Elsevier

Medical Clinics of North America

Volume 85, Issue 6, 1 November 2001, Pages 1397-1411
Medical Clinics of North America

HOW SHOULD WE MAKE THE ADMISSION DECISION IN COMMUNITY-ACQUIRED PNEUMONIA?

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DESIRABLE CHARACTERISTICS OF CLINICAL GUIDELINES AND PREDICTION RULES

A clinically useful and widely implemented guideline or prediction rule needs to show internal and external validity. To achieve internal and external validity, methodologic standards have been proposed. The quality of prediction rules should be judged against these methodologic recommendations.26, 37 Meeting the recommendations increases the chances that a tool becomes accepted by clinicians, implemented for routine patient care, and disseminated in a variety of clinical settings.

A clinically

EXISTING PREDICTION RULES AND PRACTICE GUIDELINES

Prediction rules consist of previously identified clinical risk factors for mortality and other adverse outcomes. Following and evaluating the prediction algorithm provides a strategy to assess a patient's severity of illness. In addition to estimating severity of illness, practice guidelines usually include management decisions, such as further evaluation steps, recommended antibiotics, and an appropriate site of care.

In the 1980s and 1990s, several investigators published studies that

BRITISH THORACIC SOCIETY

In 1987, the BTS7 identified a set of risk factors that were associated with increased mortality: increased age, increased respiratory rate, diastolic hypotension, elevated blood urea nitrogen, absence of chest pain, absence of vomiting, previous treatment with digoxin, confusion, leukopenia, and leukocytosis. The goal of creating the prediction rule was to identify patients at high risk of dying. Three prediction rules were formulated and evaluated. Box 1 lists the BTS prediction rule with the

AMERICAN THORACIC SOCIETY

By literature analysis, the ATS identified a series of risk factors (Box 2) associated with an increased risk of mortality or a complicated disease course.33 The ATS recommends considering hospitalization when one or multiple risk factors are present. The value of the ATS guideline in guiding the admission decision has not been studied explicitly. A retrospective study found a correlation between the number of risk factors, intensive care unit admission, length of hospital stay, mortality, and

PNEUMONIA CARE PROCESS MODEL

The pneumonia care process model of the Intermountain Health Care system is a clinical practice guideline developed using a continuous quality improvement approach.11 A committee including a diverse group of people is involved to investigate and monitor guideline application within a health care system. Initially the ATS recommendations were combined with the opinions of local experts. During monthly meetings, the committee adjusts the guideline, as new national or local information about

PNEUMONIA SEVERITY OF ILLNESS INDEX

In contrast to other prediction rules that identify patients at high risk, the PSI identifies low-risk patients that might be managed on an outpatient basis. Originally the PSI was developed as a statistical model (logistic regression) that predicted the probability of mortality.15 To ease clinical use, the statistical model subsequently was converted into a prognostic prediction rule to identify patients at low risk of mortality.17 The PSI meets the highest methodologic level among available

CONSIDERATIONS FOR CLINICAL IMPLEMENTATION OF PREDICTION RULES AND GUIDELINES

Several studies have investigated factors that are important when applying the PSI in a clinical environment. Although the PSI was developed and validated with patient information from several participating health care settings, a study showed that the statistical version of the PSI (logistic regression) may not be readily applicable in other populations.19 Although the PSI was a reliable risk assessment system, mortality was overestimated in this population. Recalibration of the PSI might be

PATIENT PREFERENCES

During a study testing the ability of the PSI to identify patients appropriate for outpatient treatment, overall patient satisfaction was found to be similar when compared with a historical control group.4 Patient satisfaction among outpatients was lower, however, with respect to the initial site of treatment (71% versus 90%). A decision-analytic study that investigated site-of-care preferences among inpatients and outpatients at low risk (mortality <4%) showed that 80% preferred outpatient

PHYSICIAN ATTITUDES ABOUT AND ADHERENCE TO PNEUMONIA GUIDELINES

Physicians' knowledge and attitudes about the PSI were assessed in an academic teaching hospital and showed that a guideline can alter practice and change physicians' beliefs toward a guideline.23 In general, the risk information and utility of the prediction rule in making admission decisions received favorable responses from participating physicians. After guideline implementation, physicians believed it to be helpful (73%) and wished to continue its use (94%). The historical belief that

SUMMARY

The spectrum of pneumonia patients ranges from only slightly compromised patients to patients who require life-sustaining measures. Admission decision support algorithms usually are not required for patients at either end of the spectrum. For patients presenting with intermediate severity of illness, decision support algorithms have shown that they can support clinicians in the admission decision and complement the clinicians' experience and clinical judgment with an objective tool. Clinical

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    Address reprint requests to Nathan C. Dean, MD, Intermountain Health Care, 333 South 9th East, Salt Lake City, UT 84102, e-mail: [email protected]

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    Copyright © 2001 W. B. Saunders Company. Published by Elsevier Inc. All rights reserved.