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Determinants for hospitalization in " low-risk" community acquired pneumonia
Zakari Y Aliyu1, Muktar H Aliyu, Ken McCormick
1Department of Medicine, St Agnes Hospital, Baltimore, MD 21229, USA. zyaliyu@cs.com
Insights
Low-risk community-acquired pneumonia (CAP) patients with high fever, tachycardia, or specific demographics were more likely to be hospitalized. Inpatient care for CAP is significantly more expensive than outpatient management without improving outcomes.
Area of Science:
- Pulmonology
- Infectious Diseases
- Health Services Research
Background:
- Community-acquired pneumonia (CAP) management involves deciding between inpatient and outpatient care, despite existing guidelines.
- Patients with a Pneumonia Severity Index (PSI) score below 70 are considered low-risk for complications and suitable for outpatient antibiotic therapy.
- Low-risk CAP patients typically are younger, without comorbidities, and not residing in nursing homes.
Purpose of the Study:
- To analyze factors influencing hospitalization decisions for low-risk CAP patients.
- To compare demographic, clinical, social, and financial parameters between emergency department (ED) discharged and hospitalized low-risk CAP patients.
- To evaluate the cost-effectiveness and outcomes of inpatient versus outpatient management for low-risk CAP.
Main Methods:
- Retrospective analysis of 296 low-risk CAP patients at St. Agnes Hospital.
- Patients were stratified into PSI classes I-V.
- Comparison of patient characteristics and outcomes between ED discharge and inpatient groups.
Main Results:
- Hospitalized patients were more likely to be female, African American, and have insurance coverage, with higher temperature and pulse rate.
- No significant differences were found in altered mental status, hypotension, tachypnea, or laboratory/radiological parameters.
- Inpatient care averaged 3.5 days, costing eight times more than outpatient management, with no difference in mortality or treatment failure.
Conclusions:
- High fever, tachycardia, female gender, African-American race, and insurance coverage were identified as determinants for hospitalization in low-risk CAP patients.
- Inpatient management of low-risk CAP is significantly more costly and does not improve outcomes compared to outpatient care.
- The PSI is a valuable tool for ED evaluation of low-risk CAP patients, guiding appropriate site-of-care decisions in suitable social contexts.
Background:
A variable decision in managing community acquired pneumonia (CAP) is the initial site of care; in-patient versus outpatient. These variations persist despite comprehensive practice guidelines. Patients with a Pneumonia Severity Index (PSI) score lower than seventy have low risk for complications and outpatient antibiotic management is recommended in this group. These patients are generally below the age of fifty years, non-nursing home residents, HIV negative and have no major cardiac, hepatic, renal or malignant diseases.
Methods:
A retrospective analysis of 296 low-risk CAP patients evaluated within a year one period at St. Agnes Hospital, Baltimore, Maryland was undertaken. All patients were assigned a PSI score. 208 (70%) were evaluated and discharged from the emergency department (E.D.) to complete outpatient antibiotic therapy, while 88 (30%) were hospitalized. Patients were sub-stratified into classes I-V according to PSI. A comparison of demographic, clinical, social and financial parameters was made between the E.D. discharged and hospitalized groups.
Results:
Statistically significant differences in favor of the hospitalized group were noted for female gender (CI: 1.46-5.89, p= 0.0018), African Americans (CI: 0.31-0.73, p= 0.004), insurance coverage (CI: 0.19-0.63, p= 0.0034), temperature (CI: 0.04-0.09, p= 0.0001) and pulse rate (CI: 0.03-0.14, p= 0.0001). No statistically significant differences were observed between the two groups for altered mental status, hypotension, tachypnea, laboratory/radiological parameters and social indicators (p>0.05). The average length of stay for in-patients was 3.5 days at about eight time's higher cost than outpatient management. There was no difference in mortality or treatment failures between the two groups. The documentation rate and justifications for hospitalizing low risk CAP patients by admitting physicians was less than optimal.
Conclusions:
High fever, tachycardia, female gender, African- American race and medical insurance coverage are determinants for hospitalization among low risk CAP patients in our study. The average length of stay for in-patients was 3.5 days (3 to 5 days). The cost of in-patient care was about eight times higher than outpatient management. This study supports the recommendation of using the PSI for E.D evaluation of patients in appropriate social settings.