Medical Groups Use AHRQ's Pneumonia Severity Index to Create Guidelines

Comparative Effectiveness
June 2007

The first joint Community-Acquired Pneumonia (CAP) guideline, prepared by the Infectious Disease Society of America (IDSA) and the American Thoracic Society (ATS), strongly recommends the use of the AHRQ-funded Pneumonia Severity Index (PSI) as one of the criteria to triage patients for inpatient and outpatient care.

The guideline, "IDSA/ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults," also used other clinical criteria validated through AHRQ-funded research to determine when a patient should be switched from intravenous to oral antibiotic therapy. The guideline was published in the March 2007 Clinical Infectious Disease.

"The guidelines represent a joint effort by the two societies to promote optimal management of CAP patients based on the most current, available data. They help to standardize and optimize the diagnosis and treatment of this important disease," says Lionel Mandell, MD, IDSA/ATS CAP Consensus Guidelines Committee Co-chair and Professor of Medicine, Division of Infectious Diseases, McMaster University, Ontario, Canada.

"The IDSA and ATS wrote the Consensus Guidelines to help the practicing physician with the management of CAP. Such guidelines have been shown to decrease costs, length of stay, morbidity, and mortality," says Richard G. Wunderink, MD, Professor of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine in Chicago. Wunderink served as IDSA/ATS Committee Co-chair with Mandell.

AHRQ funded the Pneumonia Patient Outcomes Research Team (PORT), a multidisciplinary research team, in the 1990s to examine the quality and cost of management of patients with CAP. As part of the PORT pneumonia project, the agency also funded numerous research studies to develop decision-support tools to help health care providers improve mortality and reduce the costs associated with CAP.

One of the AHRQ-funded projects supported researchers at the University of Pittsburgh in developing the PSI. Validated across a population of over 50,000 patients in the United States and Canada, the PSI helps physicians assess the severity of a patient's illness and determine the plan of care.

"We chose to give the strongest recommendation for the use of the PSI because the evidence demonstrates that, for many patients, outpatient treatment is safe, effective, and preferred. The PSI is a clinical decision-making tool providers can use to deliver higher quality of care with the appropriate use of limited health care resources," comments Mandell.

AHRQ-funded research led by Ethan A. Halm, MD, Associate Professor of Medicine and Health Policy at Mount Sinai School of Medicine, examined the question of when inpatients can be safely switched from intravenous to oral antibiotics, thereby expediting discharge. The IDSA/ATS Consensus Guidelines strongly recommend using clinical parameters validated by Halm, including temperature, heart rate, respiratory rate, systolic blood pressure, arterial oxygen saturation, ability to tolerate oral intake, and mental status, to gauge a patient's stability for discharge.

Community-acquired pneumonia affects approximately four million Americans each year, and remains, together with influenza, the seventh leading cause of death in the United States. The cost to treat CAP approaches $10 billion per year with approximately 92 percent of the cost spent on the more than one million annual hospital admissions. The average cost per patient for inpatient care is $5,700; outpatient care is approximately $300.

Impact Case Study Identifier: 
AHRQ Product(s): Patient Outcomes Research Team (PORT), Research
Topics(s): Guidelines
Geographic Location: National
Implementer: Infectious Disease Society of America, American Thoracic Society
Date: 06/01/2007

Fine MJ, Auble TE, Yealy DM, et al. A Prediction Rule to Identify Low-Risk Patients with Community-Acquired Pneumonia. New England Journal of Medicine 1997: 336: 243-250.
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. Clinical Infectious Diseases 2007: 44: S27-S72.
Halm EA, Switzer GE, Mittman BS, et al. What factors influence physicians' decisions to switch from intravenous to oral antibiotics for community-acquired pneumonia? Journal of General Internal Medicine 2001: 16: 599-605.
Halm EA, Fine MJ, Kapoor WN, et al. Instability on hospital discharge and the risk of adverse outcomes in patients with pneumonia. Archives of Internal Medicine 2002: 162: 1278-84.

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