Back to Journals » Open Access Emergency Medicine » Volume 12

Development and Implementation of a Clinical Pathway to Reduce Inappropriate Admissions Among Patients with Community-Acquired Pneumonia in a Private Health System in Brazil: An Observational Cohort Study and a Promising Tool for Efficiency Improvement

Authors Moreira RC, Mendonca-Filho HT, Farias AM, Sznejder H, Lang E, Wilson MM

Received 9 April 2020

Accepted for publication 14 July 2020

Published 30 July 2020 Volume 2020:12 Pages 181—191


Checked for plagiarism Yes

Review by Single-blind

Peer reviewer comments 2

Editor who approved publication: Dr Hans-Christoph Pape

Rodrigo C Moreira,1 Hugo T Mendonca-Filho,2 Ayla M Farias,2 Henry Sznejder,3 Eddy Lang,4 Margaret M Wilson5

1Department of Clinical Research, United Health Group, Rio de Janeiro, Brazil; 2Clinical Intelligence, Amil Assistencia Médica Internacional, Rio de Janeiro, Brazil; 3Department of Analytics, Amil Assistencia Médica Internacional, Rio de Janeiro, Brazil; 4Emergency Medicine, University of Calgary, Calgary, Canada; 5United Healthcare Global, MO, USA

Correspondence: Hugo T Mendonca-Filho Av. das Américas, 4200 - Barra da Tijuca, Rio de Janeiro, RJ 22640-102, Brazil
Tel +55 21 3805-1246

Purpose: Patients with community-acquired pneumonia (CAP) at low risk of death by CURB-65 scoring system are usually unnecessarily treated as inpatients generating additional economic and clinical burden. We aimed to implement an evidence-based clinical pathway to reduce hospital admissions of low-risk CAP and investigate factors related to mortality and readmissions within 30 days.
Patients and Methods: From November 2015 to August 2017, a clinical pathway was implemented at 20 hospitals. We included patients aged > 18 years, with a diagnosis of CAP by the attendant physician. The main outcome was the monthly proportion of low-risk CURB-65 admission after the implementation of the clinical pathway. Logistic regression models were performed to assess variables associated with mortality and readmission in the admitted population within 30 days.
Results: We included 10,909 participants with suspected CAP. The proportion of low-risk CAP admitted decreased from 22.1% to 12.8% in the period. Among participants with low risk, there has been no perceptible increase in deaths (0.80%) or readmissions (6.92%). Regression analysis identified that CURB-65 variables, presence of pleural effusion (OR= 1.74; 95%CI=1.08– 2.8; p=0.02) and leucopenia (OR= 2.47; 95%CI=1.11– 5.48; p=0.02) were independently associated with 30-day mortality, whereas a prolonged hospital stay (OR= 2.09; 95%CI=1.14– 3.83; p=0.01) was associated with 30-day readmission in the low-risk population.
Conclusion: The implementations of a clinical pathway diminished the proportion of low-risk CAP admissions with no apparent increase in clinical outcomes within 30 days. Nonetheless, additional factors influence the clinical decision about the site of care management in low-risk CAP.

Keywords: community-acquired pneumonia, hospitalization, mortality, readmission

Creative Commons License This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at and incorporate the Creative Commons Attribution - Non Commercial (unported, v3.0) License. By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms.

Download Article [PDF]  View Full Text [HTML][Machine readable]