Factors Associated with the Hospitalization of Low-risk Patients with Community-acquired Pneumonia in a Cluster-Randomized Trial

Authors

  • Jose Labarere MD, PhD,

    1. VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
    2. ThEMAS TIMC-IMAG UMR CNRS 5525 UJF, Grenoble University Hospital, Grenoble, France
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  • Roslyn A. Stone PhD,

    1. VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
    2. Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
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  • D. Scott Obrosky MSc,

    1. VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
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  • Donald M. Yealy MD,

    1. Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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  • Thomas P. Meehan MD, MPH,

    1. Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
    2. Qualidigm, Middletown, CT, USA
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  • Thomas E. Auble PhD,

    1. Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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  • Jonathan M. Fine MD,

    1. Qualidigm, Middletown, CT, USA
    2. Section of Pulmonary and Critical Care Medicine, Norwalk Hospital, Norwalk, CT, USA
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  • Louis G. Graff MD,

    1. Qualidigm, Middletown, CT, USA
    2. Department of Emergency Medicine, University of Connecticut School of Medicine, Farmington, CT, USA
    3. Department of Emergency Medicine, New Britain General Hospital, New Britain, CT, USA
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  • Michael J. Fine MD, MSc

    1. VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
    2. Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Address correspondence and requests for reprints to Dr. Fine: VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive C, Building 28, 1A102, Pittsburgh, PA 15240 (e-mail: Michael.Fine@med.va.gov).

Abstract

BACKGROUND: Many low-risk patients with pneumonia are hospitalized despite recommendations to treat such patients in the outpatient setting.

OBJECTIVE: To identify the factors associated with the hospitalization of low-risk patients with pneumonia.

METHODS: We analyzed data collected by retrospective chart review for 1,889 low-risk patients (Pneumonia Severity Index [PSI] risk classes I to III without evidence of arterial oxygen desaturation) enrolled in a cluster-randomized trial conducted in 32 emergency departments.

RESULTS: Overall, 845 (44.7%) of all low-risk patients were treated as inpatients. Factors independently associated with an increased odds of hospitalization included PSI risk classes II and III, the presence of medical or psychosocial contraindications to outpatient treatment, comorbid conditions that were not contained in the PSI (cognitive impairment, history of coronary artery disease, diabetes mellitus, or pulmonary disease), multilobar radiographic infiltrates, and home therapy with oxygen, corticosteroids, or antibiotics before presentation. While 32.8% of low-risk inpatients had a contraindication to outpatient treatment and 47.1% had one or more preexisting treatments, comorbid conditions, or radiographic abnormalities not contained in the PSI, 20.1% had no identifiable risk factors for hospitalization other than PSI risk class II or III.

CONCLUSIONS: Hospital admission appears justified for one-third of low-risk inpatients based upon the presence of one or more contraindications to outpatient treatment. At least one-fifth of low-risk inpatients did not have a contraindication to outpatient treatment or an identifiable risk factor for hospitalization, suggesting that treatment of a larger proportion of such low-risk patients in the outpatient setting could be achieved without adversely affecting patient outcomes.

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