PURPOSE: Home care for community-acquired pneumonia (CAP) has increasingly been accepted as a patient-preferred alternative to hospitalization. The Pneumonia Severity Index (PSI), which classifies patients according to mortality risk, has been used to judge when hospitalization is required, but it overemphasizes age and coexisting illnesses. We sought to determine whether substantial numbers of frail elderly patients could have avoided hospitalization, despite their high PSIs, if offered intensive home-care services such as are available to Comprehensive Care Management (CCM) patients.
METHODS: Four physicians independently reviewed the ER charts of 51 patients admitted with the diagnosis of CAP. A composite score was calculated as the number of physicians who agreed that the patient could be treated at home. The PSI was also calculated.
RESULTS: Three were excluded because they had other primary reasons for admission. Four were found not to have pneumonia. Among the 16 (36%) determined unanimously or by majority to be safe for home treatment (composite score ≥3), 9 exceeded the 90 point PSI threshold for hospitalization (see figure I). 5 of them met the criteria just on the basis of age or age plus comorbidities. Physical examination, x-ray and lab findings accounted for an average of only 12 points. Among the 23 (52%) determined unanimously or by majority to require hospitalization (composite score ≤1), 19 had PSI scores ≥90, and physical examination, x-ray and lab findings accounted for an average of 40 points.
CONCLUSION: Our evaluation suggests that a significant number of frail elderly patients with CAP could be treated at home. The PSI overemphasizes age and comorbidities, underemphasizes physical exam, laboratory, and radiographic abnormalities, and does not take into account stable pre-existing physical and laboratory abnormalities.
CLINICAL IMPLICATIONS: We plan to develop a modified PSI, de-emphasizing age and chronic comorbid illnesses and emphasizing physical, laboratory and radiographic findings. We hypothesize that applying this modified PSI would allow substantial numbers of frail elderly patients with CAP to be treated at home with appropriate home care.
DISCLOSURE: Naricha Chirakalwasan, None.