A strategy for on-site treatment—rather than automatic hospitalization—of nursing home residents who develop pneumonia reduced hospitalizations by more than half and substantially lowered treatment costs without damaging clinical outcomes, according to Dr. Mark Loeb of McMaster University, Hamilton, Ont., and his associates.
The researchers developed an algorithm, or “clinical pathway,” for treating elderly nursing home patients who had pneumonia, and then tested it in a trial involving 661 patients at 20 facilities in southern Ontario. Patients with pneumonia who had a pulse of up to 100 beats/min, a respiratory rate of fewer than 30 breaths/min, systolic blood pressure of at least 90 mm Hg, oxygen saturation of at least 92%, and the ability to eat and drink were randomly assigned to receive usual care (347 subjects) or to be treated on-site (314 subjects).
For on-site treatment, a study nurse performed chest x-rays as needed, empirically administered oral levofloxacin once daily for 10 days, gave IV hydration as needed, administered oxygen as needed, and monitored vital signs. Subjects were transferred to a hospital if at any time they deteriorated to the point at which they no longer met the enrollment criteria.
Of the on-site treatment group, 34 patients (10%) required hospitalization, compared with 76 (22%) in the usual care group. After the data were adjusted for possible confounding factors, the mean rate of hospital admission was 8% for the on-site treatment group, compared with 20% for the usual care group. The mean number of days spent in the hospital was more than twice as many in the usual care group (1.74 days) as in the on-site treatment group (0.79 days), the researchers said (JAMA 2006;295:2503–10).
The results were similar when the analysis was restricted to patients with pneumonia confirmed by x-ray. In this subgroup, 18% of those in the on-site treatment group were hospitalized, compared with 30% of the usual care group, and the mean admission rates were 9% vs. 29%, respectively.
There were no significant differences between the two groups in mortality, adverse events, health-related quality of life, or functional status. In contrast, the differences in health care costs were substantial.
The initial cost for the on-site treatment approach—which included oxygen therapy, hydration therapy, mobile x-rays, nursing care, and administrative costs—was $87 (in Canadian dollars) per patient above the cost of usual care. However, this was more than offset by reductions in professional billings, transportation fees, and hospitalization costs, which amounted to $1,103 (Canadian) in savings per patient. This would translate to $1,517 savings per patient in U.S. dollars, Dr. Loeb and his associates said.
Their results also suggest that automatically transferring nursing home residents to a hospital when they develop pneumonia has little effect on their clinical outcomes or mortality, the investigators added.