How many patients with pneumonia receive timely and effective treatment in the hospital?

During 2003, 33 percent to 81 percent of Medicare beneficiaries hospitalized for pneumonia received care in accordance with five evidence-based quality standards. Overall, hospitals provided appropriate care only 59 percent of the time, an increase of 5 percentage points from 2002. The proportion who received antibiotics within four hours of hospital arrival (one of the five measures) ranged from 54 percent to 81 percent among the states in 2003.

Why is this important?

• About 1.4 million Americans were hospitalized for pneumonia in 2003, including more than 800,000 elderly patients (ALA 2006). Among Medicare patients, pneumonia accounts for the largest number of deaths of eight conditions for which quality has been linked to outcomes (MedPAC 2005).
• Timely and appropriate hospital care—including timely collection of blood cultures to guide antibiotic selection and timely use of recommended antibiotics—is associated with lower death rates and shorter hospital stays (Gleason et al. 1999; Houck et al. 2004; Meehan et al. 1997).
• Many elderly patients who are hospitalized with pneumonia have been admitted to the hospital before, which suggests that a hospital stay provides a good opportunity to identify those who should be vaccinated to help prevent future hospitalizations for influenza and pneumonia (Fedson et al. 1990).

Findings

• Hospitals missed about two of five opportunities to provide timely and effective care to Medicare patients with pneumonia in 2003. The largest deficit in care involves a preventive measure—screening for patients' vaccination status and administering the vaccine when indicated.
• In only five states—South Dakota, Iowa, Nebraska, Colorado, and Wyoming—did hospitals deliver the first dose of antibiotics to more than 75 percent of Medicare pneumonia patients within four hours of their arrival at the hospital (AHRQ 2006).

Implications

Although quality of care for pneumonia is improving, it varies widely among hospitals and states. Evolving quality standards (such as a recent change in guidelines to provide antibiotic treatment within four rather than eight hours of admission) present a challenge for hospitals to continually improve care.

Improvement Ideas and Resources

• Hospitals in one state were more likely to improve evidence-based pneumonia treatment if they used a combination of quality improvement strategies including clinical pathways, standing orders, physician champions, multidisciplinary teams, and case managers (Tu et al. 2004).
• A multistate study found that the time to antibiotic administration was reduced through interventions including data feedback, benchmarking, and medical record checklists (Weingarten et al. 2004).
• Many hospitalizations for pneumonia might be prevented altogether if more older adults were immunized as recommended and treated appropriately when they seek care in the outpatient setting (Nichol et al. 2006).

Measure:

• The denominator for the five process measures includes Medicare fee-for-service beneficiaries discharged from the hospital with a primary diagnosis of pneumonia, or a secondary diagnosis of pneumonia with a primary diagnosis of septicemia or respiratory failure. The influenza vaccination measure is limited to those ages 50 and older discharged from October through February; the pneumococcal vaccination measure is limited to those ages 65 and older. The numerator includes the subset of the denominator population who received specified services recommended in evidenced-based guidelines of the American Thoracic Society (Niederman et al. 2001) and the Infectious Diseases Society of America (Bartlett et al. 2000). Vaccination exceptions included previous immunization (during the influenza season for influenza vaccine), patient refusal, and documented allergy/sensitivity to the vaccine or its components.
• The denominator for the "overall" measure is the total number of opportunities to provide the five recommended services, and the numerator is the subset of those opportunities in which recommended care was provided.

Limitations:

These data are not representative of treatment for all pneumonia patients. In particular, the data do not include Medicare Advantage plan members.

Source:

The Centers for Medicare and Medicaid Services sponsors the Medicare Quality Improvement Organization Program, which collects hospital medical record data from systematic random samples of hospital discharges of Medicare fee-for-service beneficiaries in each state. Results were reported by the Agency for Healthcare Research and Quality (AHRQ 2006).

References:

* Indicates source of data used in the chart(s).* AHRQ (Agency for Healthcare Research and Quality). 2006. National Healthcare Quality Report, 2005. Rockville, Md.: Agency for Healthcare Research and Quality. ALA (American Lung Association). 2006. Trends in Pneumonia and Influenza Morbidity and Mortality. New York: American Lung Association. Bartlett, J. G., S. F. Dowell, L. A. Mandell et al. 2000. Practice Guidelines for the Management of Community-Acquired Pneumonia in Adults. Infectious Diseases Society of America. Clinical Infectious Diseases 31 (2): 347–82. Fedson, D. S., M. P. Harward, R. A. Reid et al. 1990. Hospital-Based Pneumococcal Immunization. Epidemiologic Rationale from the Shenandoah Study. Journal of the American Medical Association 264 (9): 1117–22. Gleason, P. P., T. P. Meehan, J. M. Fine et al. 1999. Associations Between Initial Antimicrobial Therapy and Medical Outcomes for Hospitalized Elderly Patients with Pneumonia. Archives of Internal Medicine 159 (21): 2562–72. Houck, P. M., D. W. Bratzler, W. Nsa et al. 2004. Timing of Antibiotic Administration and Outcomes for Medicare Patients Hospitalized with Community-Acquired Pneumonia. Archives of Internal Medicine 164 (6): 637–44. MedPAC (Medicare Payment Advisory Commission). 2005. A Data Book: Healthcare Spending and the Medicare Program. Washington, D.C.: Medicare Payment Advisory Commission. Meehan, T. P., M. J. Fine, H. M. Krumholz et al. 1997. Quality of Care, Process, and Outcomes in Elderly Patients with Pneumonia. Journal of the American Medical Association 278 (23): 2080–4. Nichol, K. L., J. Nordin, and J. Mullooly. 2006. Influence of Clinical Outcome and Outcome Period Definitions on Estimates of Absolute Clinical and Economic Benefits of Influenza Vaccination in Community Dwelling Elderly Persons. Vaccine 24 (10): 1562–8. Niederman, M. S., L. A. Mandell, A. Anzueto et al. 2001. Guidelines for the Management of Adults with Community-Acquired Pneumonia. Diagnosis, Assessment of Severity, Antimicrobial Therapy, and Prevention. American Journal of Respiratory and Critical Care Medicine 163 (7): 1730–54. Tu, G. S., T. P. Meehan, J. M. Fine et al. 2004. Which Strategies Facilitate Improvement in Quality of Care for Elderly Hospitalized Pneumonia Patients? Joint Commission Journal on Quality and Safety 30 (1): 25–35. Weingarten, J. P., Jr., W. Fan, H. Peacher-Ryan et al. 2004. Hospital Quality Improvement Activities and the Effects of Interventions on Pneumonia: A Multistate Study of Medicare Beneficiaries. American Journal of Medical Quality 19 (4): 157–65.