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The clinical benefit of in-hospital observation in low-risk pneumonia patients after conversion from parenteral to oral antimicrobial therapy |
Rhew D C, Hackner D, Henderson L, Ellrodt A G, Weingarten S R |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology Conversion from parenteral to oral antimicrobial therapy for low-risk pneumonia.
Economic study type Cost-effectiveness analysis.
Study population Adult low-risk patients with CAP.
Setting Teaching community hospital. The study was set at the Cedars-Sinai Medical Center, Los Angeles, USA.
Dates to which data relate The effectiveness data were collected during a 22-month study period from 1 November 1992 to 30 August 1994.1993 cost data were used. The price year was 1993.
Source of effectiveness data The evidence for final outcomes was derived from a single study.
Link between effectiveness and cost data The costing was undertaken on the same patient sample as that used in the effectiveness study and was conducted prospectively alongside the effectiveness study.
Study sample 717 consecutive, adult patients admitted to the hospital with pneumonia were enrolled in the study. Patients who fulfilled clinical criteria for being at low risk for complications were enrolled in the study. Patients were required to be 18 years or older, converted from parenteral to oral antibiotics, and without the following exclusion criteria: serious comorbid disease, high-risk pneumonia pathogen, obvious reason for continued hospitalisation on day of conversion, and life-threatening complication during hospitalisation.145 (20%) patients were classified as low-risk. Two patients had obvious reasons for continued hospitalisation and were excluded from the analysis. The observed and not observed groups were made up of 102 (45 male) and 40 (15 male) patients respectively. The mean age for the groups was 71 years (+/- 19, range: 23 - 99) and 67 years (+/- 18, range: 24 - 95) respectively. The observed group consisted of88 white, 8 African-American and 6 other patients, whilst the not observed group consisted of 33 white, 4 African-American and 3 other patients. The number of patients who had a comorbidity score of 0, 1, 2, 3, or 4 was 17, 15, 6, 2 and 0 for the not observed group and 47, 31, 20, 2 and 2 for the observed group.
Study design Cohort study. The authors carried out a retrospective review of data collected from a prospective study. The study was conducted at a single centre. Patients were followed-up for 30 days. No patients were lost to follow-up.
Analysis of effectiveness The analysis of the clinical study was based on intention to treat. The primary health outcomes used in the study included length of stay, medical interventions within 24 hours after hospital discharge, 30-day mortality, return to the emergency department and readmission to hospital. At analysis, patient's age (p=0.15), sex (p=0.57), race (p=0.79) and comorbidity scores were similar across the two groups.
Effectiveness results For the observed group, no patient (0%, 95%CI: 0 - 4%) required medical intervention during the observation period. Upon 30-day follow-up, none (0%, 95%CI: 0 - 4%) of the patients died, five (5%, 95%CI: 2 -11%) returned to the emergency department (3 of those with respiratory complaints (3%, 95%CI: 0 - 9%)), and five (5%, 95%CI: 2 - 11%) were readmitted. Two (2%, 95%CI: 0 - 7%) of the five readmitted patients had respiratory complaints. One patient was readmitted 5 days after hospital discharge with pneumonia and asthma exacerbation. The other patient was readmitted with recurrent pneumonia 13 days after discharge.
For the not observed group, none (0%, 95%CI: 0 - 9%) of the patients required a medical intervention within 24 hours after discharge. None (0%, 95%CI: 0 - 9%) of the patients died within 30 days after discharge, although, on day 31, a 90-year-old man with dementia died of unknown cause. One (3%, 95%CI: 0 - 13%) patient returned to the emergency department within 30 days of discharge with a non-respiratory complaint. Two (5%, 95%CI: 0 - 17%) other patients were admitted to hospital within 30 days of discharge with non-respiratory complaints (one with complaints of nausea, vomiting and chest pain and the other with symptoms compatible with a transient ischemic attack).
The differences between the two groups in terms of medical interventions within 24 hours and the outcome measures collected during the follow-up period were examined using Fischer's exact test and yielded, for each measure, p=1.0. The duration of observation before discharge was 33 hours (+/- 18, median: 26 hours, range: 9 - 98 hours). The length of stay per patientfor the observed and the not observed group was 98 hours (+/- 33 hours, median: 93 hours, range: 43 - 212 hours) and 83 hours (+/- 49 hours, median: 73 hours, range: 5 - 307 hours) respectively. The difference in length of stay was 15 hours (95%CI: 3 - 27 hours).
Clinical conclusions After conversion to oral antibiotics, patients rarely have a need for continued hospitalisation and are even less likely to require a medical intervention. The elimination of this practice could potentially reduce length of stay by almost 1 day without adversely affecting patient care.
Modelling No modelling was undertaken.
Measure of benefits used in the economic analysis As no differences in clinical outcomes were observed between the intervention and the comparator, the principal benefit was the cost saving associated with reduced length of stay.
Direct costs Direct costs included the cost per day of a non-ICU patient admitted with CAP and the total additional cost of in-hospital observation during the follow-up period. Costs were not discounted. Quantities and costs were not reported separately. The quantity/cost boundary adopted was that of the hospital. The estimation of quantities and costs was based on actual data. Cost data were obtained from a database (Trendstar, Atlanta, Ga). The price year was 1993.
Statistical analysis of costs Differences between the two groups were examined, if appropriate, using Fischer's exact test.
Indirect Costs The estimate for the cost per day of a non-ICU patient admitted with CAP also included indirect costs. These indirect costs were made up of hospital overhead and indirect labour costs.
Sensitivity analysis No sensitivity analysis was carried out.
Estimated benefits used in the economic analysis Cost results Compared with in-hospital observation, hospital discharge generated a cost saving of $57,200.
Synthesis of costs and benefits The cost and benefit measures were not combined into a cost-effectiveness ratio.
Authors' conclusions Low-risk patients can probably be safely discharged without in-hospital observation after switch to oral therapy. This could potentially translate into significant cost savings.
CRD COMMENTARY - Selection of comparators The rationale for the choice of the comparator is clear.
Validity of estimate of measure of benefit All relevant outcome measures seem to be included. However, the burden on other family members for those patients staying at home has not been investigated. Moreover, it might be interesting to examine, in general, patient preferences for staying at home or in a hospital. Finally, the authors acknowledged that subtle benefits of hospitalisation may be difficult to detect from chart reviews.
Validity of estimate of costs More details on the costing method and cost differences between the two groups could have been provided although it is recognised that the primary outcome related to length of stay, which can be applied to other settings. Only costs related to the patient's stay in the hospital were included in the analysis. Costs associated with caring for patients at home were not included.
Other issues No justification for the choice of a 30-day follow-up period was given although the authors have indicated in subsequent correspondence that this is a standard period for CAP in the United States and was used in the 4 studies they reviewed. It is difficult to assess the robustness of the results since no sensitivity analysis was carried out. The study population was limited to a single community hospital and a relatively small number of patients, which contributed to a heterogeneous study population.
Implications of the study A prospective randomised controlled trial should be undertaken to validate these results. Future research projects may involve evaluating whether in-hospital observation after conversion to oral antibiotics is necessary in risk-stratified populations of pneumonia patients.
Bibliographic details Rhew D C, Hackner D, Henderson L, Ellrodt A G, Weingarten S R. The clinical benefit of in-hospital observation in low-risk pneumonia patients after conversion from parenteral to oral antimicrobial therapy. Chest 1998; 113(1): 142-146 Other publications of related interest Macrolides in community-acquired pneumonia and otitis media. Canadian Coordinating Office for Health Technology Assessment Technology Overview: Pharmaceuticals. Ottawa, Ontario: Canadian Coordinating Office for Health Technology Assessment 1997;Issue 8:1-14.
Guest J F, Morris A. Community-acquired pneumonia: the annual cost to the National Health Service in the UK. European Respiratory Journal 1997;10(7):1530-1534.
Indexing Status Subject indexing assigned by NLM MeSH Administration, Oral; Adult; Aged; Aged, 80 and over; Anti-Bacterial Agents /administration & Community-Acquired Infections /drug therapy /economics; Costs and Cost Analysis; Female; Follow-Up Studies; Health Services Research; Hospitalization /economics; Humans; Infusions, Parenteral; Length of Stay; Male; Middle Aged; Pneumonia, Bacterial /drug therapy /economics; Prospective Studies; Recurrence; Treatment Outcome; dosage /therapeutic use AccessionNumber 21998000178 Date bibliographic record published 31/03/1999 Date abstract record published 31/03/1999 |
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