Community-acquired pneumonia (CAP)—pneumonia

contracted outside of a hospital or nursing home

environment—affects approximately 4 million Americans

each year, accounting for more than 1 million hospital

discharges. The cost of treating CAP patients is

significant—$10 billion per year—with about 92 percent of

this amount spent on hospital care.1 Among the

hospitalized patients are a sizable number of low-risk

patients who could be treated safely on an outpatient basis,

but these patients must be accurately identified before such

treatment is recommended. When low-risk patients are

treated at home with the appropriate antibiotic, quality of

care can be maintained, patients are more likely to be

satisfied, and resources are conserved. When patients

requiring hospitalization can have their medical stability

more accurately determined, then discharge from the

hospital can occur at the appropriate time.

This report describes two tools developed by AHRQ-funded

research that help assess the need for hospitalization and

determine the medical stability of patients prior to

discharge. This report also discusses the importance of

early administration of antibiotic therapy and the

effectiveness of older, proven, yet inexpensive antibiotics

compared with those used in the outpatient treatment of

patients with CAP. 

The first tool, the Pneumonia Severity Index (PSI), can

assist physicians in identifying those low-risk pneumonia

patients who can be safely treated at home. Used as part of

a broader management strategy, this decision-support tool

has been shown to reduce by up to 18 percent the number

of low-risk pneumonia patients who are hospitalized, and to

save between $457 and $994 per patient without

Improving Treatment Decisions for Patients with

Community-Acquired Pneumonia

Making a Difference

• The Pneumonia Severity Index (PSI), developed by an

AHRQ-funded project, helps physicians make clinical

judgments about what care should be provided to

patients with CAP...Page 3.

• Patients with CAP were more likely to be satisfied with

home treatment than hospitalization, according to

another study...Page 4.

• When the PSI was incorporated into a critical pathway

or disease management strategy, one (non-AHRQfunded) study found that significantly more low-risk

patients were treated at home with no negative health

effects on patients...Page 5.

• VA researchers further validated the PSI. They found

that admission of low-risk pneumonia patients could be

significantly reduced...Page 5.

• Treating CAP with older antibiotics is as medically

effective and less costly than using newer antibiotics...

Page 6.

• Use of a new tool to determine medical stability can

lead to better timing of hospital discharge...Page 6.

RESEARCH IN ACTION

Agency for Healthcare Research and Quality • www.ahrq.gov

Issue #7 July 2002

Author: Mark W. Stanton, M.A.

Managing Editor: Julius A. Patterson

Contributing Editor: Daniel Stryer, M.D.

Design and Production: Joel Boches

Suggested citation: Stanton MW. Improving treatment decisions for patients with community-acquired pneumonia. Rockville (MD): Agency for Healthcare Research

and Quality; 2002. Research in Action Issue 7. AHRQ Pub. No. 02-0033.
diminishing the quality of care.2, 3 The second tool is an

instrument that enables clinicians to determine whether a

hospitalized pneumonia patient is medically stable before

being discharged. Using this instrument, which is based on

five vital signs, patients’ mental status, and their ability to

eat and drink, researchers found that patients who were

medically unstable had a 60-percent increased chance of

readmission or death, if discharged too soon. In addition,

the results of two other studies are described in this report.

One study found that elderly patients administered an

antibiotic within 8 hours of arriving at the hospital had

lower 30-day mortality rates than did other patients.

Another study, which compared the outcomes and cost of

different antibiotic therapies for patients treated at home,

found that an older antibiotic was just as effective and from

3 to 10 times less expensive than newer antibiotics. 

Background 

Research has shown that wide variations in medical

practice may occur between physicians in different

geographic regions of the United States. The treatment of

patients with CAP is no exception; analyses of hospital

admission rates for CAP show marked variation from one

region to another. This variation suggests that physicians

are using differing standards when deciding which patients

with CAP to hospitalize. In actual practice, physicians

most often tend to use their impression of the patient’s

general clinical appearance when deciding whether or not

to hospitalize.4 However, AHRQ-funded research has

shown that when making a decision about hospitalization

for any CAP patient, physicians also relied on the patient’s

respiratory status, the presence of other illnesses, lung

involvement of more than one lobe, and whether the patient

was eating and drinking fluids.5

To enhance physicians’ decisionmaking, an AHRQ-funded

multidisciplinary research team called the Pneumonia

Patient Outcomes Research Team (PORT) developed and

tested the PSI.6 This decision-support tool may be used by

physicians as a supplement to their clinical judgment when

making treatment decisions for pneumonia patients. In

studying how patients may be most effectively treated at

home and how physicians can know when hospitalized

pneumonia patients are stable enough to be discharged, the

PORT researchers have also evaluated the effectiveness and

cost of different antibiotic medications and developed a tool

to determine medical stability. 

2 www.ahrq.gov

Facts about Community-Acquired Pneumonia

• 4 million Americans are affected each year.

• Minorities are 3 to 10 times more likely to be affected than whites.

• The elderly are 60 percent more likely to be affected than the general population.

• 1 million hospital discharges per year can be attributed to CAP.

• 90,000 persons die every year from all forms of pneumonia, including CAP.

• The mortality rate for low-risk patients treated at home is less than 1 percent.

• The mortality rate for the more serious cases treated in a hospital each year is between 2 and 30 percent.

• The mortality rate for all cases is about 13 percent each year.

• About $10 billion per year is spent on caring for patients with CAP. 

• The average cost for an inpatient case is about $5,700.

• The average cost for an outpatient case is about $300.

• About $100 million per year is spent on antimicrobial therapy for CAP outpatients.

Sources: Infectious Diseases Society of America. Practice guidelines for the management of community-acquired pneumonia for adults. Clin Infect Dis 2000;31:347-82; National Institute of

Allergy and Infectious Diseases. Fact Sheet on Pneumococcal Pneumonia. August 2001. Web site: http://www.niaid.nih.gov/factsheets/pneumonia.htm; Lave JR, Lin CJ, Fine MJ, et al. The

cost of treating patients with community-acquired pneumonia. Semin Respir Crit Care Med 1999; 20(3):189-97; Gleason PP, Kapoor WN, Stone RA, et al. Medical outcomes and antimicrobial costs with the use of the American Thoracic Society guidelines for outpatients with community-acquired pneumonia. JAMA 1997:278:32-39.
The AHRQ-funded Pneumonia PORT (completed in 1996)

was one of a series of PORT projects designed to focus on

common clinical conditions that are costly to the Medicare

and Medicaid programs. These are conditions for which

there is regional variability in patients’ outcomes and use of

resources and a lack of clear consensus by physicians on the

best treatment strategies. The PORTs consisted of

multidisciplinary teams of researchers ranging from health

economists and clinicians to quality-of-life experts and

epidemiologists. PORT investigators were instructed to

explore a number of questions, including questions about

the variation in the use of treatments and what could be

done to reduce inappropriate variation. Providing care in

the appropriate setting helps to reduce variations in clinical

practice that appear to be due to differing physician practice

patterns and not patient-related factors.

Pneumonia Severity Index

PSI separates low-risk from high-risk CAP patients

The PSI, an AHRQ-funded tool developed by researchers at

the University of Pittsburgh, helps physicians determine

whether CAP patients should be treated at home or in a

hospital. The PSI was developed and extensively tested

among three groups of over 50,000 patients in 275 U.S. and

Canadian hospitals and found to be a reliable decisionsupport tool.7

Using a two-step process, the PSI provides a way for

clinicians to measure the severity of a patient’s illness and

predict the risk of mortality within 30 days of initial

diagnosis. The 30-day mortality risk ranges from 1 to 4

percent for the three low-risk categories (Classes I-III), from

4 to 10 percent for Class IV, and from 10 to 30 percent for

Class V. Patients classified in risk classes I-III are

considered a low enough risk to be eligible either for home

treatment or abbreviated inpatient care (a 1-day hospital

stay). Patients in risk classes IV and V should be

hospitalized. 

During the first step of the physician’s decision process, an

initial history and physical examination are performed. The

patient’s risk level is evaluated using factors such as age,

gender, presence of other illnesses, and abnormal physical

examination findings. Patients are asked whether they have

a history of tumors, congestive heart failure, cerebrovascular

disease, renal disease, and liver disease. The physician then

determines whether the patient has any of the following:

altered mental status, a pulse rate ≥ 125 beats per minute, a

respiratory rate ≥ 30 breaths per minute, systolic blood

pressure < 90 mm Hg, and temperature < 35° C or ≥ 40° C.7

Patients can be assigned to the lowest risk class (I) based on

this initial history and physical examination, observations

that do not require expensive lab tests (Figure 1).

No

www.ahrq.gov 3

Figure 1. Algorithm for Prediction Model

Source: Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk

patients with community-acquired pneumonia. N Engl J Med 1997;336(4):243-50. 

Does the patient have a history of

any of the following comorbid

conditions?

• Neoplastic disease

• Congestive heart failure

• Cerebrovascular disease

• Renal disease

• Liver disease

Is the patient over 50 years of age?

Does the patient have any of the

following abnormalities on

physical examination?

• Altered mental status

• Pulse ≥ 125/minute

• Respiratory rate ≥ 30/minute

• Systolic blood pressure

• < 90 mm Hg

• Temperature < 35 ̊C or ≥ 40 ̊C

Assign patient

to risk class II-V

based on

prediction

model scoring

system

No

Assign patient to risk class I

Patients with communityacquired pneumonia

Yes

Yes

Yes

No
Table 1. Identifying the level of risk in CAP patients: the risk factors and how they are scored 

Patient characteristic Points assigned*

Demographic factors 

Age:

Males Age (in years) 

Females Age (in years) -10

Nursing home residents +10

Comorbid illnesses 

Neoplastic disease +30

Liver disease +20

Congestive heart failure +10

Cerebrovascular disease +10

Renal disease +10

Physical examination findings 

Altered mental status +20

Respiratory rate 30 breaths per minute or more +20

Systolic blood pressure <90 mm Hg +20

Temperature <35°C or 40°C or more +15

Pulse 125 beats per minute or more +10

Laboratory findings 

pH <7.35 +30

BUN >10.7 mmol/L +20

Sodium <130 mEq/L +20

Glucose >13.9 mmol/L +10

Hematocrit <30 percent +10

Partial pressure of arterial oxygen <60 mm Hg +10†

Pleural effusion +10

* A risk score (total point score) for a given patient is obtained by summing the patient age in years (age minus 10 for females) and the points for each applicable patient characteristic.

† Oxygen saturation <90 percent was considered abnormal in the Pneumonia PORT cohort study. The application of the PSI to the initial site of treatment decision (translational research)

combines the PSI risk score and in addition considers the status of arterial oxygenation when used to guide the initial site of treatment.

For patients not assigned to the lowest risk class (I), the

second step is based on diagnostic tests that are used to

further determine risk of death or other adverse outcomes.

Blood tests determine the extent and effects of pneumonia

by measuring blood levels of sodium, glucose, and blood

urea nitrogen as well as arterial pH (acidity/alkalinity

balance) and the percentage of red blood cells to the whole

blood count (hematocrit). An x-ray is used to determine

how many lobes are affected and whether there is excessive

accumulation of fluid around the lungs (pleural effusion)

(Table 1). On the basis of these results, patients are placed

in a risk category ranging from II to V (Table 2).

The AHRQ-funded researchers estimated that if outpatient

care was used for all class I and II patients, brief inpatient

observation for some class III patients, and traditional

hospitalization for class IV and V patients, the percentage

of patients treated by traditional inpatient care would

decrease by 26 to 31 percent. 

Outpatient treatment is safe, effective, and preferred

by low-risk patients

Three-quarters of all CAP patients are treated in an

outpatient setting. The researchers funded through the

AHRQ Pneumonia PORT found that outpatient

management was safe, associated with substantial

improvement in symptoms, and resulted in nearly universal

return to work and usual activities within 30 days of being

first seen by a physican.6 Comparisons of low-risk

4 www.ahrq.gov
outpatients and inpatients suggest that many of them have

similar clinical profiles and similar outcomes.8

Another study, also part of AHRQ’s Pneumonia PORT,

surveyed low-risk CAP patients to determine their

treatment preferences. Researchers found that 80 percent

of patients with low-risk CAP preferred to be treated at

home, including 60 percent of those who had initially been

hospitalized; however, only 11 percent of patients recall

being asked by their physician if they had a preference for

either site. The researchers concluded that most patients

with low-risk CAP should be informed of their prognosis

and encouraged to participate in the decision for home or

hospital care.9

PSI can be a critical pathway to reducing resource

use and maintaining quality of care

A non-AHRQ-funded study performed in 19 Canadian

hospitals examined the use of a “critical pathway”

incorporating the PSI.2 Critical pathways are treatment

steps that are essential steps of a complex process. In

addition to the PSI, the critical pathway used in this study

consisted of treatment with an antibiotic and other practice

guidelines to help the physician decide when to switch the

patient from intravenous antibiotic administration to oral

administration and when to discharge the patient from the

hospital. The PSI score was used only as a guide to the

admission decision and did not take precedence over the

physician’s clinical judgment. 

Researchers in this study found that fewer low-risk CAP

patients were hospitalized in the hospitals incorporating the

critical pathway (31 percent) compared with those

hospitalized in sites using conventional management 

(49 percent). In addition, the use of the entire critical

pathway combining the PSI, the antibiotic levofloxacin, and

guidelines for switching and discharge resulted in a lower

median length of hospital stay (5.0 days versus 6.7 days). 

The researchers also studied the effects on patient health

status of treatment management using the critical pathway.

Six weeks after initial treatment, a health status survey

(Short Form-36 Physical Component Summary [SF-36

PCS]) was administered to each patient.a The survey found

that there were no negative effects on patient quality of life,

nor were there increases in negative outcomes such as

admission to the intensive care unit, readmission to the

hospital, complications, or death. 

Study of the PSI in Veterans Affairs hospital finds

avoidable hospitalization

A recent study of patients with CAP treated in a Veterans

Affairs (VA) hospital further confirmed the PSI’s value by

showing no difference in mortality rates between their

patients, grouped by risk class, and those of the original

www.ahrq.gov 5

Table 2. How risk levels are scored

Risk Level 30-Day Mortality Risk Class Based on:

Low <0.5 percent I Algorithm

Low ≥0.5 and <1.0 percent II 70 or fewer points

Low ≥1.0 and <4.0 percent III 71-90 points

Moderate ≥4.0 and <10.0 percent IV 91-130 points

High ≥10.0 percent V > 130 points

Source: Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997;336(4):243-50. 

a

The SF-36 is a questionnaire used to measure the general health of

populations as well as to compare the health of patients with different

medical conditions. It is a general measure that is intended to capture

quality of life as well as whether an individual is healthy or not.
PORT study.10 In examining the hospital records of patients

admitted with a diagnosis of pneumonia, the VA researchers

found that 20 of 82 low-risk pneumonia patients might have

avoided hospitalization if the PSI had been used to make

admission decisions. The researchers recommended that the

VA incorporate the PSI and current CAP guidelines into an

interactive decision-support tool to be made available

through the VA’s computerized patient record system. This

could potentially facilitate physician ability to make realtime application of the PSI. 

Health systems and professional societies use 

the PSI

At least one health care system has adopted the PSI to help

improve the quality of care provided in its hospitals. Tenet

Health Systems is using the PSI in 30 of its 113 hospitals;

however, rather than using it as a tool to guide triage

decisions, it is being used to look back at the severity levels

of admitted patients as well as the appropriateness of care

provided to patients within that severity level. As case

managers enter the various risk factors into the database,

Tenet’s program automatically calculates a patient’s severity

level and projected mortality. The PSI has been very useful

in their process improvement to date, and they are

eventually planning to make it part of the system’s real-time

concurrent case management review at all Tenet hospitals.11

The PSI also has been incorporated into the practice

guidelines developed by the Infectious Diseases Society of

America (IDSA) for the management of adults with CAP.

The IDSA believes that the clinical prediction rule provided

by the PSI is methodologically sound and “may help

physicians make decisions about the initial location and

intensity of treatment”12 for CAP patients. The IDSA

represents physicians, scientists, and other health care

professionals who specialize in infectious diseases.12

Timely and appropriate antibiotic therapy 

produces better outcomes

In addition to developing the PSI, AHRQ-funded research

helped to establish that the early administration of antibiotic

therapy (within 8 hours of hospital arrival) was associated

with improved survival. In a study of 14,000 elderly

patients with pneumonia treated at over 3,500 hospitals,

patients who received early antibiotic therapy had lower 30-

day mortality. b, 13 Another AHRQ-funded study found that

for CAP outpatients under age 60 and without additional

illnesses, the use of erythromycin was just as medically

effective and less than one-third as expensive ($5.43 vs.

$18.31) than other antibiotics. For CAP outpatients older

than 60 years with one or more other illnesses, the use of

erythromycin instead of the new generation antibiotics also

resulted in similar medical outcomes and at a cost one-tenth

as expensive ($7.50 vs. $73.50).14 The 30-day outcomes

that were assessed included mortality, subsequent

hospitalization, medical complications, resolution of

symptoms, return to work and usual activities, and healthrelated quality of life. 

Determining medical stability before 

discharge can reduce mortality

An AHRQ-funded study interviewed physicians who

identified aspects of the hospital care of pneumonia

patients that could be made more efficient to decrease the

patient’s length of stay in the hospital.15 These factors were

diagnostic evaluation or treatment of comorbid illness,

completion of a standard course of antimicrobial therapy,

and delays with arrangement of long-term care. In

addition, the researchers concluded that providing more

home treatment programs could also reduce the length of

the average hospital stay. 

Concerned both with unnecessarily prolonged hospital stays

and the potential danger of releasing pneumonia patients

from the hospital too soon, AHRQ-funded researchers

developed a simple measure of how sick patients with

pneumonia are that can be used to judge whether it is safe

for them to be discharged from the hospital.16 The measure

uses information from the five basic vital signs that are

checked several times a day in hospitalized patients—

temperature, heart rate, blood pressure, respiratory rate, and

oxygen levels in the blood—as well as an assessment of the

patient’s mental status and ability to eat and drink. 

6 www.ahrq.gov

b

The article did not state what percentage of the patients studied were

CAP patients.
www.ahrq.gov 7

In a followup study, the researchers found that patients who

were medically unstable—defined as having problems with

at least one of the seven factors in the measure—had a 

60-percent increased chance of readmission or death and a

50- percent higher chance of not returning to their usual

activities within 30 days.c Th e researchers also found that

the risk of readmission or death was 5 times greater for the

small proportion of patients who were discharged with two

or more unstable factors. Among the patients studied, 1 in

5 had been discharged “medically unstable.”17

The researchers believe that hospital and insurance plan

guidelines that shorten the length of hospital stays should

build in a safety check to measure clinical stability prior to

discharge to ensure that patients are not discharged too

soon. 

Ongoing AHRQ research 

AHRQ’s current research related to pneumonia is

examining guideline implementation and dissemination, the

effects of influenza vaccination on pneumonia and

influenza hospitalizations in the elderly, and long-term

mortality rates for CAP patients.

• Guideline to Improve Quality of Initial Pneumonia

Care; Grant No. R01 HS10049. This study is aimed at

providing further validation of guideline

recommendations arising from AHRQ’s Pneumonia

PORT. It assesses the outcomes obtained when the

guideline recommendations are used. The researchers

compare and evaluate the effectiveness of two strategies

to decrease the proportion of low-risk patients treated in

the hospital—an experimental guideline implementation

strategy and a hospital-designed strategy. 

• Dissemination of Guidelines for Pneumonia Length of

Stay; Grant No. R01 HS08282. This study assesses the

effectiveness of a medical practice guideline to reduce

length of stay in patients with CAP by using a

dissemination strategy implemented through a hospital

utilization management program. It considers both

patient outcomes and costs of care.

• The Effectiveness of Influenza Vaccination; Grant No.

R03 HS10154. This study examines the relationship

between immunization rates and pneumonia and

influenza hospitalizations in the elderly. It takes into

account Medicare managed-care selection effects, health

care market factors, immunologic factors, and vaccine

selection effects.

• Long-Term Mortality of Community-acquired

Pneumonia; Grant No. F32 HS00135. This study

assesses 5-year mortality from CAP to supplement the

short-term mortality (30- and 90-day) data from the

Pneumonia PORT. This information could potentially

help clinicians in managing CAP patients.

AHRQ-Funded Research on Community-Acquired Pneumonia

Pneumonia Patient Outcomes Research Team (PORT), 1990-1996. University of Pittsburgh School of Medicine. Provided

information on processes of care, costs, and medical outcomes that can be used to devise the best treatment strategies for CAP,

lead to more cost-effective care, and promote patient satisfaction. In addition to developing a clinically meaningful prediction

rule to identify low-risk patients, it assessed physician and patient decisionmaking processes for initial site of care and length of

hospital care, documented resource use and costs of care for CAP, and identified preventive health care issues for patients with

CAP.

c

The patients in this study were mostly patients with CAP; only 9 percent

were admitted from a nursing home.
Conclusion 

Improving the effectiveness and quality of health care is a

major part of AHRQ’s mission. Two tools developed by

AHRQ-funded research help assess the need for

hospitalization and determine the medical stability of

patients prior to discharge. The first tool, the PSI, has been

shown to reduce unnecessary hospitalizations and costs

associated with the management of patients with CAP

without diminishing quality or patient satisfaction. In fact,

most patients favor outpatient care, as it is associated with

an earlier return to work and usual activities.

Implementation and use of the PSI, as either a stand-alone,

decision-support tool for clinicians or as part of a broader

set of process improvement tools used by health care

organizations, could result in substantial savings without

compromising outcomes, safety, or quality of care. Also,

the selection of the most cost-effective antibiotic for CAP

patients treated at home and improving the discharge

criteria for hospitalized CAP patients can conserve

resources without diminishing quality. The second tool

uses information from the five basic vital signs as well as

an assessment of the patient’s mental status and their ability

to eat and drink to determine whether it is safe to discharge

them from the hospital. AHRQ-funded researchers found

that measuring medical stability before discharge can

become an indicator of quality of care. It then could be

used to compare provider and health plan performance or to

stimulate quality improvement activities.

For More Information

For further information on AHRQ-funded pneumonia

research, contact Daniel Stryer, M.D., at 301-594-4038.

Comments on this article can be forwarded to the author at

mstanton@ahrq.gov.

8 www.ahrq.gov
References

1. Lave, JR, Lin CJ, Fine MJ, et al. The cost of treating

patients with community-acquired pneumonia. Semin

Respir Crit Care Med 1999;20(3):189-97.

2. Marrie TJ, Lau CY, Wheeler SL, et al. A controlled trial

of a critical pathway for treatment of communityacquired pneumonia. JAMA 2000;283(6):749-55.

3. Palmer CS, Zhan C, Elixhauser A, et al. Economic

assessment of the community-acquired pneumonia

intervention trial employing levofloxacin. Clin Ther

2000;22(2):250-64.

*4. Fine MJ, Smith DN, Singer DE. Hospitalization

decision in patients with community-acquired

pneumonia: a prospective cohort study. Am J Med

1990;89:713-21.

*5. Fine MJ, Hough LJ, Medsger AR, et al. The hospital

admission decision for patients with communityacquired pneumonia. Arch Intern Med 1997;157:36-44.

*6. Kapoor WN. Assessment of the Variation and Outcomes

of Pneumonia. Pneumonia Patient Outcomes Research

Team (PORT). Final Report. June 28, 1996. Web site:

<http://www.ahrq.gov/coer/respiratory diseases.html>

*7. Fine MJ, Auble TE, Yealy DM, et al. A prediction rule

to identify low-risk patients with community-acquired

pneumonia. N Engl J Med 1997;336(4):243-50. 

*8. Fine MJ, Singer DE, Marrie TJ, et al. Medical outcomes

of ambulatory and hospitalized low risk patients with

community-acquired pneumonia. J Gen Intern Med

1994;9(suppl.2):29A.

*9. Coley CM, Li YH, Medsger AR, et al. Preferences for

home vs. hospital care among low-risk patients with

community-acquired pneumonia. Arch Intern Med

1996;156:1565-71.

10. Ortiz E, Quach CH, and Lenert LA. The Pneumonia

Severity Index. Assessing its potential as a triage tool.

Federal Practitioner; September 2001:11-25.

11. AHRQ Impact Case Studies Notebook. 2001.

12. Infectious Diseases Society of America. Practice

guidelines for the management of community-acquired

pneumonia for adults. Clin Infect Dis 2000;31:347-82.

13. Meehan TP, Fine MJ, Krumholz HM, et al. Quality of

care, process, and outcomes in elderly patients with

pneumonia. JAMA 1997; 278(23):2080-4.

*14. Gleason PP, Kapoor WN, Stone RA, et al. Medical

outcomes and antimicrobial costs with the use of the

American Thoracic Society guidelines for outpatients

with community-acquired pneumonia. JAMA

1997:278:32-39.

*15. Fine MJ, Medsger AR, Stone RA, et al. The hospital

discharge decision for patients with community-acquired

pneumonia. Arch Intern Med 1997;157:47-56.

*16. Halm EA, Fine MJ, Marrie TJ, et al. Time to clinical

stability in patients hospitalized with communityacquired pneumonia. JAMA 1998; 279:1452-7.

*17. Halm EA, Fine MJ, Kapoor WN, et al. Instability on

hospital discharge and the risk of adverse outcomes in

patients with pneumonia. Arch Intern Med 2002;

162:1278-84.

* AHRQ-funded/sponsored research

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www.ahrq.gov 11

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