Keeping Nursing Home Residents with Pneumonia out of the Hospital

HAMILTON, Ontario, June 6 ? A more intensive program of treating pneumonia in nursing home residents can keep many of them out of the hospital, researchers here said.

While the new treatment program did not improve mortality rates or other patient outcomes, it substantially reduced hospitalizations, saving more than ,000 (U.S.) in health care costs per patient, said Mark Loeb, M.D., M.Sc., of McMaster University here.

If the program, which was developed by Dr. Loeb and colleagues, were employed throughout the United Sates, it could save more than million annually in health care costs, the investigators said in the June 7 issue of the Journal of the American Medical Association.

The study involved nearly 700 residents of 22 nursing homes here with pneumonia and other lower respiratory tract infections during 2001 to 2005. Roughly half the participants were randomized to receive usual care, which was whatever the resident physician deemed appropriate. The other half received a prescribed program of treatment that included oral antimicrobials, chest x-rays performed by a mobile unit, oxygen saturation monitoring, rehydration, and close monitoring by a study nurse.

Thirty-four (10%) of 327 residents in the intervention group were hospitalized compared with 76 (22%) of 353 residents in the usual-care group. The mean reduction in hospitalizations was 12% (95% confidence interval=5% to 18%; P=.001).

The mean number of hospital days per resident was 0.79 in the intervention group versus 1.74 in the usual care group, with a mean difference of 0.95 days per resident (95% CI=0.34 to 1.55 days; P=.004).

The mortality rate was 8% (24 deaths) in the intervention group compared with 9% (32 deaths) in the usual care group, with a mean difference of 2.9% (95% CI= -2.0% to 7.9%; P=.23). There were no significant differences between the groups in health-related quality of life or functional status.

The new treatment program resulted in an overall cost savings of ,016 (U.S.) per patient (95% CI=.07 to ,824), the researchers said.

"These results confirm observational studies in which rates of death did not differ between residents with pneumonia who were transferred and those who remained onsite in the nursing home," the authors said. "Our data suggest that hospitalization of residents of nursing homes for pneumonia and other lower respiratory tract infections has little impact on mortality."

"These data have important implications for the delivery of health care services for both long-term care facilities and acute care hospitals," the authors said. "Treating nursing home residents with pneumonia with the clinical pathway approach can reduce the burden to emergency departments and inpatient hospital units, particularly during influenza season, when many nursing home residents with pneumonia are frequently sent to the hospital."

"Based on an estimated 1.5 million elderly residents in nursing homes in the United States and using U.S. costs, the cost savings of implementing clinical pathways in the United States could approximate million per year," they concluded.

Implementing the program in the United States, with its multiple-payer health care system, would be more difficult than implementing the program in Canada, with its single-payer system, the authors said. One challenge in the United States would be that nursing homes would bear the burden of additional cost, while hospitals would realize the benefit of cost savings.

For the program to work in the United States, nursing homes would need to receive supplemental funds to cover its cost, the authors said.