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Abstract title: Underperformance of Processes of Care for Veterans Hospitalized with Community-Acquired Pneumonia

Author(s):
EM Mortensen - VERDICT and Division of General Internal Medicine, Audie L. Murphy VA Hospital, San Antonio, Texas
MI Restrepo - VERDICT and Division of Pulmonary/Critical Care Medicine, Audie L. Murphy VA Hospital, San Antonio, Texas
A Anzueto - Division of Pulmonary/Critical Care Medicine, Audie L. Murphy VA Hospital, San Antonio, Texas
JA Pugh - VERDICT and Division of General Internal Medicine, Audie L. Murphy VA Hospital, San Antonio, Texas

Objectives: In 1996 over 40,000 veterans were hospitalized with community-acquired pneumonia (CAP) in the VA health care system. Previous studies have demonstrated that for Medicare patients hospitalized with CAP certain processes of care (POC) are associated with decreased mortality, and that there is considerable variation between hospitals in the performance rates for these POC. To our knowledge, no parallel data has been gathered for the VA. Our aim was to assess these POC at a single VA acute care hospital.

Methods: Eligible patients were admitted with a diagnosis of CAP between 1/1/2000 and 12/31/2000, had a chest x-ray consistent with CAP, and had a primary or secondary ICD-9 diagnosis of pneumonia. Patients were excluded if they were “comfort measures only” or transferred from another acute care hospital. Of the 461 eligible patients, based on our power calculations 151 patients were randomly selected for review. POC measures examined include: initial administration of antibiotics within 8 hours of admission, collection of blood cultures prior to antibiotic administration, oxygen saturation measurement within 24 hours of presentation, and concordance of antibiotic therapy with national guidelines. Severity of illness was quantified using the Pneumonia Severity Index (PSI).

Results: The median age was 67.4 years and 96.0% were male. 76.2% were admitted through urgent care, and 24.5% were initially admitted to the ICU. By the PSI 39.8% were low risk, 34.4% were moderate risk, and 25.8% were high risk. Median LOS was 6.0 days. Mortality was 13.9% at 30-days. The mean time to antibiotics was 8:25 hours with only 59.0% of patients receiving antibiotics within 8 hours. Blood cultures were obtained in 80.8% but prior to antibiotic administration in only in 32.5 %. Oxygenation status was assessed in 78.8%, and vaccination status was assessed in 11.9% for the influenza vaccine and 13.9% for the Pneumococcal vaccine. The antibiotics were concordant with national guidelines in 82.1% of patients.

Conclusions: There is significant underperformance of important processes of care for veterans with CAP.

Impact statement: Further study is needed to evaluate the quality of care for CAP throughout the entire VA health care system and assess the potential for reducing mortality for veterans with CAP.