Study objectives: Considerable variation exists in
hospital admission rates for patients with community-acquired
pneumonia. Logic to determine need for admission has been proposed by
several authors. We compared Intermountain Health Care pneumonia
guideline recommendations for inpatient vs outpatient care with actual
physician decision making and clinical outcomes before vs after
implementation. A secondary objective was to determine whether the
pneumonia severity index predicts need for admission in this
Design: Prospective study after
implementation vs historic controls.
ambulatory, urgent-care facilities.
hundred sixty-three immunocompetent adults with radiographically
confirmed community-acquired pneumonia.
A pneumonia practice guideline including decision support logic was
implemented for a 12-month period.
results: After implementation, physicians used the pneumonia
guideline form in 90% of cases. The percentage of patients admitted
within 30 days decreased from 13.6% to 6.4% (p = 0.01). Only five
patients before (2.5%) and three patients after (1.1%, p = 0.3)
guideline implementation required subsequent hospital admission within
30 days after initial outpatient treatment. Only two deaths occurred in
the study cohort, both outpatients before implementation. The positive
predictive value was 14.4%, and the negative predictive value for
admission was 98.8% after guideline implementation. Guideline
recommendation for admission was more likely to be followed in patients
with more risk factors and hypoxemia.
Decreased admission rate was observed after implementation of admission
decision support in combination with specific recommendations for
outpatient antibiotic therapy. Favorable outpatient outcomes suggest
that implementation of decision support was