Guidelines for CAP — Are They Really Worth it?
Guidelines for CAP—Are They Really Worth it?
Abstract & commentary
Synopsis: Guidelines for the care of patients hospitalized for community-acquired pneumonia can be helpful if there is variance—they can even save hospital days and money if the physicians are involved. It is important, however, to select practical outcomes indicators and to focus on saving patient lives rather than simply saving money.
Source: Nathwani D, et al. Do guidelines for community-acquired pneumonia improve the cost-effectiveness of hospital care? Clin Infect Dis. 2001;32:728-741.
Community-acquired pneumonia (cap) has become a major focus of investigation and publication because of the large amount of money spent on antibiotics for respiratory infections, the release of new antibiotics, and the changing susceptibility of respiratory pathogens. The British Thoracic Society, the American Thoracic Society, and the Infectious Diseases Society of America have all produced guidelines although they differ somewhat in recommendations. The attempt to bring conformity in decision making by managed care organizations has led to efforts to apply, if not enforce, these guidelines, but the effect they have had is not clear.
Nathwani and associates took on the daunting task of reviewing 76 published studies of the effect of guidelines for patients hospitalized for CAP. They asked 4 questions and found the following answers:
Do guidelines change practices? Yes, they can. Although not all did, studies showed they could lead to earlier hospital discharge through use of the pneumonia severity-of-index scale. Obstacles to change included physician lack of awareness of the guidelines, a lack of trust or disagreement with the guidelines, patient attitudes toward going home, and adequate community services to take responsibility. Successful implementation related to broad physician involvement in developing the guidelines, continuing reinforcement of them, and providing resources to facilitate compliance.
How could CAP guidelines lead to improved outcome of care? Even if changes in process of care can be accomplished, it may not be possible to demonstrate patient benefit or to actually improve patient outcomes. There are some indicators, however, which do relate to mortality at a statistically significant level. These include obtaining blood cultures, including a macrolide in the initial therapeutic regimen, and the speed of initiation of intravenous antibiotic therapy.
How could CAP guidelines lead to reductions in the cost of care? Better patient care through guidelines has been able to save money through reduced hospital admissions, shortened hospital stays, and shortened courses of intravenous antibiotic therapy, but these have not been shown to improve outcomes in patient care. Cost-effectiveness rather than cost-minimalization studies are needed.
What evidence exists that implementation of CAP guidelines recommendations improves the cost-effectiveness of care? The studies have shown that changes in process can result in cost reduction without loss of quality of care or patient outcomes, but none have shown actual patient benefit.
An assessment of variance in practice before introduction of guidelines may also be worthwhile. If physicians are already compliant, there is little need for change.
Nathwani et al suggest that practice guidelines can be valuable and should be used, but they caution that enhanced patient care rather than simply cost reduction should be the goal. Costs appear to be less when patient outcomes are improved. They also suggest that early physician involvement in developing guidelines is important and that outcomes indicators should be simple, practical, and achievable (ie, how long it takes for a medication to be given after it is ordered, duration of hospital stay, readmission rate, and 30-day mortality). They also note that "the impact of practice guidelines on physicians is never as great as their authors intend" and encourage the development of guidelines for patients to be treated in the community rather than the hospital.
Comment by Alan D. Tice, MD, FACP
The amount of information being published about the management of respiratory infections has been remarkable. The impetus appears to be the large potential market for antibiotic use (greater than any other infection) that a number of manufacturers are targeting for their new products. With the conflicting influence of growing pressures to reduce the use of antibiotics, the results have been interesting. There is also the increasing demand for accountability from managed care, which has led to an evidence-based medicine approach to decision making. Just how far these endeavors will go and what changes will actually occur is not clear.
At this point in outcomes research, it seems a bit like the proverbial blind men trying to describe an elephant. Outcomes are different in everyone’s eyes and there are few quantitative measures of them other than cost, which has clear and tangible features. What else to measure, how to measure it, and its relation to changes in process or patient benefit are uncertain.
Using outpatient intravenous antibiotic therapy (OPAT) instead of hospitalization yields a clear cost advantage, but there are not yet enough cases to know whether there is a compromise in mortality at 30 days. It is also a problem because there may be a number of factors (ie, the lack of a telephone at home, which may prevent OPAT) that are unrelated to the infection being evaluated. The lack of community resources for home care may be a more important factor in deciding on early hospital discharge than practice guidelines.
Another point that emerges is the shortcomings of guidelines compared to physician decision making. It is just not possible to incorporate enough factors into a computer program to match the decision-making ability and accuracy of an experienced physician—at least not yet. Even if it were, it would take so long to enter the data on each patient that the physician’s services would be well worthwhile in speed as well as accuracy.
In conclusion, this review encourages guideline use for CAP and provides some insight into their development and application. It is best to involve as many physicians as possible in their development so they know what they are and are willing to accept and implement them in their practice. The objective of the guidelines should be for better patient care. Outcomes measures should not simply be monetary but simple, easy to measure, and with a demonstrated benefit in patient care. If they are used and variations are reduced, money should be saved as well. Continuous monitoring should lead to continual changes in the system and improvement in the understanding of what to monitor and use for further improvements to affect a continuous quality improvement system.
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