Adherence to guidelines for community-acquired pneumonia: does it decrease cost of care?

Community-acquired pneumonia (CAP) is a common diagnosis and care of CAP is responsible for significant healthcare expenditures, the majority of which are for patients who require hospitalisation. Studies have shown that significant variation exists among institutions with respect to antibacterial costs and length of stay (LOS) for CAP. These variations do not appear to be associated with significant differences in patient outcomes. This information has stimulated the development of practice guidelines and critical pathways to optimise the care of patients with CAP. The central focus of guidelines is recommendations for antibacterial therapy; critical pathways include recommendations for therapy, but focus on the process of care for patients with CAP. Guidelines and critical pathways are time consuming to develop and their implementation requires significant institutional resources. Therefore, it is essential that they are shown to be effective, and there has been significant interest in determining if guidelines and pathways can improve the cost effectiveness of care. In the past several years, a number of studies have evaluated the impact of treatment consistent with guidelines on outcomes for patients with CAP. These studies have shown that antibacterial therapy that is consistent with guidelines can reduce LOS, decrease costs, and several have shown a favourable impact on mortality. The majority of these studies have been retrospective reviews. One multicenter prospective, randomised trial of a critical pathway for CAP revealed significant reductions in the hospital admission of patients, LOS and cost of care. Other studies of processes of care have been mainly 'before and after' interventions; many have shown reductions in LOS and costs. Based on the available data, it is reasonable to expect that adherence to guidelines and critical pathways can reduce the cost of care for CAP; however, randomised controlled trials that include a formal cost-effectiveness analysis are needed. Even if the data to support the use of guidelines and pathways are robust, those who develop and implement them need to anticipate and understand barriers to physician adherence.