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Clinical Decisionmaking

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Researchers from the Pneumonia PORT examine triage and management of community-acquired pneumonia

More than 2 million cases of community acquired pneumonia (CAP) are diagnosed each year in the United States, resulting in about 10 million physician visits, 500,000 hospitalizations, and 45,000 deaths. The Pneumonia Patient Outcomes Research Team (PORT) was a multicenter, 5-year project focused on care and outcomes of outpatient and hospitalized patients with CAP. The PORT was led by Wishwa N. Kapoor, M.D., M.P.H., of the University of Pittsburgh, and is supported by the Agency for Healthcare Research and Quality (HS06468).

The researchers used retrospective data from over 14,000 adult inpatients with CAP and 30-day hospital mortality to derive a Pneumonia Severity Index (PSI) to identify which patients were most at risk of dying from CAP. They later validated the PSI in inpatients and outpatients. A study by AHRQ researcher, Eduardo Ortiz, M.D., M.P.H., and other investigators suggests that the PSI has potential for helping doctors triage CAP patients—that is, decide which patients can go home and which patients should be admitted to the hospital. A second study concludes that increased measurement of arterial oxygenation among CAP patients could increase detection of dangerous arterial hypoxemia, another means to help doctors decide which CAP patients need to be hospitalized. A third study finds that doctors generally agree on signs which indicate that hospitalized CAP patients can be switched from intravenous to oral antibiotics.

Ortiz, O., Quach, C.H., and Lenert, L.A. (2001, September). "The Pneumonia Severity Index: Assessing its potential as a triage tool." Federal Practitioner, pp. 11-25.

Since doctors rely mainly on clinical impressions when triaging CAP patients, it is not surprising that hospital admission rates for CAP vary dramatically among regions, facilities, and providers. Use of the PSI during initial patient assessment may enable doctors to make more appropriate treatment decisions, concludes this study. The researchers compared triage decisions made by doctors at one hospital for 161 CAP patients with PSI recommendations and assessed the potential impact of the PSI on the hospital's admission practices.

The PSI stratifies CAP patients into five risk classes using a cumulative scoring system based on 19 variables in 4 areas: demographic factors, other coexisting (comorbid) illnesses, physical examination findings, and laboratory findings. Patients in risk classes 1 and 2 (with 70 points or less) are at sufficiently low risk to make outpatient management appropriate. Patients in risk class 3 (71 to 90 points) also are potential candidates for outpatient management, but they may benefit from a brief hospitalization. Patients in risk classes 4 and 5 (with more than 90 points) should be hospitalized.

Doctors initially hospitalized 24 percent of class 1 and 2 patients, for whom the PSI would suggest outpatient management. Application of the PSI could improve triage decisions by helping doctors identify the class 1 and 2 patients who could be treated safely as outpatients. On the other hand, use of the PSI would not have greatly improved doctors' management of high-risk patients. For example, doctors initially treated only 11 percent of patients in class 4 and no patients in class 5 as outpatients. Only one of these patients required subsequent hospitalization, and none of them died. The fact that 25 percent of class 3 patients, who were initially treated as outpatients, required subsequent hospitalization reinforces the uncertainty involved in treating this group of patients.

Reprints (AHRQ Publication No. 02-R012) are available from the AHRQ Publications Clearinghouse.

Levin, K.P., Hanusa, B.H., Rotondi, A., and others. (2001, September). "Arterial blood gas and pulse oximetry in initial management of patients with community-acquired pneumonia." Journal of General Internal Medicine 16, pp. 590-598.

Arterial hypoxemia (deficient arterial oxygen) is a dangerous sign for CAP patients, often prompting doctors to hospitalize them. Hypoxemia can signal impending respiratory failure, need for intensive care, and risk of death. Arterial oxygen should be measured for more CAP patients, especially outpatients, because even patients with no risk factors for this problem can be hypoxemic, according to these authors. They found that use of arterial blood gas (ABG) measurements and pulse oximetry (PO) to measure arterial oxygenation varied widely across five study sites in the United States and Canada.

Six factors increased the risk of hypoxemia by 1.5 to 3 times: age over 30 years, chronic obstructive pulmonary disease, congestive heart failure, respiratory rate more than 24 per minute, altered mental status, and chest radiographic infiltrate involving more than one lobe. Although patients with three or more risk factors were more likely to be hypoxemic, 10 percent of patients who had none of these risk factors were hypoxemic when tested. Unfortunately, 70 percent of all outpatients with two or more risk factors for hypoxemia had neither ABG nor PO performed.

In contrast, 90 percent of inpatients received some measure of arterial oxygenation within 48 hours of presentation, with minimal variation across hospitals. Outpatients who had either an ABG or PO performed were more likely to be admitted to the hospital than patients who had neither test performed (17 vs. 5 percent). Inpatients who had either ABG or PO performed and whose supplemental oxygen status was known were more likely to be admitted to an ICU for management of hemodynamic compromise or respiratory failure than patients who received neither test (20 vs. 4 percent).

Halm, E.A., Switzer, G.E., Mittman, B.S., and others. (2001, September). "What factors influence physicians' decisions to switch from intravenous to oral antibiotics for community-acquired pneumonia?" Journal of General Internal Medicine 16, pp. 599-605.

A major determinant of how long people with CAP stay in the hospital is how long they remain on intravenous (IV) antibiotics. Although patients usually are discharged 1 day after switching to oral antibiotics, there is considerable variability in the overall duration of IV therapy. Many practice guidelines for hospitalized patients with CAP recommend early conversion to oral antibiotics once patients are clinically stable. This is to minimize risk of IV line infections and sepsis, decrease patient deconditioning, and expedite recovery at home. This study found that doctors generally believed that patients could be switched to oral antibiotics once vital signs and mental health status had stabilized and oral intake was possible.

Doctors cited the following median thresholds for when a typical patient could be converted to oral therapy: temperature of 100 degrees F or less, respiratory rate of 20 breaths or less per minute, heart rate of 100 beats or less per minute, systolic blood pressure of 100 mm Hg or more, and oxygen saturation in room air of 90 percent or more. Over half (58 percent) of the doctors felt that patients should be without a fever for 24 hours before conversion to oral antibiotics.

However, attitudes about the switch to antibiotics varied considerably by age, inpatient care activities, attitudes about guidelines, and personality. For example, pulmonary and infectious diseases doctors were the most predisposed and other medical specialists were the least disposed towards early conversion to oral antibiotics. Doctors who were older, more involved in inpatient care, and worked more clinical hours were more reluctant to convert to oral antibiotics early. Physicians who were based at a university hospital, who spent more time on non-patient care matters such as research and administration, or had more favorable opinions about practice guidelines were more inclined to make the switch or oral antibiotics. These findings are based on survey responses of 345 generalist and specialist physicians who managed pneumonia in seven hospitals.

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