Original article
Vol. 146 No. 3940 (2016)
Influence of hospital characteristics on quality of care in patients with community-acquired pneumonia
- Katrin Straubhaar
- Philipp Schuetz
- Claudine Angela Blum
- Nicole Nigro
- Briel Matthias
- Matthias Briel
- Mirjam Christ-Crain
- Beat Mueller
- STEP study group
Summary
PRINCIPLES: In-hospital care of patients with community-acquired pneumonia (CAP) varies across hospitals. Understanding of the underlying factors is the basis for tailored quality improvements. Using data from a randomised controlled Swiss-wide multicentre trial, we compared length of stay (LOS) and other patient outcomes according to (A) the use of a procalcitonin (PCT)-based antibiotic stewardship protocol, (B) institution type (university vs non-university), and (C) historical time period in relation to the introduction of Diagnosis Related Group (DRG) reimbursement (2012).
METHODS: We included 784 patients hospitalised with CAP from six institutions into this secondary analysis. We used multivariable regression models adjusted for age, comorbidities and disease severity to determine the influence of institution characteristics on LOS and patient outcomes.
FINDINGS: LOS was significantly shorter in the institution using a PCT-based antibiotic stewardship protocol (9.2 vs 5.3 days; adjusted mean difference 3.92 days; 95% confidence interval [CI] 5.16–2.68) with shorter antibiotic treatment. There was no difference in LOS in university vs non-university hospitals, but antibiotic courses in university-type hospitals were longer (11.0 vs 8.3 days; adjusted mean difference 2.59 days; 95% CI, 1.69–3.49). No significant difference in LOS was found when comparing the time period before and after the introduction of the DRG system in Switzerland.
CONCLUSIONS: We found differences in LOS associated with theuse of a PCT-based antibiotic stewardship protocol, which remained robust after multivariable adjustment. Importantly, the type of institution and model of reimbursement did not influence LOS in our CAP cohort. More health services research studies are needed to establish causal effects.
References
- The Federal Council’s health-policy priorities – Health 2020. 2013 [cited April, 2016; Available from: http://www.bag.admin.ch/gesundheit2020/index.html?lang=en&download http://www.bag.admin.ch/gesundheit2020/index.html?lang=en&download=NHzLpZeg7t,lnp6I0NTU042l2Z6ln1ad1IZn4Z2qZpnO2Yuq2Z6gpJCLdIF4gWym162epYbg2c_JjKbNoKSn6A-
- Menendez R, Cremades MJ, Martinez-Moragon E, et al. Duration of length of stay in pneumonia: influence of clinical factors and hospital type. Eur Respir J. 2003;22:643–8.
- Cabre M, Bolivar I, Pera G, et al. Factors influencing length of hospital stay in community-acquired pneumonia: a study in 27 community hospitals. Epidemiol Infect. 2004;132:821–9.
- Ewig S, Birkner N, Strauss R, et al. New perspectives on community-acquired pneumonia in 388 406 patients. Results from a nationwide mandatory performance measurement programme in healthcare quality. Thorax. 2009;64:1062–9.
- Welte T, Torres A, Nathwani D. Clinical and economic burden of community-acquired pneumonia among adults in Europe. Thorax. 2012;67:71–9.
- Rozenbaum MH, Mangen MJ, Huijts SM, et al. Incidence, direct costs and duration of hospitalization of patients hospitalized with community acquired pneumonia: A nationwide retrospective claims database analysis. Vaccine. 2015;33:3193–9.
- Hall MJ, DeFrances CJ, Williams SN, et al. National hospital discharge survey: 2007 summary. Natl Health Stat Report. 2010;29:1–20.
- National Hospital Discharge Survey – Number and rate of discharges by first-listed diagnostic categories. 2010 [cited April, 2016]; Available from: http://www.cdc.gov/nchs/data/nhds/2average/2010ave2_firstlist.pdf
- European Lung White Book – The burden of lung disease. 2015 [cited April, 2016]; Available from: http://www.erswhitebook.org/chapters/the-burden-of-lung-disease/
- Mathers C, Fat DM, Boerma JT. The global burden of disease: 2004 update: World Health Organization 2008.
- The top 10 causes of death. 2014 [cited April, 2016]; Available from: http://www.who.int/mediacentre/factsheets/fs310/en/index.html
- Dean NC, Jones JP, Aronsky D, et al. Hospital admission decision for patients with community-acquired pneumonia: variability among physicians in an emergency department. Ann Emerg Med. 2012;59:35–41.
- Klausen HH, Petersen J, Lindhardt T, et al. Outcomes in elderly Danish citizens admitted with community-acquired pneumonia. Regional differencties, in a public healthcare system. Respir Med. 2012;106:1778–87.
- Bartolome M, Almirall J, Morera J, et al. A population-based study of the costs of care for community-acquired pneumonia. Eur Respir J. 2004;23:610–6.
- Menendez R, Ferrando D, Valles JM, et al. Initial risk class and length of hospital stay in community-acquired pneumonia. Eur Respir J. 2001;18:151–6.
- Fine MJ, Singer DE, Phelps AL, et al. Differences in length of hospital stay in patients with community-acquired pneumonia: a prospective four-hospital study. Med Care 1993;31:371–80.
- Dambrava PG, Torres A, Vallès X, et al. Adherence to guidelines’ empirical antibiotic recommendations and community-acquired pneumonia outcome. Eur Respir J. 2008;32:892–901.
- Garau J, Baquero F, Perez-Trallero E, et al. Factors impacting on length of stay and mortality of community-acquired pneumonia. Clin Microbiol Infect. 2008;14:322–9.
- Jin Y, Marrie TJ, Carriere KC, et al. Variation in management of community-acquired pneumonia requiring admission to Alberta, Canada hospitals. Epidemiol Infect. 2003;130:41–51.
- Feagan BG, Marrie TJ, Lau CY, et al. Treatment and outcomes of community-acquired pneumonia at Canadian hospitals. CMAJ. 2000;162:1415–20.
- Fine MJ, Stone RA, Lave JR, et al. Implementation of an evidence-based guideline to reduce duration of intravenous antibiotic therapy and length of stay for patients hospitalized with community-acquired pneumonia: a randomized controlled trial. Am J Med. 2003;115:343–51.
- Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997;336:243–50.
- Stanton MW. Improving treatment decisions for patients with community-acquired pneumonia: Agency for Healthcare Research and Quality 2002.
- Christ-Crain M, Stolz D, Bingisser R, et al. Procalcitonin guidance of antibiotic therapy in community-acquired pneumonia: a randomized trial. Am J Respir Crit Care Med. 2006;174:84–93.
- Schuetz P, Christ-Crain M, Thomann R, et al. Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections: the ProHOSP randomized controlled trial. JAMA. 2009;302:1059–66.
- Schuetz P, Mueller B. Biomarker-guided de-escalation of empirical therapy is associated with lower risk for adverse outcomes. Intensive Care Med. 2014;40:141–.
- de Jong E, van Oers JA, Beishuizen A, et al. Efficacy and safety of procalcitonin guidance in reducing the duration of antibiotic treatment in critically ill patients: a randomised, controlled, open-label trial. Lancet Infect Dis. 2016.
- Menendez R, Ferrando D, Valles JM, Vallterra J. Influence of deviation from guidelines on the outcome of community-acquired pneumonia. Chest. 2002;122:612–7.
- Schuetz P, Aujesky D, Muller C, Muller B. Biomarker-guided personalised emergency medicine for all – hope for another hype? Swiss Med Wkly. 2015;145:w14079.
- Widmer PK. Does prospective payment increase hospital (in)efficiency? Evidence from the Swiss hospital sector. Eur J Health Econ. 2015;16(4):407–19.
- Langenbrunner JC, Cashin C, O’Dougherty S. Designing and implementing provider payment systems: how to manuals. Washington: The World Bank; 2009.
- Busato A, von Below G. The Implementation of DRG-based hospital reimbursement in Switzerland: A population-based perspective. Health Res Policy Syst. 2010;8:31.
- Or Z, Häkkinen U. DRGs and quality: for better or worse. Diagnosis-related groups in Europe: moving towards transparency, efficiency and quality in hospitals. Open University Press, Maidenhead 2011: Chapter 8, p 115–29.
- Widmer M, Weaver F. Der Einfluss von APDRG auf Aufenthaltsdauer und Rehospitalisierungen. Auswirkungen von Fallpauschalen in Schweizer Spitälern zwischen 2001 und 2008 (Obsan Bericht 49). 2011.
- Blum CA, Nigro N, Briel M, et al. Adjunct prednisone therapy for patients with community-acquired pneumonia: a multicentre, double-blind, randomised, placebo-controlled trial. Lancet. 2015;385(9977):1511–8.
- Blum CA, Nigro N, Winzeler B, et al. Corticosteroid treatment for community-acquired pneumonia – the STEP trial: study protocol for a randomized controlled trial. Trials. 2014;15:257.
- Niederman MS, Mandell LA, Anzueto A, et al. Guidelines for the management of adults with community-acquired pneumonia. Diagnosis, assessment of severity, antimicrobial therapy, and prevention. Am J Respir Crit Care Med. 2001;163:1730–54.
- Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(Suppl 2):S27–72.
- Moran GJ, Rothman RE, Volturo GA. Emergency management of community-acquired bacterial pneumonia: what is new since the 2007 Infectious Diseases Society of America/American Thoracic Society guidelines. Am J Emerg Med. 2013;31:602–12.
- Krankenhaustypologie. 2006 [cited April, 2016]; Available from: http://www.bfs.admin.ch/bfs/portal/de/index/infothek/erhebungen__quellen/blank/blank/kh/02.Document.90761.pdf
- Suter-Widmer I, Christ-Crain M, Zimmerli W, et al. Predictors for length of hospital stay in patients with community-acquired pneumonia: results from a Swiss multicenter study. BMC Pulm Med. 2012;12:21.
- Huang JQ, Hooper PM, Marrie TJ. Factors associated with length of stay in hospital for suspected community-acquired pneumonia. Canadian respiratory journal: journal of the Canadian Thoracic Society 2006;13:317.
- Christ-Crain M, Stolz D, Bingisser R, et al. Procalcitonin guidance of antibiotic therapy in community-acquired pneumonia: a randomized trial. Am J Respir Crit Care Med. 2006;174:84–93.
- Christ-Crain M, Jaccard-Stolz D, Bingisser R, et al. Effect of procalcitonin-guided treatment on antibiotic use and outcome in lower respiratory tract infections: cluster-randomised, single-blinded intervention trial. Lancet. 2004;363:600–7.
- Nobre V, Harbarth S, Graf J, et al. Use of procalcitonin to shorten antibiotic treatment duration in septic patients: a randomized trial. Am J Respir Crit Care Med. 2008;177:498.
- Bouadma L, Luyt C-E, Tubach F, et al. Use of procalcitonin to reduce patients’ exposure to antibiotics in intensive care units (PRORATA trial): a multicentre randomised controlled trial. Lancet. 2010;375:463–74.
- Albrich WC, Dusemund F, Bucher B, et al. Effectiveness and safety of procalcitonin-guided antibiotic therapy in lower respiratory tract infections in “real life”: an international, multicenter poststudy survey (ProREAL). Arch Intern Med. 2012;172:715–22.
- Schuetz P, Batschwaroff M, Dusemund F, et al. Effectiveness of a procalcitonin algorithm to guide antibiotic therapy in respiratory tract infections outside of study conditions: a post-study survey. Eur J Clin Microbiol Infect Dis.2010;29:269–77.
- Rosenthal GE, Harper DL, Quinn LM, Cooper GS. Severity-adjusted mortality and length of stay in teaching and nonteaching hospitals. Results of a regional study. JAMA. 1997;278:485–90.
- Au AG, Padwal RS, Majumdar SR, McAlister FA. Patient outcomes in teaching versus nonteaching general internal medicine services: a systematic review and meta-analysis. Acad Med. 2014;89:517–23.
- Papanikolaou PN, Christidi GD, Ioannidis JP. Patient outcomes with teaching versus nonteaching healthcare: a systematic review. PLoS medicine. 2006;3:e341.
- Keeler EB, Rubenstein LV, Kahn KL, et al. Hospital characteristics and quality of care. JAMA. 1992;268:1709–14.
- DesHarnais S, Kobrinski E, Chesney J, et al. The early effects of the prospective payment system on inpatient utilization and the quality of care. Inquiry. 1987;24:7–16.
- Rogers WH, Draper D, Kahn KL, et al. Quality of care before and after implementation of the DRG-based prospective payment system: a summary of effects. JAMA. 1990;264:1989–94.
- Gerety MB, Soderholm-Difatte V, Winograd CH. Impact of prospective payment and discharge location on the outcome of hip fracture. J Gen Intern Med. 1989;4:388–91.
- Schuetz P, Albrich WC, Suter I, et al. Quality of care delivered by fee-for-service and DRG hospitals in Switzerland in patients with community-acquired pneumonia. Swiss Med Wkly. 2011;141:w13228.
- Kuwabara H, Fushimi K. The impact of a new payment system with case-mix measurement on hospital practices for breast cancer patients in Japan. Health Policy. 2009;92:65–72.
- Bartkowski R. Length of hospital stay due to DRG reimbursement. Therapeutische Umschau Revue therapeutique 2012;69:15–21.
- Thommen D, Weissenberger N, Schuetz P, et al. Head-to-head comparison of length of stay, patients' outcome and satisfaction in Switzerland before and after SwissDRG-Implementation in 2012 in 2012: an observational study in two tertiary university centers. Swiss Med Wkly. 2014;144:w13972.