Increasing outpatient treatment of mild community-acquired pneumonia: systematic review and meta-analysis

Chalmers, James D.; Akram, Ahsan R.; Hill, AT

doi:10.1183/09031936.00065610

Cited by 51 publications

(38 citation statements)

References 33 publications

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“…Reducing mortality from CAP requires rapid identification of patients at risk and several scoring systems have been developed to identify severe CAP [2,3].…”

Section: Introductionmentioning

confidence: 99%

Simplification of the IDSA/ATS criteria for severe CAP using meta-analysis and observational data

Salih

Schembri

Chalmers

2013

European Respiratory Journal

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The 2007 Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) guidelines proposed ''minor'' criteria to predict intensive care unit (ICU) admission in patients with community-acquired pneumonia. These criteria were based on expert opinion. Consequently, the authors of the guidelines asked investigators to determine whether the score could be simplified by excluding noncontributory variables.Each IDSA/ATS minor criterion was validated using a random effects meta-analysis of seven studies. Variables present in ,5% of cases or that were nonsignificantly associated with mortality/ICU admission were excluded. A simplified score excluding these variables was tested for prediction of mortality and ICU admission in an established database. Prediction was assessed using the area under the receiver operator characteristic curve (AUC).Leukopenia (,4000 cells?mm -3 ), thrombocytopenia (,100 000 cells?mm -3 ) and hypothermia ,36uC occurred in ,5% of cases. A simplified score excluding these variables was performed similarly for prediction of mortality, AUC 0.77 (95% CI 0.73-0.81) versus 0.78 (95% CI 0.74-0.82) (p50.9) and intensive care unit admission, AUC 0.85 (95% CI 0.82-0.87) versus 0.85 (95% CI 0.82-0.88) (p50.9). Additional predictors suggested by the IDSA/ATS were associated with mortality and ICU admission, but only incorporating acidosis (pH ,7.35) altered the AUC (0.82 (95% CI 0.78-0.86) (p50.6) for mortality and 0.86 (95% CI 0.82-0.88) (p50.8) for ICU admission). No improvements were statistically significant.The IDSA/ATS criteria can be simplified by removing three infrequent variables. @ERSpublicationsThe IDSA/ATS criteria can be simplified by removing three infrequent variables

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“…Reducing mortality from CAP requires rapid identification of patients at risk and several scoring systems have been developed to identify severe CAP [2,3].…”

Section: Introductionmentioning

confidence: 99%

Simplification of the IDSA/ATS criteria for severe CAP using meta-analysis and observational data

Salih

Schembri

Chalmers

2013

European Respiratory Journal

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“…El manejo ambulatorio de pacientes con neumonía comunitaria de bajo riesgo (categorías I a III de Fine) ha sido validado en diversos estudios [26][27][28][29][30] , reduciendo los costos de la atención sanitaria, garantizando la seguridad de los enfermos, promoviendo la autonomía y la reintegración a sus actividades cotidianas, sin afectar la satisfacción de los usuarios acerca de la atención brindada. Cabe mencionar que dos tercios de los pacientes atendidos en el hospital de día correspondían a las categorías de riesgo III a V de Fine y sobre 90% tenían dos o más factores de riesgo de la Guía Clínica Nacional de Neumonía.…”

Section: Discussionunclassified

“…Con el propósito de aumentar el manejo ambulatorio de pacientes con neumonía comunitaria de riesgo bajo o moderado, los médicos clínicos han implementado diversas intervenciones [26][27][28][29][30] , empleado índices pronósticos validados en la literatura para estimar la gravedad de los pacientes 21,23,24 , logrando aumentar significativamente el número de pacientes manejados en la comunidad (OR 2,31; IC95% 2,03-2,63) 29 . Estas intervenciones han demostrado ser seguras, sin afectar en forma significativa la mortalidad (OR 0,83; IC95% 0,59-1,17), los reingresos hospitalarios (OR 1,08; IC95% 0,82-1,42) o la satisfacción del paciente con la atención (OR 1,21; IC95% 0,97-1,49) 29 .…”

Section: Discussionunclassified

“…Estas intervenciones han demostrado ser seguras, sin afectar en forma significativa la mortalidad (OR 0,83; IC95% 0,59-1,17), los reingresos hospitalarios (OR 1,08; IC95% 0,82-1,42) o la satisfacción del paciente con la atención (OR 1,21; IC95% 0,97-1,49) 29 . Debe tenerse en cuenta que la hospitalización diurna u hospital de día no constituye la única alternativa válida a los objetivos de gestión clíni-ca planteados en este estudio, ya que algunos de ellos pueden quedar cubiertos por la unidad de corta estancia, la hospitalización domiciliaria o los programas de alta precoz con apoyo domiciliario [15][16][17][18][19]25 .…”

Section: Discussionunclassified

“…Los estudios sugieren que los médicos que trabajan en los servicios de atención primaria (consultorios y servicios de urgencia) deberían ser alentados a desarrollar estrategias específicas que promuevan el manejo ambulatorio de pacientes adultos con infecciones respiratorias agudas de riesgo moderado, empleando criterios de gravedad validados (CURB-65, CRB-65, índice de Fine, factores de riesgo de la Guía Clínica Nacional de Neumonía) en la evaluación de la gravedad y decisión del lugar de manejo (ambulatorio vs hospitalario), para asegurar que estas intervenciones sean seguras [26][27][28][29][30] . Se requieren más estudios de intervención, en particular con respecto a los criterios de gravedad que aún no han sido probados para guiar el tratamiento ambulatorio.…”

Section: Discussionunclassified

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Hospitalización diurna como modelo de atención de salud en pacientes adultos inmunocompetentes con neumonía adquirida en la comunidad

P²,

M³

et al. 2015

Rev. méd. Chile

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Alternative Strategies to Inpatient Hospitalization for Acute Medical Conditions

et al. 2016

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IMPORTANCE Determining innovative approaches that better align health needs to the appropriate setting of care remains a key priority for the transformation of US health care; however, to our knowledge, no comprehensive assessment exists of alternative management strategies to hospital admission for acute medical conditions. OBJECTIVE To examine the effectiveness, safety, and cost of managing acute medical conditions in settings outside of a hospital inpatient unit.EVIDENCE REVIEW MEDLINE, Scopus, CINAHL, and the Cochrane Database of Systematic Reviews (January 1995 to February 2016) were searched for English-language systematic reviews that evaluated alternative management strategies to hospital admission. Two investigators extracted data independently on trial design, eligibility criteria, clinical outcomes, patient experience, and health care costs. The quality of each review was assessed using the revised AMSTAR tool (R-AMSTAR) and the strength of evidence from primary studies was graded according to the Oxford Centre for Evidence-Based Medicine.FINDINGS Twenty-five systematic reviews (representing 123 primary studies) met inclusion criteria. For outpatient management strategies, several acute medical conditions had no significant difference in mortality, disease-specific outcomes, or patient satisfaction compared with inpatient admission. For quick diagnostic units, the evidence was more limited but did demonstrate low mortality rates and high patient satisfaction. For hospital-at-home, a variety of acute medical conditions had mortality rates, disease-specific outcomes, and patient and caregiver satisfaction that were either improved or no different compared with inpatient admission. For observation units, several acute medical conditions were found to have no difference in mortality, a decreased length of stay, and improved patient satisfaction compared to inpatient admission; results for some conditions were more limited. Across all alternative management strategies, cost data were heterogeneous but showed near-universal savings when assessed.CONCLUSIONS AND RELEVANCE For low-risk patients with a range of acute medical conditions, evidence suggests that alternative management strategies to inpatient care can achieve comparable clinical outcomes and patient satisfaction at lower costs. Further study and application of such opportunities for health system redesign is warranted.

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Increasing outpatient treatment of mild community-acquired pneumonia: systematic review and meta-analysis

Cited by 51 publications

References 33 publications

Simplification of the IDSA/ATS criteria for severe CAP using meta-analysis and observational data

Simplification of the IDSA/ATS criteria for severe CAP using meta-analysis and observational data

Hospitalización diurna como modelo de atención de salud en pacientes adultos inmunocompetentes con neumonía adquirida en la comunidad

Alternative Strategies to Inpatient Hospitalization for Acute Medical Conditions

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