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Thomas P. Meehan, MD, MPH; Michael J. Fine, MD, MSc; Harlan M. Krumholz, MD; Jeanne D. Scinto, PhD, MPH; Deron H. Galusha, MS; Joyce T. Mockalis, RN; Georgina F. Weber, BSN; Marcia K. Petrillo, MA; Peter M. Houck, MD; Jonathan M. Fine, MD

JAMA. 1997;278(23):2080-2084.

Abstract
Context.
—Pneumonia is a frequent cause of hospitalization and death among elderly patients, but the relationships between processes of care for pneumonia and outcomes are uncertain, making quality improvement a challenge.

Objectives.
—To assess quality of care for Medicare patients hospitalized with pneumonia and to determine whether process of care performance is associated with lower 30-day mortality.

Design.
—Multicenter retrospective cohort study with medical record review.

Setting.
—A total of 3555 acute care hospitals throughout the United States.

Patients.
—A total of 14069 patients at least 65 years old hospitalized with pneumonia.

Main Outcome Measures.
—Four processes of care: time from hospital arrival to initial antibiotic administration; blood culture collection before initial hospital antibiotics; blood culture collection within 24 hours of hospital arrival; and oxygenation assessment within 24 hours of hospital arrival. Associations between processes of care and 30-day mortality were determined with logistic regression analysis.

Results.
—National estimates of process-of-care performance were antibiotic administration within 8 hours of hospital arrival, 75.5% (95% confidence interval [Cl], 73.1-77.9); blood cultures before antibiotics, 57.3% (95% Cl, 54.5-60.1); initial blood culture collection, 68.7% (95% Cl, 66.2-71.2); and initial oxygenation assessment, 89.3% (95% Cl, 87.5-90.9). Lower 30-day mortality was associated with antibiotic administration within 8 hours of hospital arrival (odds ratio [OR], 0.85; 95% Cl, 0.75-0.96) and blood culture collection within 24 hours of arrival (OR, 0.90; 95% Cl, 0.81-1.00). State and territory performance estimates varied from 49.0% to 89.7% for antibiotics given within 8 hours and from 45.6% to 82.6% for blood cultures drawn within 24 hours.

Conclusions.
—Administering antibiotics within 8 hours of hospital arrival and collecting blood cultures within 24 hours were associated with improved survival. The fact that states varied widely in the performance of these measures suggests that opportunities exist to improve hospital care of elderly patients with pneumonia.

Author Affiliations
From the Connecticut Peer Review Organization, Middletown, Conn (Drs Meehan, M. J. Fine, Krumholz, Scinto, Weber, and J. M. Fine, Mr Galusha, and Mss Mockalis and Petrillo); the Health Care Financing Administration, Region 10, Seattle, Wash (Dr Houck); the Division of General Internal Medicine and the Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pa (Dr M. J. Fine); the Section of Cardiovascular Medicine, Department of Medicine, and the Section of Chronic Disease Epidemiology, Department of Epidemiology and Public Health, Yale University School of Medicine and the Yale—New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, Conn (Dr Krumholz); and the Section of Pulmonary and Critical Care Medicine, Norwalk Hospital, Norwalk, Conn (Dr J. M. Fine).

Dr M. J. Fine is a Robert Wood Johnson Foundation Generalist Physician Scholar. Dr Krumholz is a Paul Beeson Faculty Scholar. Dr J. M. Fine is supported in part by a grant from the Polly Annenberg Levee Charitable Trust, St Davids, Pa.

Footnotes
The content of this publication does not necessarily reflect the views or policies of the US Department of Health and Human Services nor does the mention of trade names, commercial products, or organizations imply endorsement by the US government. The authors assume full responsibility for the accuracy and completeness of the ideas presented.

Reprints: Thomas P. Meehan, MD, MPH, 100 Roscommon Dr, Middletown, CT 06457 (e-mail: ctpro. tmeehan@sdps.org).

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ABSTRACT | FULL TEXT  

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ABSTRACT | FULL TEXT  

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