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

• Published in: Open access emergency medicine Vol. 12; pp. 181 - 191
• Main Authors: Moreira, Rodrigo C, Mendonca-Filho, Hugo T, Farias, Ayla M, Sznejder, Henry, Lang, Eddy, Wilson, Margaret M
• Format: Journal Article
• Language: English
• Published: New Zealand Taylor & Francis Ltd 01.01.2020; Dove
• Subjects: Antibiotics; Blood; Cohort analysis; Emergency medical care; Family physicians; Health care; Hospitalization; Hospitals; Hypotension; Hypothermia; Intensive care; Mortality; Observational studies; Original Research; Outpatient care facilities; Oxygen saturation; Patient admissions; Patient care planning; Pneumonia; Trends; Brazil; mortality; hospitalization; community-acquired pneumonia; readmission
• ISSN: 1179-1500; 1179-1500
• DOI: 10.2147/OAEM.S256220

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. 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. 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. 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.