to oral antibiotics is equally effective as the standard intravenous therapy in severe community acquired pneumonia

OBJECTIVE: To compare an early switch from intravenous to oral antibiotics with the standard intravenous therapy in patients admitted to hospital with severe community acquired pneumonia. DESIGN: Multicentre randomised prospective trial with follow-up at 28 days. METHOD: Patients with severe pneumonia who were admitted to hospital were randomised for 7 days intravenous antibiotic therapy (control group) or for an early switch to oral antibiotic therapy after 3 days of intravenous antibiotic therapy (intervention group). An intention-to-treat analysis was performed. The primary outcome measure was clinical cure. The length of hospital stay was a secondary outcome measure. RESULTS: Out of the 302 patients included in the trial, data was analysed from 265 patients. The mortality rate in the intervention group did not differ significantly from that of the control group (mean difference: 2%; 95% CI: -3-8). After 28 days, 83% of the patients in the intervention group and 85% in the control group were clinically cured (mean difference: 2%; 95% CI: -7-10). The length of hospital stay was 1.9 days shorter in the intervention group (95% CI: 0.6-3.2 days). CONCLUSION: An early switch from intravenous to oral antibiotics in patients admitted to hospital for severe community acquired pneumonia is safe and reduces the length of hospital stay by approximately 2 days.     

Ventilator-associated pneumonia; controversies with respect to diagnosis, pathogenesis, therapy and prevention]

Ventilator-associated pneumonia (VAP) is the most frequent nosocomial infection among intensive care patients; it is associated with increased morbidity and mortality. VAP is always preceded by colonization of the upper respiratory tract with potentially pathogenic micro-organisms. Oropharyngeal colonization is pivotal in the pathogenesis of VAP, while gastric and intestinal colonization appear to be less important than generally believed. The diagnosis is difficult and usually relies on a combination of clinical, microbiological and radiographic criteria. This combination of criteria may have a high sensitivity for VAP, but specificity is low. As a result, many patients receive antibiotics unnecessarily. Bronchoscopic sampling of lower airways can increase specificity, but whether these relatively expensive techniques are cost-effective remains to be established. The best antibiotic therapy for VAP is unknown. General infection control measures remain the cornerstone of infection prevention in each intensive care unit (ICU). Selective digestive decontamination (SDD) was associated with a reduction in the incidence of VAP, but mortality rates remained largely unaffected, and selection of antibiotic-resistant pathogens remains a potential disadvantage. Routine SDD in ICU is discouraged. Decontamination of the oropharynx appears to be equally effective.     

Performance measurement for schizophrenia: adherence to guidelines for antipsychotic dose.

OBJECTIVE: This report describes the development, application, and exploratory evaluation of a clinical performance measure based on recently published schizophrenia guidelines for antipsychotic dose. DESIGN, SETTING, PARTICIPANTS: The performance measure, which assesses adherence to antipsychotic dose recommendations for acute schizophrenia treatment, was calculated at hospital discharge for 116 patients with schizophrenia who had participated in a 6-month outcomes study. MAIN OUTCOME MEASURE: The Brief Psychiatric Rating Scale (BPRS) was used to assess symptom severity at 6-month followup. RESULTS: At discharge, almost one-half of the patients were prescribed doses outside the recommended range. For the entire sample, linear regression models showed that the performance measure variable was not significantly associated with followup symptom severity (BPRS total scores). However, a significant association was observed for patients prescribed oral antipsychotics only (n = 69). Patients prescribed recommended doses had lower adjusted mean BPRS totals than patients prescribed doses either greater than (P < 0.05) or less than (P < 0.05) recommended. CONCLUSIONS: Our findings suggest that the antipsychotic dose performance measure may be useful for monitoring quality. It assesses a modifiable aspect of care for which clinical improvement is needed, and such improvement is likely to improve patient outcomes. Future research is needed to confirm our findings and to develop and test interventions to improve the quality of care for schizophrenia that incorporate this clinical performance measure.     

The need for performance measures on testing for latent tuberculosis infection in primary care

BACKGROUND: The millions of people living in the United States with latent tuberculosis infection (LTBI) represent a reservoir of potentially active tuberculosis (TB) disease. When LTBI is left to activate, the consequences may include intense suffering, permanent disability, and high economic costs for patients, their caretakers, and society at large as TB spreads. The introduction of performance measures would improve accountability for quality of care and to reduce disparities, especially if the measures are group-targeted. PERFORMANCE MEASURES PROPOSAL: One National Quality Forum-endorsed measure (#0408) calculates the rate of TB screening in persons with HIV. Using the measure as a model, a set of performance measures is proposed. Denominators will include all persons in a given high-risk category, and numerators will include those persons from the denominators with LTBI test results. National guidelines informed appropriate exclusions. IMPLEMENTATION CHALLENGES AND SOLUTIONS: Challenges to implementation include lack of TB knowledge among primary care providers, potential for overwhelming already burdened schedules, and stigma associated with TB. However, the new measures, along with publication of educational resources, would raise clinicians' awareness. Short checklists and electronic supports would minimize time pressures. The routinization of screening would help reduce stigma. Finally, new federal funding and political will for electronic health records would facilitate data collection and impact assessment. CONCLUSIONS: TB sits at the crossroads of health and economic inequity and is a huge public health problem. The proposed performance measures will address a neglected secondary prevention opportunity and will be consistent with national priorities and health reform.     

Clinical and economic consequences of failure of initial antibiotic therapy for hospitalized patients with complicated skin and skin-structure infections.

OBJECTIVE: To estimate the consequences of failure of initial antibiotic therapy for patients with complicated skin and skin-structure infections. DESIGN: Retrospective cohort study. SETTING: Large US multihospital database. PATIENTS: We identified a total of 47,219 patients (age 18 years or older) who were admitted to the hospital for complicated skin and skin-structure infections from April 1, 2003, through March 31, 2004, and who received intravenous antibiotics during the first 2 hospital-days (ie, initial antibiotic therapy). Failure of therapy was defined as drainage, debridement, or receipt of other intravenous antibiotics at any subsequent time (except for changes to narrower-spectrum agents or any therapy change immediately before discharge). Predictors of failure of antibiotic therapy and mortality were examined using multivariate logistic regression. Analysis of covariance was used to estimate the impact of treatment failure on duration of intravenous antibiotic therapy, length of stay, and total inpatient charges. RESULTS: For 10,782 admitted patients (22.8%), there was evidence of failure of initial antibiotic therapy. In multivariate analyses, treatment failure was associated with receipt of vasoactive medications during the first 2 hospital-days (odds ratio [OR], 1.66 [95% confidence interval {CI}, 1.19-2.31]), initiation of antibiotic therapy in the intensive care unit (OR, 1.53 [95% CI, 1.28-1.84]), and the patient's Charlson comorbidity index (OR per 1-point increase, 1.06 [95% CI, 1.04-1.08]); treatment failure was also was associated with a 3-fold increase in mortality (OR, 2.91 [95% CI, 2.34-3.62]). Compared with patients for whom initial treatment was successful, patients who experienced treatment failure received intravenous antibiotic therapy for a mean of 5.7 additional days, were hospitalized for a mean of 5.4 additional days, and incurred a mean of $5,285 (in 2003 dollars) in additional inpatient charges (all P<.01). CONCLUSION: Failure of initial antibiotic therapy in the treatment of complicated skin and skin-structure infections is associated with significantly worse clinical and economic outcomes.     

Ceftaroline fosamil for the treatment of hospital-acquired pneumonia and ventilator-associated pneumonia

Objectives: Ceftaroline fosamil is a novel cephalosporin with bactericidal activity against common pathogens associated with hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP). Ceftaroline is inactive against extended-spectrum β-lactamase-producing or AmpC-overexpressing Enterobacteriaceae and has limited activity against Pseudomonas aeruginosa. CAPTURE is a multicenter, retrospective study designed to collect information on contemporary clinical use of ceftaroline fosamil in the USA. Data on off-label use of ceftaroline fosamil for the treatment of patients with HAP/VAP between September 2013 and March 2014 are presented. Methods: Data were collected at participating study centers by randomized selection and review of patients’ charts, and included patients’ demographics, disease characteristics, pathogens isolated, antibiotic treatment and clinical outcomes. Patients receiving at least four consecutive doses of ceftaroline fosamil, with data available for determination of clinical cure, comprised the evaluable population. Clinical success was defined as either clinical cure with no further need for antibiotics treatment, or clinical improvement with a switch to another antibiotic. Results: A total of 40 patients were evaluated: 27 with HAP and 13 with VAP. Demographics for patients with HAP and VAP were similar (59% male, mean age of 63 years and 54% male, mean age of 58 years, respectively). The clinical success rates were 75% overall, 82% in patients with HAP and 62% in patients with VAP. Clinical success rates for patients with methicillin-resistant Staphylococcus aureus (MRSA) isolated were 58% in patients with HAP and 57% in patients with VAP. Ceftaroline fosamil was used as a second-line therapy in majority of patients (85%) with clinical success rates of 79% similar to the published literature. Conclusion: The CAPTURE study data support further evaluation of ceftaroline fosamil as an effective treatment option for HAP and VAP when a ceftaroline susceptible etiologic pathogen is identified, including MRSA, or as a concurrent therapy when resistant Gram-negative pathogens are suspected.