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
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
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