In the United States, community-acquired pneumonia (CAP) is the leading cause of morbidity and mortality due to infection and most often strikes the elderly and individuals with comorbidities. The 30-day mortality rate for Medicare patients admitted to the hospital for CAP is about 12% and has not changed significantly in decades (Table 1). CAP has been shown to increase long-term mortality to as high as 40% within 1 year of admission. The infection is one of seven conditions that account for nearly 30% of potentially preventable readmissions in the 15-day window after initial hospital discharge. Estimates show that the cost of treating CAP exceeds $17 billion per year.
Hospitalizing Patients With Community-Acquired Pneumonia
“The decision on whether or not hospitalization is necessary for CAP is critical because there are multiple consequences,” says Thomas M. File, Jr., MD, MSc. “Hospitalizations can influence the cost of care, the intensity of diagnostic testing, and the selection of antimicrobial agents.” There are several advantages to outpatient treatment of CAP—when used appropriately—including cost, patient preference, faster convalescence, and fewer nosocomial complications. Hospitalization decisions should be based on several factors, including (among others): age over 50; significant underlying coexisting conditions; elevated blood urea nitrogen levels; and the presence of altered mental status or significant abnormalities in vital signs.
“Readmission for CAP patients recently discharged after hospitalization represents an important, expensive, and often preventable adverse outcome,” Dr. File says. “The risk of readmission can be modified by the quality and type of care that is provided. Improving CAP readmission rates is the joint responsibility of hospitals and clinicians.” He adds that measuring readmission rates can help create incentives to invest in interventions to improve hospital care. This can also help clinicians better assess the readiness of patients for discharge and facilitate transitions to outpatient settings.
Quality Measures on CAP for Hospitals
In an effort to improve care, the Joint Commission has issued core measurement areas for hospitals that include CAP (Table 2). The CAP core measures are reviewed quarterly by the Pneumonia Expert Panel and regularly by the Joint Commission and CMS. They are based on process-of-care recommendations within the control of healthcare practitioners or outcomes. “These core performance measures should be complementary to antimicrobial stewardship,” adds Dr. File. “They should ultimately improve patient outcomes and ideally be based on strong evidence from clinical studies. However, it’s also important to evaluate them for unintended consequences. We need to allow for deviation, if documented, and have realistic thresholds for compliance. The measures cannot replace appropriate clinical judgment.”
Patient Education at Discharge
Patients need to be educated on several points prior to discharge after being hospitalized for CAP, according to Dr. File. “Careful attention should be paid to the treatment of common comorbid illnesses that are associated with an increased risk of rehospitalization, including COPD and coronary artery disease, to help reduce readmission rates.” Strategies to prevent such hospital readmissions at the time of initial hospital discharge include:
• Immunizations for influenza and pneumococcus, when indicated, to improve long-term burden of disease.
• Clear instructions for the correct use of medications.
• A review of signs/symptoms that may suggest a worsening of the underlying condition.
• An emphasis on appropriate outpatient follow-up with a medical provider within 1 week of hospital discharge.
“Effective inpatient care is a team sport,” says Dr. File. “Clinicians need to develop shared goals and improve communication. A team-based model in the inpatient setting can enhance coordination of care and improve patient outcomes. Patients are integral members of the team, and efforts should be made to engage them in their care. When patients are discharged, they should be able to recognize when they need to return to the hospital for care. Ultimately, they must understand the gravity of what it means to have CAP.”
A Continuing Movement
Hospitals throughout the U.S. are being publicly reported for compliance to performance measures for hospitalized patients. As a result, it is becoming increasingly important to develop a collaborative approach to consistently monitor outcomes and adherence to CAP core measures. “Physician education, acceptance from physicians and staff, participation from multiple provider levels, and assistance from automated hospital information systems and decision support are all important components,” Dr. File says. “Considering the increasing prevalence of drug resistance and our limited number of new antibiotics, it’s critical that validated risk-assessment tools be used to guide management decisions. With comprehensive planning, these tools and quality measures may ultimately improve outcomes and prevent readmissions.”
Readings & Resources (click to view)
CSC. Preventing hospital readmissions: the first test case for continuity of care. Available at http://assets1.csc.com/health_services/downloads/CSC_Preventing_Hospital_Readmission.pdf.
Jasti H, Mortensen EM, Obrosky DS, Kapoor WN, Fine MJ. Causes and risk factors for rehospitalization of patients hospitalized with community-acquired pneumonia. Clin Infect Dis. 2008;46:550-556. Available at: http://cid.oxfordjournals.org/content/46/4/550.full.
Mandell LA, Wunderink RG, Anzueta A, Bartlett JG, Infectious Diseases Society of America; American Thoracic Society. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(Suppl):S27-S72.
File TM Jr, Gross PA. Performance measurement in community-acquired pneumonia: consequences intended and unintended. Clin Infect Dis. 2007;44:942-944.
File TM Jr, Tan JS. Pneumonia in older adults: reversing the trend. JAMA. 2005;294:2760-2763.
Wunderlink RJ, Waterer GW, Rello J. Management of community-acquired pneumonia in adults. Am J Resp Crit Care Med. 2010;8:2-41.