Dedier J, Singer D E, Chang Y, Moore M, Atlas S J
Section of General Internal Medicine Research Unit, Department of Medicine, Boston Medical Center, 91 E Concord St, Suite 200, Boston, MA 02118-2393, USA.
Arch Intern Med. 2001 Sep 24;161(17):2099-104. doi: 10.1001/archinte.161.17.2099.
Prompt antibiotic administration, oxygenation measurement, and blood cultures are generally considered markers of high-quality care in the inpatient management of community-acquired pneumonia (CAP). However, few studies have examined the relationship between prompt achievement of process-of-care markers and outcomes for patients with CAP. We examined whether antibiotic administration within 8 hours of hospital arrival, a blood culture within 24 hours, an oxygenation measurement within 24 hours, or performing blood cultures before giving antibiotics was associated with the following: (1) reaching clinical stability within 48 hours of hospital admission, (2) a decreased length of hospital stay, or (3) fewer inpatient deaths.
A retrospective medical record review identified 1062 eligible patients discharged from the hospital with a diagnosis of CAP between December 1, 1997, and February 28, 1998, among 38 US academic hospitals. We assessed the independent relationship between each process marker and the 3 clinical outcomes, controlling for the Pneumonia Severity Index on admission. We also examined the relationship of pneumonia severity on admission to process marker achievement and clinical outcomes.
Overall, there was no consistent or statistically significant relationship between achieving process markers and better clinical outcomes (P>.40 for all). We did observe that performing blood cultures within 24 hours was related to not achieving clinical stability within 48 hours (odds ratio, 1.62; 95% confidence interval, 1.13-2.33). However, this finding likely reflects residual confounding by severity of illness, since increasing pneumonia severity on admission was associated with blood culture performance (P =.009) and with shorter times to antibiotic administration (P =.04).
Achieving process-of-care markers was not associated with improved outcomes, but was related to the severity of pneumonia as assessed on admission. Our results highlight the difficulty in demonstrating a link between process-of-care markers and outcomes in observational studies of CAP. Randomized studies are needed to objectively evaluate the impact of process-of-care markers on CAP outcomes.
在社区获得性肺炎（CAP）的住院治疗中，及时给予抗生素、进行氧合测量和血培养通常被视为高质量医疗的标志。然而，很少有研究探讨及时达到医疗过程指标与CAP患者预后之间的关系。我们研究了入院8小时内给予抗生素、24小时内进行血培养、24小时内进行氧合测量或在给予抗生素之前进行血培养是否与以下情况相关：（1）入院48小时内达到临床稳定，（2）缩短住院时间，或（3）减少住院死亡人数。
一项回顾性病历审查确定了1997年12月1日至1998年2月28日期间在美国38家学术医院出院诊断为CAP的1062例合格患者。我们评估了每个过程指标与3个临床结局之间的独立关系，并对入院时的肺炎严重程度指数进行了控制。我们还研究了入院时肺炎严重程度与过程指标达成情况及临床结局之间的关系。
总体而言，达到过程指标与更好的临床结局之间没有一致的或统计学上显著的关系（所有P值均>.40）。我们确实观察到24小时内进行血培养与48小时内未达到临床稳定有关（比值比，1.62；95%置信区间，1.13 - 2.33）。然而，这一发现可能反映了疾病严重程度的残余混杂因素，因为入院时肺炎严重程度增加与血培养的进行（P =.009）以及抗生素给药时间缩短（P =.04）相关。
达到医疗过程指标与改善结局无关，但与入院时评估的肺炎严重程度有关。我们的结果凸显了在CAP的观察性研究中证明医疗过程指标与结局之间联系的困难。需要进行随机研究以客观评估医疗过程指标对CAP结局的影响。
