SAFELY INCREASING THE PROPORTION OF PATIENTS WITH COMMUNITY-ACQUIRED PNEUMONIA TREATED AS OUTPATIENTS - AN INTERVENTIONAL TRIAL

Background: Patients with community-acquired pneumonia who are at low risk for short-term mortality can be identified using a validated pred iction rule, the Pneumonia Severity Index. Such patients should be can didates for outpatient treatment, yet many are hospitalized. Objective : To assess a program to safely increase the proportion of low-risk pa tients with pneumonia treated at home. Methods: The intervention provi ded physicians with the Pneumonia Severity Index score and correspondi ng mortality risk for eligible patients and offered enhanced visiting nurse services and the antibiotic clarithromycin. Prospectively enroll ed, consecutive low-risk patients with pneumonia presenting to an emer gency department during the intervention period (n = 166) were compare d 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 coho rt study served as controls for patient-reported measures of recovery. Results: There were no significant baseline differences between patie nts in the intervention and control groups. The percentage initially t reated as outpatients increased from 42% in the control period to 57% in the intervention period (36% relative increase; 95% confidence inte rval, 8%-72%; P =.01). However, more outpatients during the interventi on period were subsequently admitted to the study hospital (9% vs 0%). When any admission to the study hospital within 4 weeks of presentati on was considered, there was a trend toward more patients receiving al l their care as outpatients in the intervention group (42% vs 52%; 25% relative increase; 95% confidence interval -2% to 59%; P =.07). No pa tient in the intervention group died in the 4-week follow-up period. S ymptom resolution and functional status were not diminished. Satisfact ion with overall care was similar, but patients treated in the outpati ent setting during the intervention were less frequently satisfied wit h the initial treatment location than comparable control patients (71% vs 90%; P =.04). Conclusions: Use of a risk-based algorithm coupled w ith enhanced outpatient services effectively identified low-risk patie nts with community-acquired pneumonia in the emergency department and safely increased the proportion initially treated as outpatients. Outp atients in the intervention group were more likely to be subsequently admitted than were controls, lessening the net impact of the intervent ion.