Safely Increasing the Proportion of Patients With Community-Acquired Pneumonia Treated as Outpatients

Abstract

COMMUNITY-acquired pneumonia is among the most common severe acute infections in adults. It leads to approximately 600000 hospitalizations each year in the United States, and roughly $4 billion in direct medical costs.^1,2 Hospital care for patients with pneumonia is much more expensive than outpatient care. Studies^3,4 demonstrating large variations in rates of hospital admission for patients with pneumonia across nearby geographic regions suggest that the criteria for hospital admission are uncertain. Surveys indicate that the decision to hospitalize individuals is driven by physicians' assessment of severity of illness.^5,6 However, these assessments are not well calibrated, with physicians tending to overestimate the likelihood of death from pneumonia.⁶ A recently validated prediction rule for severity of illness in patients with community-acquired pneumonia, the Pneumonia Severity Index (PSI),⁷ now provides a means to accurately assess risk at patient presentation. The PSI was derived and validated in more than 50000 patients in the United States and Canada. A PSI score of 90 or lower identifies patients at low risk (7 approximately 50% of hospitalized patients were classified as low risk. These patients may have been appropriate candidates for outpatient care. Indeed, a majority of such low-risk patients surveyed after hospitalization indicated that they would have preferred treatment at home.⁸