NHAP
Quality of Care and Survival in Nursing Home Acquired Pneumonia
Funded by: Merck, Inc., through the Academic Medicine and Managed Care Forum
Project Period: 12/99 - 6/00
Abstract
Objective: To determine whether there is an association between
nursing home quality of care and surviving an episode of nursing home acquired
pneumonia (NHAP).
Design: Nursing home medical record review comparing management
of NHAP with quality measures developed by an expert panel.
Subjects: 135 incidents of NHAP among 2251 random Medicare nursing
home admissions at 58 nursing homes in five states during 1997.
Methods: Nine quality measures for management of NHAP, addressing
timing and thoroughness of nurse and physician evaluation of lower respiratory tract infections,
criteria for hospitalization, and criteria for antibiotic spectrum, timing, route, and duration
were developed by experts in infectious disease, pharmacology, pulmonology, geriatrics, and
nursing, using a modified Delphi approach. We assessed the association between these quality
measures and 30-day survival, adjusting for case mix and facility characteristics using
multivariate methods.
Results: Overall, the process of care was deficient. For 67% of
the episodes, contact between the nursing home and physician was made within one shift of the
nurse noting symptoms. Fifty-five percent met criteria for appropriate hospitalization, 31%
met criteria for appropriate timing of initial antibiotic, and 43% received antibiotics for
10-14 days. For each episode, a total quality score was computed based on the number of
criteria met. The quality score was greater in patients who survived (4.9 of nine measures)
than in those who died (3.8 measures, p=.008). The difference remained significant after case
mix adjustment. Patients treated with antibiotics covering S. pneumococcus, H. influenza,
and either gram negative rods or S. aureus were significantly more likely to survive
(OR 5.5, CI: 1.42-21.59). There was a strong trend toward improved survival when criteria for
appropriate hospitalization were met (OR 2.5, CI: 0.92-6.55).
Conclusions: Better quality of care for NHAP was associated with
greater survival, improving quality of care of NHAP has the potential to improve outcomes.
Key Staff: Hutt, Kramer, Frederickson
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