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Thomas J. Marrie, MD; Catherine Y. Lau, PhD; Susan L. Wheeler, RN; Cindy J. Wong, MSc; Margaret K. Vandervoort, MSc; Brian G. Feagan, MD; for the CAPITAL Study Investigators

JAMA. 2000;283:749-755.

Context  Large variations exist among hospitals in the use of treatment resources for community-acquired pneumonia (CAP). Lack of a common approach to the diagnosis and treatment of CAP has been cited as an explanation for these variations.

Objective  To determine if use of a critical pathway improves the efficiency of treatment for CAP without compromising the well-being of patients.

Design  Multicenter controlled clinical trial with cluster randomization and up to 6 weeks of follow-up.

Setting  Nineteen teaching and community hospitals in Canada.

Patients  A total of 1743 patients with CAP presenting to the emergency department at 1 of the participating institutions between January 1 and July 31, 1998.

Intervention  Hospitals were assigned to continue conventional management (n = 10) or implement the critical pathway (n = 9), which consisted of a clinical prediction rule to guide the admission decision, levofloxacin therapy, and practice guidelines.

Main Outcome Measures  Effectiveness of the critical pathway, as measured by health-related quality of life on the Short-Form 36 Physical Component Summary (SF-36 PCS) scale at 6 weeks; and resource utilization, as measured by the number of bed days per patient managed (BDPM).

Results  Quality of life and the occurrence of complications, readmission, and mortality were not different for the 2 strategies; the 1-sided 95% confidence limit of the between-group difference in the SF-36 PCS change score was 2.4 points, which was within a predefined 3-point boundary for equivalence. Pathway use was associated with a 1.7-day reduction in BDPM (4.4 vs 6.1 days; P = .04) and an 18% decrease in the admission of low-risk patients (31% vs 49%; P = .01). Although inpatients at critical pathway hospitals had more severe disease, they required 1.7 fewer days of intravenous therapy (4.6 vs 6.3 days; P = .01) and were more likely to receive treatment with a single class of antibiotic (64% vs 27%; P<.001).

Conclusion  In this study, implementation of a critical pathway reduced the use of institutional resources without causing adverse effects on the well-being of patients.

Author Affiliations: Department of Medicine, University of Alberta, Edmonton (Dr Marrie); Janssen-Ortho Inc, Toronto, Ontario (Dr Lau and Ms Wheeler); and the London Clinical Trials Research Group, London, Ontario (Mss Wong and Vandervoort and Dr Feagan).

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JAMA. 2000;283(20):2654-2655.
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