Quality Indicators for the Management of Pneumonia in Vulnerable Elders
Authors: David C. Rhew
Journal: Annals of Internal Medicine (2001)

Quality Indicators for Assessing Care of Vulnerable Elders16 October 2001Quality Indicators for the Management of Pneumonia in Vulnerable EldersFREEDavid C. Rhew, MDDavid C. Rhew, MDFrom Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; University of California, Los Angeles, Los Angeles, California; and Zynx Health Inc., Cedars-Sinai, Beverly Hills, California.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-135-8_Part_2-200110161-00013 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Pneumonia is the most common cause of death from infection in persons 60 years of age and older and is the fourth most common cause of death overall for persons 80 years of age and older (1). Furthermore, the annual cost of treating patients with pneumonia in the United States is approximately $9.7 billion (2), and most of this cost is incurred when patients (the majority of whom are older) are hospitalized. It has been estimated that 962 patients per 100 000 persons 65 years and older will require hospitalization for pneumonia annually; this figure is nearly four times the rate in the general population (3). The vulnerable older patient is at even greater risk for death and morbidity from pneumonia, and improving quality of care for this high-risk population may lead to substantial reductions in morbidity and mortality.MethodsThe methods for developing these quality indicators, including literature review and expert panel consideration, are detailed elsewhere in this supplement (4). For pneumonia, the structured literature review identified 4531 titles, from which abstracts and articles relevant to this report were identified. On the basis of the literature and the authors' expertise, 17 potential quality indicators were proposed.ResultsOf the 17 potential quality indicators, 11 were judged valid by the expert panel process (see the quality indicators) and 6 were not accepted. The literature summaries that support each indicator judged to be valid by the expert panel process are described below.Quality Indicator 1Pneumococcal VaccineIF a vulnerable elder with no history of allergy to the pneumococcal vaccine is not known to have already received a pneumococcal vaccine or if the patient received it more than 5 years ago (if before age 65), THEN a pneumococcal vaccine should be offered BECAUSE it may be efficacious in preventing pneumococcal pneumonia in elderly patients.Supporting Evidence. A meta-analysis of randomized clinical trials demonstrates that the pneumococcal vaccine reduces the overall incidence of bacteremic pneumococcal pneumonia but is not effective in high-risk patients (5). Although high-risk patients include those 65 years of age and older, the original meta-analysis does not separately analyze the benefit of the vaccine in the elderly. The authors comment that if immunocompromised patients (including those who have received a renal transplant or have renal failure, hematologic or metastatic cancer, the nephrotic syndrome, systemic lupus erythematosus, or sickle-cell anemia) are removed from the analysis, the vaccine may show a benefit for the elderly because vaccination has been shown to increase antibody levels in elderly patients (6, 7). Other studies, including a randomized, controlled trial (8), a large case–control study (9), a small matched case–control study (10), a seroprevalence study (11), a retrospective study (12), a cost-effectiveness study (13), and expert opinion–based recommendations from the Advisory Committee on Immunization Practices (14) and the American College of Physicians–American Society of Internal Medicine and Infectious Diseases Society of America (IDSA) (15, 16), support the recommendation that elderly patients with no history of allergy to the pneumococcal vaccine should receive this vaccine if they have not already done so or if they received it before age 65 and more than 5 to 6 years ago. Since the development of this indicator, the IDSA has updated its 1998 recommendations; the IDSA maintains its support for administering the pneumococcal vaccine to elderly patients (17).Quality Indicator 2Influenza VaccineIF a vulnerable elder has no history of anaphylactic hypersensitivity to eggs or to other components of the influenza vaccine, THEN the patient should be offered an annual influenza vaccination BECAUSE the influenza vaccine is effective in limiting severe disease caused by influenza virus and is effective in elderly patients at all levels of risk.Supporting Evidence. A meta-analysis of 20 cohort studies, three case–control studies, two cost-effectiveness studies, and one randomized, double-blind, placebo-controlled trial demonstrate that the influenza vaccine prevents pneumonia, hospitalization, and death in elderly persons and that it is cost-effective (18). One large observational study has shown that the influenza vaccine reduces mortality for all risk groups of elderly patients (19). In addition, expert opinion–based recommendations support the use of influenza vaccine in elderly patients (15–17, 20).Quality Indicator 3Administering Pneumococcal and Influenza VaccinationsIF a vulnerable elder is hospitalized and he or she is eligible for vaccination (that is, the patient is not up-to-date with pneumococcal or influenza vaccination), THEN the patient should be offered vaccination against pneumococcus and influenza (during flu season) BECAUSE hospitalization offers an opportune moment to administer the vaccines.Supporting Evidence. More than half of patients hospitalized with pneumococcal disease have been hospitalized during the previous 5 years (21). A systematic review (22) of published and unpublished studies evaluating the effectiveness of various delivery strategies for immunizations, two prospective studies (23, 24), five retrospective studies (21, 25–28), and one expert opinion–based recommendation by the IDSA (17) support the recommendation to offer pneumococcal or influenza vaccinations to elderly patients when they are hospitalized.Quality Indicator 4Administering Pneumococcal and Influenza VaccinationsIF pneumococcal or influenza vaccination rates among patients of a health delivery organization are low (<60% of persons at risk for pneumococcal and influenza disease and <90% of institutionalized elderly [29]), THEN methods to increase the rate of vaccination should be used BECAUSE these interventions increase vaccination rates in inpatient and outpatient settings.Supporting Evidence. The objectives of the Public Health Service for the year 2010 call for vaccinating at least 60% of persons at risk for pneumococcal and influenza disease and 90% of the institutionalized elderly (29). In 1997, only 45% of persons older than 65 years of age had ever received the pneumococcal vaccine, and the annual influenza rate for the elderly was 66% (30).A systematic review (22) of published and unpublished studies evaluating the effectiveness of various delivery strategies for immunizations, four prospective studies (24, 31, 32), three retrospective studies (27, 33, 34), and expert opinion–based recommendations by the Advisory Committee on Immunization Practices (14, 20) support the recommendation to increase low rates of pneumococcal or influenza vaccinations by using methods such as patient information, patient reminders, standing orders for nurses, provider education, and provider feedback and reminders. The systematic review (22) found that interventions aimed at hospitalized patients may have the greatest effect on increasing influenza vaccinations. The Advisory Committee on Immunization Practices recommendation, which is based on an informal review of the literature, identifies standing orders as the most effective method to increase pneumococcal vaccination rates.Quality Indicator 5Influenza Vaccination of Health Care WorkersIF a health care organization cares for vulnerable elders, THEN it should have a formal plan to offer and encourage influenza vaccination among its employees BECAUSE vaccination of health care workers is associated with reductions in total patient mortality and in the incidence of influenza-like illness.Supporting Evidence. A randomized, controlled study supports the finding that vaccination of health care workers who care for elderly patients reduces total patient mortality and the incidence of influenza-like illness (35). In this study, 1059 patients in 12 geriatric medical long-term care sites were randomly assigned for vaccination of health care workers during the winter of 1994–1995. Among hospitals that offered vaccination, 653 of 1078 health care workers were vaccinated (61%). Vaccination of health care workers was associated with reductions in total patient mortality from 17% to 10% (odds ratio, 0.56 [95% CI, 0.40 to 0.80]) and in the incidence of influenza-like illness (odds ratio, 0.57 [CI, 0.34 to 0.94]). A separate analysis found that vaccination of patients was not associated with significant effects on mortality (odds ratio, 1.15 [CI, 0.81 to 1.64]). Results of this study support recommendations for influenza vaccination of health care workers employed in long-term geriatric care. In addition, an expert opinion–based recommendation by the IDSA (17) supports the recommendation for influenza vaccination of health care workers.Quality Indicator 6Smoking CessationIF a vulnerable elder smoker develops pneumonia, THEN the smoker should be advised to quit smoking BECAUSE interventions tailored for such acutely ill patients may increase the rate of long-term cessation of smoking. This, in turn, may ultimately reduce the risk for developing recurrent pneumonia or other long-term complications of cigarette smoking.Supporting Evidence. A meta-analysis (36) and a large observational study, the Pneumonia Patient Outcomes Research Team (PORT) cohort study (37), support the finding that interventions to advise smokers with pneumonia to quit smoking may increase the rate of long-term cessation of smoking. In the meta-analysis, 17 studies (n = 14 438) evaluated the effect of one-time advice by physicians to stop smoking. The estimated efficacy for this intervention was 2% (CI, 1% to 3%; P < 0.001), and the results persisted for at least 1 year (36).The PORT cohort study enrolled 262 self-identified smokers between 15 March 1993 and 31 March 1994 (37). Of the 247 patients who survived until follow-up, 202 (82%) were interviewed for the smoking cessation survey (194 patient respondents and 8 proxies). At follow-up, 30 (15%) of the respondents had quit smoking (defined as “not smoked a cigarette, even a puff, during the past 7 days”); 28 (93%) of these patients initially stopped smoking during the episode of community-acquired pneumonia. The following factors were major univariate predictors of quitting: age >45 years (odds ratio, 3.6 [CI, 1.6 to 8.3]), hospitalization for community-acquired pneumonia (odds ratio, 5.6 [CI, 1.3 to 24.4]), and stopping smoking for 1 or more days during the episode of pneumonia (odds ratio, 5.6 [CI, 1.3 to 24.4]).When asked what effect they thought smoking had on their contracting community-acquired pneumonia, the 194 respondents replied in the following manner: 36% thought smoking had no effect, 26% thought it had some effect, 16% thought it contributed “a lot” or “a great deal,” and 22% responded “don't know.”When the 146 patient respondents who had smoked at any time after their diagnosis of community-acquired pneumonia were asked what effect they thought smoking had on their recovery, they replied as follows: 42% thought smoking had no effect on their recovery, 32% thought it interfered somewhat, 23% thought it interfered “a lot” or “a great deal,” and 3% responded “don't know.”Sixty-six percent of the patient respondents indicated that their physician had advised them to stop smoking during treatment for this episode of pneumonia. These findings indicate that interventions tailored for such acutely ill patients may increase the rate of long-term cessation of smoking.In addition, since the development of these indicators, an evidence-based clinical practice guideline by the U.S. Public Health Service has recommended that at every visit, clinicians and health care delivery systems should screen and provide treatment for every person who uses tobacco (38). The U.S. Public Health Service recommends five brief strategies [called the “5 A's”] to help the patient to quit smoking: 1) Ask all patients if they smoke; 2) advise all smokers to quit; 3) assess the smoker's willingness to quit; 4) assist the smoker in quitting by providing a plan, counseling, social support, or pharmacologic treatments; and 5) arrange for a follow-up visit to address smoking cessation.Quality Indicator 7AntibioticsIF a vulnerable elder is admitted to the hospital with pneumonia, THEN antibiotics should be administered within 8 hours of hospital arrival BECAUSE this is associated with lower 30-day mortality.Supporting Evidence. Three large cohort studies (39–41), two of them specific to elderly persons (39, 40), support the association between early antibiotic delivery and decreased mortality for patients hospitalized with pneumonia.The first investigation was a multicenter cohort study (n = 14 069) that reviewed the medical records of elderly patients 65 years of age and older who were hospitalized with pneumonia (39). The researchers found that antibiotic administration within 8 hours of hospital arrival was associated with significantly lower 30-day mortality in both unadjusted analyses (odds ratio, 0.85 [CI, 0.76 to 0.95]) and analyses that adjusted for patient risk status and performance of other processes of care (odds ratio, 0.85 [CI, 0.75 to 0.96]). This study was different from the studies described below by Kahn and colleagues (40) and McGarvey and colleagues (41) in that it separated the effect of time to antibiotic administration from other processes of care. This study also showed that initiating antibiotics before 4 hours or before 2 hours was not associated with decreased mortality.The second study, by Kahn and colleagues, developed explicit process criteria for Medicare patients hospitalized with pneumonia (as well as those hospitalized with congestive heart failure, myocardial infarction, cerebrovascular accident, and hip fracture) and applied a process scale to a nationally representative sample of 14 012 patients hospitalized before and after the implementation of the diagnosis-related group–based prospective payment system [40]. The authors identified an association between decreased 30-day mortality and the performance of “good” technical therapeutic measures. “Good” technical therapeutic measures consisted of 1) providing oxygen therapy or intubating patients who had a Po2 less than 60 mm Hg and 2) beginning antibiotic therapy in a timely manner (for example, within 2 hours of admission or, for patients who are not immunocompromised, within 4 hours of admission). However, the study did not assess independent effects of antibiotic administration.The third report, by McGarvey and colleagues, was of a prospective study (n = 870) evaluating the effect of an 18-month intervention that stressed adherence to locally derived Quality Improvement Task Force recommendations for treatment of patients admitted with a diagnosis of pneumonia [41]. The Quality Improvement Task Force recommendations included the following: 1) Obtain sputum cultures on all patients, 2) draw blood cultures twice for all patients, 3) administer antibiotics to all patients within 4 hours of hospitalization, 4) consider antibiotic coverage for Mycoplasma and Legionella species, and 5) encourage pulmonary and infectious disease consultation if the patient does not improve within 48 hours.The setting for this study was a single community hospital in Pennsylvania. The authors found that adherence to the recommendation for prompt administration of antibiotics increased from 42% at baseline to 87% at the end of the study. The authors also noted that the mortality rate did not differ significantly from MedisGroups expected mortality rates before the study (10.2% observed vs. 34% expected; P > 0.2) but that it was significantly lower at the end of the study (6.8% observed vs. 49% expected; P = 0.03). Again, this study did not address the independent effect of antibiotic therapy.Expert opinion from the IDSA recommends that the initiation of antibiotic therapy within 8 hours be used as a performance indicator (17). Since the development of this indicator, the IDSA has updated its 1998 recommendations; the IDSA now recommends that the initiation of antibiotic therapy within 8 hours be used as a performance indicator (17).Quality Indicator 8OxygenIF a vulnerable elder is admitted to the hospital with community-acquired pneumonia with hypoxia, THEN the patient should receive oxygen therapy BECAUSE poor compliance with this “technical therapeutic” process indicator was found to be significantly associated with increased 30-day mortality, after adjustment for sickness at admission. (Oxygen can suppress the respiratory drive in patients who have chronic obstructive pulmonary disease and retain carbon dioxide [42]. In these patients, careful monitoring of blood gases is indicated [43].)Supporting Evidence. As described in quality indicator 7, a RAND study of Medicare patients hospitalized with pneumonia demonstrated that 30-day mortality rates were lower in elderly patients with community-acquired pneumonia who received “good” technical therapeutic measures (consisting of oxygen therapy or intubation for patients with hypoxia and timely administration of antibiotics). This study, however, did not assess the independent effect of oxygen therapy (40).Quality Indicator 9EmpyemaIF a vulnerable elder has an empyema, THEN drainage is required BECAUSE an undrained empyema may drain through the chest wall (empyema necessitatis) or into the lung (bronchopleural fistula).Supporting Evidence. Empyema is observed in approximately 5% of patients hospitalized with community-acquired pneumonia (44). A randomized trial (45), a 1998 recommendation based on expert opinion (16), and a review article (46) support the need to drain pus from the pleural cavity. Empyemas may be managed in several ways, including drainage via chest tube, image-guided catheters, rib resection, thoracotomy with decortication, tube thoracostomy with intrapleural administration of fibrinolytic agents, or thoracoscopic pleural debridement (16, 45, 46). The optimal drainage procedure has not been well established. However, one prospective study of patients with empyema thoracis in the fibrinolytic stage (that is, effusion with a pH <7.20 or loculations) (45) showed that video-assisted thoracoscopic surgery was associated with greater treatment success, shorter duration of chest intubation, and a shorter hospital stay compared with chest tube pleural drainage with streptokinase. Since the development of this indicator, the IDSA has updated its 1998 recommendations; the IDSA has added that indications for drainage of pleural fluid include the presence of pus in the pleural space or pleural fluid with a positive Gram stain or culture or a pH less than 7.2 (17).Quality Indicator 10Conversion from Parenteral to Oral Antimicrobial AgentsIF a vulnerable elder with community-acquired pneumonia is to be switched from parenteral to oral antimicrobial therapy, THEN the patient must meet all of the following criteria: a clinically improving condition, hemodynamic stability, and tolerance of oral medication or food and fluids BECAUSE failure to meet these basic criteria is associated with a greater risk for relapse of vital-sign abnormalities and admission to special care units.Supporting Evidence. Data from retrospective, prospective observational, and prospective intervention trials support the preceding criteria for switching from parenteral to oral antibiotics for patients with community-acquired pneumonia. A prospective observational study showed that clinical deterioration requiring admission to an intensive care, coronary care, or telemetry unit occurred in 1% or fewer cases once clinical stability was reached (47). Clinical stability was defined in five ways. The most “lenient” definition included heart rate less than or equal to 100 beats/min, systolic blood pressure of 90 mm Hg or greater, respiratory rate less than or equal to 24 breaths/min, oxygen saturation greater than or equal to 90%, temperature less than or equal to 38.3 °C (101 °F), ability to eat, and normal mental status. The other four definitions differed only in terms of respiratory rate, oxygen saturation, and temperature. The most conservative definition described a respiratory rate less than or equal to 20 breaths/min, oxygen saturation greater than or equal to 94%, and temperature less than or equal to 37.2 °C (99 °F). Two other prospective observational studies (48, 49), one of which was published after the development of the indicators [48], demonstrated that early switching to oral antibiotics was reasonable for hospitalized patients with community-acquired pneumonia who met the following criteria: 1) resolution of fever, 2) improvement of cough and respiratory distress, 3) improvement of leukocytosis, and 4) presence of normal gastrointestinal tract absorption.Another set of criteria was applied in two prospective controlled studies [50, 51]. In these studies, low-risk patients with pneumonia were switched from parenteral to oral antibiotics on day 3 and were discharged home after 4 days of hospitalization. Patients were considered to be at low risk if they met all three of the following criteria: 1) no obvious reason for continued hospitalization, 2) absence of hemodynamic instability factors, and 3) ability to take medications or fluids orally.A 1998 expert opinion–based recommendation from the IDSA stated that before a patient who has community-acquired pneumonia is switched from parenteral to oral antimicrobial therapy, the patient should be improving clinically, should be hemodynamically stable, and should have a functioning gastrointestinal tract (16). Since the development of this indicator, the IDSA has updated its 1998 recommendations; the IDSA maintains its position that the patient should be improving clinically, should be hemodynamically stable, and should have a functioning gastrointestinal tract (including the ability to ingest drugs) (17). In addition, a prospective, multicenter, controlled trial with cluster randomization has shown that application of a critical pathway reduces median length of stay for patients with community-acquired pneumonia (52). In this study, the pathway consisted of three major components. First, patients were evaluated for hospital admission by using a pneumonia prediction rule. Second, patients received intravenous antibiotics within 4 hours of presentation to the emergency department. Third, patients were switched to an oral fluoroquinolone (levofloxacin) and were discharged from the hospital once they fulfilled explicit criteria for switching and discharge. Switching criteria included ability to eat and drink, negative blood cultures, temperature less than or equal to 38.0 °C, respiratory rate less than or equal to 24 breaths/min, and pulse less than or equal to 100 beats/min. The hemodynamic criteria (that is, the last three criteria) must have been present for at least 16 hours.Quality Indicator 11Discharge CriteriaIF a vulnerable elder with community-acquired pneumonia is to be discharged home, THEN the patient should not be unstable on the day before or the day of discharge BECAUSE patients discharged with at least one instability have a higher probability of dying after discharge than patients discharged without any instability.Supporting Evidence. A RAND study of Medicare patients hospitalized with pneumonia and studies detailed in quality indicator 10 support the finding that patients discharged with at least one instability have a higher probability of dying after discharge than patients discharged without any instability.In the RAND study (53), explicit process criteria for Medicare patients hospitalized with pneumonia were developed and applied to evaluate the quality of care before and after the implementation of the diagnosis-related group–based prospective payment system. This study demonstrated that 30-day mortality was increased among patients with community-acquired pneumonia who were discharged with at least one instability. Patients meeting any of the following criteria at discharge were considered to be unstable: fever (temperature >38.3 °C), new incontinence, new chest pain, new shortness of breath, new confusion, new heart rate 130 beats/min or greater, new respiratory rate 30 breaths/min or greater, diastolic blood pressure 105 mm Hg or greater, systolic blood pressure less than 90 mm Hg, new low heart rate less than 50 beats/min, or new premature ventricular contractions.Other studies, including a prospective, multicenter, controlled trial of a critical pathway (53); several prospective observational studies (47–49); and two prospective controlled studies (50, 51) and a retrospective study (52) of a pneumonia practice guideline in “low-risk” patients with pneumonia support the need to achieve hemodynamic stability before discharge.DiscussionEleven indicators were judged to be sufficiently valid for use as measures of quality of pneumonia care for vulnerable elders. All of these indicators may be applied to hospitalized elders. These indicators can potentially serve as a basis for comparing the care provided by different health care delivery systems and comparing the change in care over time. However, before general acceptance and implementation of these indicators, limitations should be noted.First, quality indicators 10 (conversion from parenteral to oral antibiotics) and 11 (discharge criteria) require expert opinion to precisely define the terms. The American College of Physicians–American Society of Internal Medicine Task Force on Aging clarified the discharge criteria and suggested that incontinence should be defined as two or more episodes.Second, many of the quality indicators are not supported by meta-analyses or large randomized, controlled trials but rather by observational or retrospective data showing an association between process-of-care indicators and outcomes. In some situations, performing randomized, controlled trials to answer the question may not be ethical. For example, it would be unethical to randomly assign patients to receive antibiotics before and after 8 hours in order to identify the optimal time to administer antibiotics. In such cases, the best level of evidence may be observational.In summary, 11 indicators for assessing quality of care have been developed and approved by using evidence-based medicine techniques and a formal consensus process. The future of quality-of-care research in pneumonia may rely on further studies linking process indicators with clinical outcomes. For now, selection of quality indicators based on thorough understanding of the strengths and limitations of the underlying evidence and approval process may help establish a standard of care for managing patients with community-acquired pneumonia.References 1. 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