Abstract

Transferring nursing home residents to the hospital is often associated with declines in functional status, quality of life, and falls. Pneumonia is one of the most common reasons for transferring residents to a hospital. This study sought to determine whether a clinical pathway for pneumonia treatment used by nursing staff in nursing homes reduce hospital admissions and costs without affecting the health of the residents. The clinical pathway substantially reduced hospital admissions and overall system costs without affecting the quality of care or quality of life of nursing home residents. Background: Nursing home residents frequently develop pneumonia and are commonly sent to the hospital for treatment. Transfers to the hospital are often associated with declines in functional status, developing pressure ulcers, and falls. Hospital care is also significantly more expensive than nursing home care. This study was designed to determine whether a clinical pathway implemented by nursing staff in the nursing home could reduce hospital admissions and costs to the health care system without affecting other important outcomes.

Methods: Nursing homes and their residents from the Hamilton region of Ontario were asked to participate in this study. Residents were eligible for participation if: 1) they met a clinical definition of pneumonia; 2) were expected to live longer than 30 days or did not have advance directives precluding hospital transfer; and 3) they were not allergic to the study antibiotic. Residents were assigned to receive pneumonia care using either a clinical pathway or usual care. Each participating home was assigned to either the clinical pathway group or the usual care group.

The clinical pathway consisted of a series of steps to be used by nursing staff. The pathway had a series of criteria that outlined whether the resident should be treated in the nursing home or hospital. If treatment in the facility was indicated by the clinical pathway, an antibiotic available from the Ontario Drug Benefit program was initiated and fluids for hydration were administered. If the clinical pathway indicated that hospital admission was necessary, admitting physicians were asked to transfer the resident back to the facility as soon as the resident no longer met the criteria for hospital transfer. Usual care consisted of treatment decisions being made by the facility's physician and nursing staff without any aid from the clinical pathway. The number of hospitalizations was recorded for 30 days for each resident. Functional status, health-related quality of life and falls were recorded in each group to assess whether the clinical pathway had an adverse impact on the overall health of the residents. The cost of care in the nursing home and the hospital for both groups was calculated.

Findings: A total of 680 residents from 22 nursing homes participated in the study - 327 residents received care using the clinical pathway group and the remaining 353 received usual care. The average age in both groups was approximately 85 and 70% of the participants were female. There were similar rates of preexisting disease, such as cancer, liver disease, heart disease, and kidney disease, in both groups. The residents in the clinical pathway group had a lower rate of hospitalizations (8 vs. 20 admissions) and fewer hospital-days per resident (0.79 vs. 1.74 days). There was no change in quality of life, functional status, or death between the two groups. The nursing home treatments costs included assessments, xrays, oxygen, fluids, and administration. Hospitalizations costs included emergency department visits, physician fees, hospital stays, diagnostic imaging, and ambulance transport. The upfront cost associated with the clinical pathway treatment was $87 per resident. However, the reduced hospitalization in the clinical pathway group resulted in a total cost savings of $1016 per patient compared to usual care. (Costs were based on Canadian figures but converted to American currency).

Conclusions: This study demonstrates that many residents with pneumonia can be treated in the nursing home without the need for transferring them to a hospital. The results of this study suggest that policymakers might examine the use of clinical pathways for treating pneumonia in the nursing home and design funding formulas to reflect the increased cost of facility care and decreased costs of acute care.

Reference: M. Loeb, S.C. Carusone, R. Goeree, S.D. Walter, K. Brazil, P. Krueger, A. Simor, L. Moss, T. Marie. "Effect of a Clinical Pathway to Reduce Hospitalization in Nursing Home Residents with Pneumonia: A Randomized Controlled Trial." Journal of the American Medical Association, 2006; 295 (21): 2503-2510.