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Am Fam Physician. 2006;74(9):1604-1606

Pneumonia often occurs in residents of nursing homes and is one of the most common reasons for hospital transfer. Hospitalization is not benign and is associated with increased economic costs. A strategy for treating pneumonia in the nursing home would presumably result in reduction of hospital-associated hazards and in lower costs. Loeb and associates conducted a study comparing usual care of pneumonia with a clinical pathway for on-site treatment.

Nursing homes were paired according to number of beds, with one of each pair being randomized to usual care and the other to the clinical pathway protocol. Residents 65 years and older were considered to have pneumonia if they had two new or changed chest signs or symptoms (e.g., cough, chest pain, or sputum production) or fever combined with radiographic evidence of pneumonia. Nurses assessed vital signs, nutrition and fluid intake, and oxygen saturation. All on-site criteria had to be satisfied, otherwise the patient was transferred for hospital care (see accompanying table).

Pulse: 100 beats per minute or less
Respiratory rate: less than 30 breaths per minute
Systolic blood pressure: 90 mm Hg or higher
Oxygen saturation: 92 percent or higher (90 percent or higher with chronic obstructive pulmonary disease)
Ability to eat and drink

A chest radiograph was obtained but did not influence the decision to transfer. On-site treatment included rehydration for dehydrated patients and administration of levofloxacin (Levaquin) 500 mg daily for 10 days. Patients could be transferred to the hospital anytime they failed to meet on-site treatment criteria. Usual care involved treatment decision making and hospital transfer by the physician in charge. Primary outcome measures included hospital admission and length of stay, and the secondary measure was a nursing home–based health scale (Minimum Data Set Health Status Index).

Drawing from the 22 participating nursing homes, 680 residents were enrolled, with complete hospitalization data for 661 participants. Hospitalization occurred in 34 (10 percent) of the intervention group and in 76 (22 percent) of the usual care group, with a weighted mean difference of 12 percent (P = .001). Number of hospitalized days was 0.79 in the intervention group and 1.74 in the usual care group. The results were similar in patients with and without radiographic confirmation of pneumonia. Mortality rates in both groups were similar, and there were no significant differences in measured health status or quality of life. Up-front costs for the intervention group were higher per resident; however, in the end, there was an overall average cost savings of $1,016 per resident.

Hospitalization rates of pneumonia in nursing home residents were reduced by more than one half when using a clinical pathway for on-site treatment. There also was no negative impact on health status and considerable hospital cost savings. The authors note that the cost savings may not be the same in the United States as in Canada, where nursing homes and hospitals receive funding by the same payer.

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