FROM: Theodore O. Will, Chief Executive Officer
DATE: Aug 20, 1999
SUBJECT: Community-Acquired Pneumonia Among New York State Medicare Inpatients
IPRO CONTACTS:
Marguerite Shaffer, R.N., Director Downstate, Improvement Strategies QI - Ext. 356
Barbara Shields, R.N., C.P.H.Q., Upstate Director, Improvement Strategies/QI (1-800-233-0360)
Enclosed please find the report entitled "Community-Acquired Pneumonia among New York State Medicare Inpatients : Trends in Clinical Stability Prevalence and Early Switch Therapy Among 42 Hospitals Participating a Health Care Quality Improvement Program Project."
This report shows improving trends in the earlier use of oral antibiotic therapy for clinically stable patients hospitalized with pneumonia. This is especially so for patients who are $ 75 years of age. Nevertheless, there still exist opportunities for improvement in the use of oral antibiotics, particularly in patients transferred from long-term care facilities. IPRO will continue its effort to improve New York State community-acquired pneumonia treatment practices as part of a three-year HCQIP national project on pneumonia prevention and treatment (1999-2001).
Should you have any questions about this project or report, please feel free to call one of the above-mentioned contacts.
Community-acquired pneumonia (CAP) affects approximately four million adults each year and incurs an estimated aggregate cost of $23 billion annually. In 1995, IPRO collaborated with 42 hospitals in developing a CAP quality improvement project focusing on the use of clinical risk assessment in patients admitted for pneumonia and the timely use of oral antibiotics in clinically stable patients, so-called Aswitch therapy@. IPRO analyzed and reported hospital-specific information to the 42 hospitals regarding the risk status, switch therapy and length-of-stay for patients discharged with pneumonia from 1994-95. This report describes a re-measurement of CAP process-of-care elements after the initial feedback.
The patients were identified from the Medicare claims database for December 1997-February 1998. Using retrospective chart review, patients were determined to be clinically stable if they lacked any of nine clinical findings, such as unstable co-morbid disease on hospital day three; evidence of a high risk pathogen or metastatic infection; the occurrence of any of eight cardiac complications; or documentation of a life-threatening complication anytime during the first 72 hours.
The 1997-98 impact sample age, gender, co-morbidities and admission source were very similar to the 1994-95 baseline sample. The aggregate proportion of clinically stable patients in the two samples were the same, 63%. The proportion of patients who were switched to oral antibiotics by day four increased from 14% in 1994-95 to 18% in 1997-98 (p=0.02). The proportion of patients who were switched to oral antibiotics by day five also increased, from 25% in 1994-95 to 32% in 1997-98 (p= 0.001). Unlike the 1994-95 baseline period, there were no statistically significant differences in the proportion of switched patients for those patients less than 75 years of age versus those $75 years of age.
Although switch therapy proportions have risen in the New York State elderly, many patients still appear to be on prolonged courses of parenteral antibiotics. IPRO will continue to work with hospitals in promoting optimal care for their patients.