Fine M J, Hough L J, Medsger A R, Li Y H, Ricci E M, Singer D E, Marrie T J, Coley C M, Walsh M B, Karpf M, Lahive K C, Kapoor W N
Department of Medicine, University of Pittsburgh, Pa, USA.
Arch Intern Med. 1997 Jan 13;157(1):36-44.
The hospital admission decision directly influences the magnitude of resource use in patients with community-acquired pneumonia, yet little information exists on how medical practitioners make this decision.
To determine which factors medical practitioners consider in making the hospital admission decision and which health care services they believe would allow ambulatory treatment of low-risk hospitalized patients with community-acquired pneumonia.
Medical practitioners responsible for the hospital admission decision for low-risk patients with community-acquired pneumonia were asked to describe patient characteristics at initial examination that influenced the hospitalization decision, and to identify the health care services that would have allowed initial outpatient treatment of hospitalized patients.
A total of 292 medical practitioners completed questionnaires for 472 (76%) of the 624 low-risk patients eligible for this study. Although all patients had a predicted probability of death of less than 4%, practitioners estimated that 5% of outpatients and 41% of inpatients had an expected 30-day risk of death of more than 5%. Univariate analyses identified 3 practitioner-rated factors that were nearly universally associated with hospitalization: hypoxemia (odds ratio, 173.3; 95% confidence interval, 23.8-1265.0), inability to maintain oral intake (odds ratio, 53.3; 95% confidence interval, 12.8-222.5), and lack of patient home care support (odds ratio, 54.4; 95% confidence interval, 7.3-402.6). In patients without these 3 factors, logistic regression analysis demonstrated that practitioner-estimated risk of death of more than 5% had a strong independent association with hospitalization (odds ratio, 18.4; 95% confidence interval, 6.1-55.7). Practitioners identified home intravenous antibiotic therapy and home nursing observation as services that would have allowed outpatient treatment of more than half (68% and 59%, respectively) of the patients initially hospitalized for treatment.
Practitioners' survey responses suggest that the availability of outpatient intravenous antimicrobial therapy and home nursing care would allow outpatient care for a large proportion of low-risk patients who are hospitalized for community-acquired pneumonia. These data also suggest that methods to improve practitioners' identification of low-risk patients with community-acquired pneumonia could decrease the hospitalization of such patients. Future studies are required to help physicians identify which low-risk patients could safely be treated in the outpatient setting on the basis of clinical information readily available at presentation.
医院收治决策直接影响社区获得性肺炎患者的资源使用规模，但关于执业医师如何做出这一决策的信息却很少。
确定执业医师在做出医院收治决策时考虑的因素，以及他们认为哪些医疗服务能够使低风险的社区获得性肺炎住院患者接受门诊治疗。
负责对低风险社区获得性肺炎患者做出医院收治决策的执业医师被要求描述初次检查时影响住院决策的患者特征，并确定能够使住院患者接受初始门诊治疗的医疗服务。
共有292名执业医师为624名符合本研究条件的低风险患者中的472名（76%）填写了问卷。尽管所有患者的预计死亡概率均低于4%，但执业医师估计，5%的门诊患者和41%的住院患者预期30天死亡风险超过5%。单因素分析确定了3个几乎与住院普遍相关的执业医师评定因素：低氧血症（比值比，173.3；95%置信区间，23.8 - 1265.0）、无法维持经口摄入（比值比，53.3；95%置信区间，12.8 - 222.5）以及缺乏患者家庭护理支持（比值比，54.4；95%置信区间，7.3 - 402.6）。在没有这3个因素的患者中，逻辑回归分析表明，执业医师估计的死亡风险超过5%与住院有很强的独立相关性（比值比，18.4；95%置信区间，6.1 - 55.7）。执业医师确定家庭静脉抗生素治疗和家庭护理观察为能够使超过一半（分别为68%和59%）最初因治疗而住院的患者接受门诊治疗的服务。
执业医师的调查答复表明，门诊静脉抗菌治疗和家庭护理的可获得性将使很大一部分因社区获得性肺炎住院的低风险患者能够接受门诊治疗。这些数据还表明，改进执业医师识别社区获得性肺炎低风险患者的方法可能会减少此类患者的住院率。未来需要开展研究，以帮助医生根据就诊时 readily available（此处原文有误，根据语境推测可能是readily available，意为“现成可得的”）的临床信息确定哪些低风险患者可以在门诊环境中安全地接受治疗。
