LONDON, ONTARIO-- Implementation of a critical pathway reduced the use of institutional resources in caring for patients who present to the emergency department (ED) with community-acquired pneumonia (CAP) without compromising outcomes, a Canadian study has found.[1]

Hospitals using the critical pathway had a median 1.7 fewer hospital days per patient, Marrie et al reported. Savings were estimated to be $1,700 per patient treated, based on a minimum cost of $1,000 per bed-day.

Community-acquired pneumonia is the leading cause of death from infectious disease in North America. Approximately 15% of the 600,000 people admitted to hospitals each year in the United States die of the disease. Lack of a common approach to diagnosis and treatment has been cited as an explanation for the large variations that exist among hospitals in the use of treatment resources for CAP.

"It is interesting that care paths have been implemented as a component of managed care without the experimental underpinning that we would normally expect of, say, a new drug or a new surgical procedure," said study coauthor Brian Feagan, MD, professor of medicine at the University of Western Ontario, in London, Ontario. "They have been utilized as part of managed care to reduce costs and improve efficiency, [but] there has been a paucity of controlled trials that have shown that care paths 1) are safe and 2) save money. This is a large experiment to demonstrate that in one specific application."

In the study, 10 hospitals were assigned to continue conventional management for CAP. Nine others were selected to implement the critical pathway, which included:

• The Pneumonia Severity Index (PSI), a clinical prediction rule to guide admission decisions.
• Levofloxacin administration.
• Practice guidelines for inpatient care.
• Discharge criteria.

The study population included 1,743 patients with CAP who presented to the ED at one of the participating institutions between January 1 and July 31, 1998. At the critical pathway sites, emergency nurses used the 20-item PSI to measure disease severity. Patients who scored 90 points or less were recommended for discharge; those with higher scores were recommended for admission. Those admitted were assessed daily for discontinuation of intravenous therapy or fulfillment of hospital discharge criteria.

At the conventional management sites, CAP was managed according to the usual practice of individual specialists or primary care physicians. Levofloxacin therapy was not available, and practice guidelines were not implemented.

Critical pathways are typically complex multifactorial packages, Dr. Feagan explained, making it difficult to determine which component is primarily responsible for the result. "Now, having said that, the most important [aspect] of the pathway probably was the PSI score, because we saw an 18% reduction in the admission of low-risk patients," he said. "It's hard to believe that the drug or practice guidelines, which were inpatient-based, would have anything to do with that at the point of first contact in the ED."

In addition, the patients admitted under the critical pathway had more severe disease than did the other patients, yet they still had a decreased length of stay and received fewer days of antibiotic therapy.

--Debra Hughes

Reference
1. Marrie TJ, Lau CY, Wheeler SL, et al. A controlled trial of a critical pathway for treatment of community-acquired pneumonia. JAMA. 2000;283:749-755.