Algorithm Cuts Pneumonia Hospitalizations in Elderly

MONTREAL — Hospitalization can be reduced by more than half among nursing home residents with pneumonia and other lower respiratory tract infections, with no compromise in morbidity or mortality, Dr. Mark Loeb said at an international conference on community-acquired pneumonia.

“Pneumonia is the most important reason why residents are transferred to hospital, but hospitalization can lead to functional decline, infection with multiresistant organisms, urinary tract infections, and delirium,” said Dr. Loeb of the department of pathology and molecular medicine at McMaster University, Hamilton, Ont.

Reducing the rate of hospitalization in this population would not only avoid these potential hazards, but also reduce the overall burden on the health care system, an issue “which has particular relevance for pandemic planning,” he noted at the conference, which was sponsored by the International Society for Chemotherapy. “Most pandemic plans tend to ignore the long-term care facilities—they basically focus on the acute care setting—but a very relevant issue is when there's a pandemic, what happens to nursing home residents? Do they get sent to the acute care hospital for management, or do we just manage them on-site?”

A study by Dr. Loeb and his colleagues randomized 680 nursing home residents with pneumonia or other lower respiratory tract infections to either usual care or treatment according to a clinical algorithm designed to encourage on-site care (JAMA 2006;295:2503–10).

Patients were eligible to be treated on-site only if they could eat and drink and had stable vital signs; otherwise, they were transferred to a hospital.

The clinical algorithm involved the use of oral antimicrobials, portable chest radiographs, oxygen saturation monitoring, rehydration, and close monitoring by a research nurse.

Only 10% of patients randomized to the algorithm were hospitalized, compared with 22% of the usual care patients, Dr. Loeb said at the meeting. Over the 30-day follow-up, there were no significant differences in quality of life scores, functional status, or mortality (8% in the algorithm group vs. 9% in the usual care group), but there was a marked reduction in cost associated with the treatment algorithm.

Although the initial cost was $87 more per resident in the algorithm vs. usual care groups (because of the up-front cost of oxygen and hydration therapy, mobile radiographs, and administration), this was offset by reduced professional billing, transportation, and hospitalization costs, he said. Overall, the algorithm resulted in a saving of $1,016 (in U.S. dollars) per patient, based on the Canadian health care costs. Using U.S. prices, the saving was $1,517 (in U.S. dollars). The researchers estimated that the clinical algorithm could save $831 million annually among the approximately 1.5 million elderly residents in U.S. nursing homes.

Dr. Loeb and his coauthors acknowledged that health care funding in the United States could pose a barrier to the implementation of such an algorithm because, unlike in Canada, the costs of implementation would be shouldered by the nursing home, while the resulting savings would be realized by the hospital.

“Prospective payment and flat-rate systems of Medicare reimbursement to nursing homes represent financial disincentives to have residents treated on-site in the nursing home,” they wrote. “Therefore, nursing homes would need to receive supplemental funding to implement the pathway [algorithm].”

MONTREAL — Hospitalization can be reduced by more than half among nursing home residents with pneumonia and other lower respiratory tract infections, with no compromise in morbidity or mortality, Dr. Mark Loeb said at an international conference on community-acquired pneumonia.

“Pneumonia is the most important reason why residents are transferred to hospital, but hospitalization can lead to functional decline, infection with multiresistant organisms, urinary tract infections, and delirium,” said Dr. Loeb of the department of pathology and molecular medicine at McMaster University, Hamilton, Ont.

Reducing the rate of hospitalization in this population would not only avoid these potential hazards, but also reduce the overall burden on the health care system, an issue “which has particular relevance for pandemic planning,” he noted at the conference, which was sponsored by the International Society for Chemotherapy. “Most pandemic plans tend to ignore the long-term care facilities—they basically focus on the acute care setting—but a very relevant issue is when there's a pandemic, what happens to nursing home residents? Do they get sent to the acute care hospital for management, or do we just manage them on-site?”

A study by Dr. Loeb and his colleagues randomized 680 nursing home residents with pneumonia or other lower respiratory tract infections to either usual care or treatment according to a clinical algorithm designed to encourage on-site care (JAMA 2006;295:2503–10).

Patients were eligible to be treated on-site only if they could eat and drink and had stable vital signs; otherwise, they were transferred to a hospital.

The clinical algorithm involved the use of oral antimicrobials, portable chest radiographs, oxygen saturation monitoring, rehydration, and close monitoring by a research nurse.

Only 10% of patients randomized to the algorithm were hospitalized, compared with 22% of the usual care patients, Dr. Loeb said at the meeting. Over the 30-day follow-up, there were no significant differences in quality of life scores, functional status, or mortality (8% in the algorithm group vs. 9% in the usual care group), but there was a marked reduction in cost associated with the treatment algorithm.

Although the initial cost was $87 more per resident in the algorithm vs. usual care groups (because of the up-front cost of oxygen and hydration therapy, mobile radiographs, and administration), this was offset by reduced professional billing, transportation, and hospitalization costs, he said. Overall, the algorithm resulted in a saving of $1,016 (in U.S. dollars) per patient, based on the Canadian health care costs. Using U.S. prices, the saving was $1,517 (in U.S. dollars). The researchers estimated that the clinical algorithm could save $831 million annually among the approximately 1.5 million elderly residents in U.S. nursing homes.

Dr. Loeb and his coauthors acknowledged that health care funding in the United States could pose a barrier to the implementation of such an algorithm because, unlike in Canada, the costs of implementation would be shouldered by the nursing home, while the resulting savings would be realized by the hospital.

“Prospective payment and flat-rate systems of Medicare reimbursement to nursing homes represent financial disincentives to have residents treated on-site in the nursing home,” they wrote. “Therefore, nursing homes would need to receive supplemental funding to implement the pathway [algorithm].”

MONTREAL — Hospitalization can be reduced by more than half among nursing home residents with pneumonia and other lower respiratory tract infections, with no compromise in morbidity or mortality, Dr. Mark Loeb said at an international conference on community-acquired pneumonia.

“Pneumonia is the most important reason why residents are transferred to hospital, but hospitalization can lead to functional decline, infection with multiresistant organisms, urinary tract infections, and delirium,” said Dr. Loeb of the department of pathology and molecular medicine at McMaster University, Hamilton, Ont.

Reducing the rate of hospitalization in this population would not only avoid these potential hazards, but also reduce the overall burden on the health care system, an issue “which has particular relevance for pandemic planning,” he noted at the conference, which was sponsored by the International Society for Chemotherapy. “Most pandemic plans tend to ignore the long-term care facilities—they basically focus on the acute care setting—but a very relevant issue is when there's a pandemic, what happens to nursing home residents? Do they get sent to the acute care hospital for management, or do we just manage them on-site?”

A study by Dr. Loeb and his colleagues randomized 680 nursing home residents with pneumonia or other lower respiratory tract infections to either usual care or treatment according to a clinical algorithm designed to encourage on-site care (JAMA 2006;295:2503–10).

Patients were eligible to be treated on-site only if they could eat and drink and had stable vital signs; otherwise, they were transferred to a hospital.

The clinical algorithm involved the use of oral antimicrobials, portable chest radiographs, oxygen saturation monitoring, rehydration, and close monitoring by a research nurse.

Only 10% of patients randomized to the algorithm were hospitalized, compared with 22% of the usual care patients, Dr. Loeb said at the meeting. Over the 30-day follow-up, there were no significant differences in quality of life scores, functional status, or mortality (8% in the algorithm group vs. 9% in the usual care group), but there was a marked reduction in cost associated with the treatment algorithm.

Although the initial cost was $87 more per resident in the algorithm vs. usual care groups (because of the up-front cost of oxygen and hydration therapy, mobile radiographs, and administration), this was offset by reduced professional billing, transportation, and hospitalization costs, he said. Overall, the algorithm resulted in a saving of $1,016 (in U.S. dollars) per patient, based on the Canadian health care costs. Using U.S. prices, the saving was $1,517 (in U.S. dollars). The researchers estimated that the clinical algorithm could save $831 million annually among the approximately 1.5 million elderly residents in U.S. nursing homes.

Dr. Loeb and his coauthors acknowledged that health care funding in the United States could pose a barrier to the implementation of such an algorithm because, unlike in Canada, the costs of implementation would be shouldered by the nursing home, while the resulting savings would be realized by the hospital.

“Prospective payment and flat-rate systems of Medicare reimbursement to nursing homes represent financial disincentives to have residents treated on-site in the nursing home,” they wrote. “Therefore, nursing homes would need to receive supplemental funding to implement the pathway [algorithm].”