Implementing a standardized order set for community-acquired pneumonia: impact on mortality and cost

Order sets have shown some success in improving compliance with clinical guidelines, as well as patient and financial outcomes. Baylor Health Care System (BHCS) deployed a standardized adult pneumonia order set throughout its eight acute care hospitals in 2006.

All non-comfort care adult patients admitted with community-acquired pneumonia who met The Joint Commission definition of pneumonia and were discharged from an acute care BHCS hospital for a 30-month period (March 1, 2006-August 31, 2008) were included. Mortality, core measures compliance, and direct cost were compared for patients who did and did not receive the order set.

Some 4,454 patients met study inclusion criteria. Significant variation in use between hospitals, however, persisted. Unadjusted analysis showed significant reductions in inhospital mortality, 30-day mortality, and direct cost and a significant increase in core measures compliance. Following risk adjustment, the difference in core measures compliance was retained (relative risk [95% confidence interval (C.I.)] 1.08 [1.03, 1.12]). Inhospital mortality and 30-day mortality reductions both approached significance (hazard ratios [95% C.I.] of 0.73 [0.51,1.02] and 0.79 [0.62, 1.00], respectively). Mean (standard error) benefits of order set use in in-hospital mortality and costs were estimated at 1.67 (0.62)% and $383 (207). The incremental cost-effectiveness ratio point estimate was -$22,882 per life saved, with an upper 95% confidence limit of$1,278 per life saved.

Widespread adoption of the order set was achieved, with use consistently at or above 75% across all BHCS acute care hospitals since February 2007. The reductions in mortality observed with order set use, in combination with the favorable estimate of cost-effectiveness, make standardized evidence-based order sets an attractive improvement methodology for improving quality of pneumonia care.