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Can Clinical Guidelines Improve the Outcomes of CAP?



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Am Fam Physician. 2007 Jan 15;75(2):257.

Background: In the United States, one of the most common causes of death from an infection is community-acquired pneumonia (CAP). To care for patients with this infection, committees of experts have developed treatment guidelines; however, the guidelines have not been validated, and it is debatable whether they improve clinical outcomes. Mortality may be reduced with guidelines that call for the early administration of antibiotics and prophylaxis for deep venous thrombosis (DVT) in patients with CAP. Previous studies also have shown that implementing these two measures can reduce mortality; however, the limitations of the guidelines may exclude severe cases. In this study, Dean and colleagues evaluated the influence of treatment guidelines for CAP and compliance with these guidelines.

The Study: The study was performed in a health care system that included 16 general adult hospitals and more than 90 outpatient clinics. Data for 1993 through 2003 were collected from Medicare Part A claims forms with International Classification of Diseases, 9th ed., Clinical Modification codes for CAP, respiratory failure, and sepsis, with a secondary pneumonia code. Patients were excluded if they were hospitalized within the past 10 days, had human immunodeficiency virus, or had an organ transplant. The guidelines for CAP were implemented from 1995 to 1998. Information used in the analysis of the patients included age, sex, comorbidities, previous hospitalizations, admission year, and race. Compliance with the treatment guidelines was based on the timeliness of antibiotic administration. The main outcomes were 30-day mortality, the length of hospital stay, and 30-day all-cause readmission rates.

During the study, there were 17,728 patients with CAP who met the inclusion criteria. Their mean age was 72.3 years, 55.2 percent were women, and 96 percent were white.

Results: A 10 percent increase in the utilization of the treatment guidelines during the study was associated with a mortality odds ratio (OR) of 0.92 (95% confidence interval [CI], 0.87 to 0.98). When compared with other hospitals in the same state, the study hospitals had a mortality OR of 0.89 (95% CI, 0.82 to 0.97). Timeliness of antibiotic therapy did have a positive effect on outcomes, but DVT prophylaxis had no significant effect. Readmission rates also were lower in those hospitals using treatment guidelines.

Conclusion: This study validates the current treatment recommendations, and the findings suggest that the difference in the mortality OR would result in 20 lives saved per year in the study hospital if the treatment guidelines were implemented. The authors conclude that implementing and complying with the CAP treatment guidelines could improve the clinical outcomes.

Source:

Dean NC, et al. Improved clinical outcomes with utilization of a community-acquired pneumonia guideline. Chest. September 2006;130:794–9.



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