Assessment of Quality of Care Among Patients with Community-Acquired Pneumonia Admitted to the Dr. Jose R.

Reyes Memorial Medical Center Medical Ward* Pio T. Esguerra II, M.D.,** Mario M. Panaligan, M.D.,*** Audie V. Cuntapay, M.D. ,**** Irma Claire O. Bautista, M.D. and **** Mari Karr Andaya-Esguerra, M.D.,**** (*First Place, Department of Medicine Research Contest, Dr. Jose R. Reyes Memori al Medical Center. **Chief Resident, ***Consultant in Infectious Diseases, ****Resident, Department of Medi cine, Dr. Jose R. Reyes Memorial Medical Center, Taft Avenue Manila, and *****Chief resident, Department of Patho logy and Laboratory, FEUNRMF, Morayta St, Manila) ABSTRACT Limited information is available on how physicians perform the important process es of care on the management of patients with community-acquired pneumonia. A non-concurrent cohort study was done to assess the quality of care rendered to pneumonia patients admitted in a tertiary government hospital, using quality indicators based on th e latest Philippine clinical practice guidelines on the diagnosis, empiric management and prevention of community acqu ired pneumonia in immunocompetent adults and the study of Meehan, et al. and correlate these indic ators with in-hospital mortality. This study reviewed the medical charts of 153 adult patients admitted to the Dr. Jose R. Reyes Memorial Medical Center with primary or secondary diagnosis of community-acquired pneumon ia from January 1 to December 31, 2000. Of the total 153 potential pneumonia cases, 85 patients (55.6%) were left with c onfirmed diagnosis of pneumonia. Quality indicator performance were appropriateness of home medication s, 94.3%; oxygenation assessment within 24 hours of hospital arrival, 80%; correctness of risk stratification, 71 .8%; performance of sputum studies (gram stain, culture and sensitivity), 71.8%; blood culture collection within 24 hours of hospital arrival, 42.4%; blood culture collection before initial hospital antibiotics, 38.8%; antibiotic administration within 8 hours of hospital arrival, 35.3% and appropriateness of empiric antibiotic therapy, 9.4%. No patient was admitted to the medical ICU. Higher rate of inhospital mortality was noted with failure of antibiotic administration within 8 hours of hospital arrival (p-value=0.0252) and oxygenation assessment within 24 hours of hospital arrival (p-value=0.00002) . Poor performance of process of care was noted in the following: appropriateness of empiric antibiotic therapy, ICU admission when indicated, blood cultures before initial hospital an tibiotic, blood cultures within 24 hours of hospital arrival, antibiotic administration within 8 hours of hospital arriva l, and immunization for selected patients.

Good performance was noted with the following quality indicators: sputum studies , risk stratification, appropriateness of home medications, and oxygenation assessment within 24 hours of hospital arri val. Failure to administer initial antibiotics within 8 hours of hospital arrival and assessment of oxygenation wit hin 24 hours of hospital arrival were associated with increased in-hospital mortality. (Phil J Microbiol Infect Dis 20 01; 30(3):87-93) Key words: Community-acquired pneumonia, quality of care INTRODUCTION Pneumonia is one of the most common infectious diseases treated in the ambulator y and hospital setting.1 In the United States, pneumonia is consistently placed among the top 10 causes of mortality among hospitalized patients. It is the fourth leading cause of morb idity and third leading cause of mortality among Filipinos based on the 1994 Philippine Health S tatistics from the Department of Health.2 In Dr. Jose R. Reyes Memorial Medical Center (JRRMMC) , pneumonia is the leading cause of morbidity (Rate-19.7%) and mortality (Case Fat ality Rate20.5%) among patients admitted at the medical ward.3 With the increasing cost of medical care and the recent cuts on the budget of th e Department of Health, it is necessary to ensure that medical economics is balanc ed by good medical care. Substandard care generally results from poor process design, inade quate information and poor training, rather than from stupidity, indifference or greed .4 Evaluation of the quality of care rendered to patients with different disease conditions and in va rious settings is

important to assess the performance of the health care provider and determine th e effectiveness of management and institute measures to improve our institution's service to patien ts. To address this issue, several guidelines for common diseases were developed ove r the last few years. In the Philippines, one such guideline is the clinical practice guidelines (CPG) in the diagnosis, empiric management and prevention of community-acquired pneumonia (CAP) in immunocompetent adults.5 The purpose of the guideline is to provide physicians w ith a rational approach to the management of community acquired pneumonia. It was developed bas ed on the recognition that despite proliferation of newer antibiotics, diagnostic technolo gy and therapeutic modalities, there is still considerable morbidity and mortality from this condit ion.5 A couple of studies were done to assess the quality of care given to these patie nts. One such study is that of Meehan, where four quality indicators of care were used ba sed on Medicare Quality Indicator System (MQIS) pneumonia module.6 They analyzed the association of these quality indicators with in-hospital and 30-day mortality using multiple logistic regression analysis and concluded that administration of antibiotics within 8 hours of hospital arri val and collection of blood cultures within 24 hours were associated with improved survival. At lea st two local studies were done at the Philippine General Hospital. Sandoval used quality indi cators based on the Philippine Clinical Practice Guidelines on community acquired pneumonia.7 Pe reyna used quality indicators from the study of Meehan.8 In these articles however, the aut hors failed to analyze the impact of the process of care measures used with the outcome (e.g. m ortality). This study generally aimed to evaluate the quality of care rendered to community acquired pneumonia patients admitted to medical ward. Specifically, we assessed the quality of care rendered using quality indicators based on the latest Philippine Clinical P ractice Guidelines on community-acquired pneumonia (1998) and the study of Meehan. We also determin ed the impact of the quality indicators used by Meehan on acute-care-outcome. By doing this audit, physicians and other health care providers of the hospital might have better awa reness of their performance. MATERIALS AND METHODS Study Design

Non-concurrent cohort Selection of Subjects Patients admitted and discharged with principal or secondary diagnosis of commun ity acquired-pneumonia from Jan 1, 2000 to Dec 31, 2000 were eligible for the study. After potential cases were identified, data were extracted from the medical records to confirm t he pneumonia diagnosis and to apply exclusion criteria. Case confirmation required that patie nts should have an appropriate ICD-9-CM code (International Classification of Disease, Ninth Editio n, Clinical Modification), that a clinician documents an initial working diagnosis of pneumo nia, and that a chest x-ray examination, performed within the first 48 hours of hospitalization be reported as consistent with pneumonia, defined as new findings using any of the following te rms: pneumonia, air bronchogram, air space disease, consolidation, infiltrate, inflammation, opa city or pneumonitis. Patients were excluded if they were younger than 18 years, had expe rienced acute care hospitalization within 10 days, were infected with the human immunodeficien cy virus, had history of organ transplant, had been exposed to chemotherapy or immunosuppressi ve therapy within the previous 2 months, or had died or was discharged within 24 hours of a dmission. Data Collection

A medical record abstraction instrument for data collection was developed based on the Philippine clinical practice guidelines and on the study of Meehan. The data col lection form was divided into two parts: the first contained pertinent information on patient's c linical profile and the second included questions on the audit criteria. Two of the researchers abstracted the data from the medical charts, with the thi rd acting as an arbiter, in cases of conflict in the gathered (e.g. time from hospital arr ival to initial antibiotic administration) data. Data Elements Four categories of variables were used in this study: case confirmation and excl usion criteria indicators (previously listed), severity of illness indicators, process of care and outcomes of care. Severity-of-illness variables included demographic (age, sex), co-morbid illnes ses (diabetes mellitus, cancer, neurological disease, congestive heart failure, rena l insufficiency, chronic obstructive pulmonary disease, chronic liver disease/cirrhosis, and chro nic alcohol abuse), physical examination findings (abnormal mental status, temperature, hear t rate, respiratory rate, systolic and diastolic blood pressures), and laboratory values or test results (blood culture, blood urea nitrogen, white blood cell count, arterial pH, partia l pressure of oxygen, multilobar/bilateral pulmonary infiltrates and pleural effusion). Quality indicators are measures of care that are clearly linked to improved outc omes by clinical trial, can be measured through existing data sources, and are objective ly quantifiable. A quality indicator is expressed as ratio with the denominator defined as "all pat ients eligible to receive care" and the numerators as "all patients who actually received care." All patients who actually received care Quality Index = All patients eligible to receive care The quality of care indicators we used were those evaluated by Meehan who used f our measures of the process of care.6 These were based on the Medicare Quality Indic ator System (MQIS) pneumonia module. The MQIS is a standardized data collection system devel oped to assess the quality of care for hospitalized patients with specific clinical cond itions. The quality indicators in the study of Meehan were the following:

1. antibiotic administration within 8 hours of hospital arrival; 2. blood culture collection before initial hospital antibiotic; 3. blood culture collection within 24 hours; 4. oxygenation assessment within 24 hours of hospital arrival. Also included as indicators of quality of care in this study were correctness of risk stratification, ICU admission when indicated, performance of sputum studies (gra m stain, culture and sensitivity), appropriateness of the empiric antimicrobial therapy given, an d discharge planning (home medications given, pneumococcal and/or influenza immunizations fo r selected patients). Some of these variables were included in the recommendations of the p ractice guidelines, while others have been found to predict poor outcome by several stud ies.9,10 Outcome-of-care variables used were: discharged improved, home per request (HPR) , home against medical advice (HAMA), transfer to hospital of choice (THC), abscon ded, and expired. Additional information was also gathered regarding occurrence of compli cations (organ failure, septic shock and hospital-acquired pneumonia) and length of hospital st ay.

Statistical Analysis All data were entered into a database using Epi-Info Version 6.0. Data were anal yzed using frequency, means, chi-square and Fisher's exact test. In the analysis of q uality indicators in relation to outcome, subjects who went HAMA, home per request, and transferred t o hospital of choice were regarded as mortality. RESULTS A total of 153 potential pneumonia cases were abstracted. Using the above mentio ned exclusion criteria, 27 patients (17.6%) were excluded. Reasons for exclusion wer e the following: died or discharged on the date of admission (21 patients), had chemotherapy or immunosuppression treatment within 2 months (5 patients) and experienced acute c are hospitalization within 10 days (1 patient). Case confirmation using the ICD-9 CM code rendered 41 patients (26.8%) unqualified. A total of 85 patients (55.6%) were left with c onfirmed diagnosis of pneumonia. Table 1 shows the demographic and clinical characteristics of all the evaluated patients. Mean age was 58.04: on average, women were older than men (55.92 vs 52.11). The most common co-morbid illness was congestive heart failure, followed with DM, chronic liver disease and CNS disease. Forty-four (51.8%) patients had at least one co-morbid illness. There were 16 patients with multiple co-morbid illnesses (two or more). Common physical findin gs on admission were tachypnea (RR>30/min), systolic blood pressure of 100 mmHg and le ss, fever and abnormal mental status. Elevation of blood urea nitrogen levels, hypoxemia a t room air, and multilobar/bilateral pulmonary infiltrates were the most common laboratory abnor malities occurring in 20%, 17.6% and 11.8%, respectively. Table 1. Demographic data and clinical characteristics (n=85) Demographics N % Age Mean 58.047 Sex: Female 48 56.5 Male 37 43.5 Co-morbid illness Congestive heart failure 11 12.9 Diabetes mellitus 7 8.2 Chronic liver disease 6 7.1 CNS disease 6 7.1 COPD 4 4.7 CA 4 4.7 Chronic alcohol abuse 3 3.5 Renal insufficiency 3 3.5 Physical Examination findings

Abnormal mental status 9 10.6 Respiratory rate of = 30 breaths/min. 14 16.5 Pulse rate = 125/min. 6 7.1 SBP = 90 mmHG 1. 11.8 DBP < 60 mmHg 6 7.1 Temperature > 38.3oC 9 10.6 Laboratory and radiographic results Bacteremia (positive blood culture) 1 1.2 BUN > 7 mmol/L WBC <4.0 or > 30x109/L PaO2 <60 mm Hg 17 5 15 20.0 5.9 17.6 Multilobar/bilateral pulmonary infiltrates 10 11.8 Pleural effusion 7 8.2

Correct risk stratification was made in 65/85 patients yielding a QI of 76.5%. O f those incorrectly stratified, 18.8% (16/85) were under-stratified and 4.7% (4/85 ) were given higher stratification. Low risk patients were admitted because of co-morbid illn esses. No patient was admitted under minimal risk (Table 2). Table 2. Risk stratification (n=85) Minimal Risk I Low Risk II Moderate Risk III High Risk IV Correct Incorrect Correct Incorrect Correct Incorrect Correct Incorrect 0 0 4 5 42 13 19 2 Quality indicator (QI) performance was higher for oxygenation assessment within 24 hours of hospital arrival (80%), followed by correctness of risk stratification (76.5%), and performance of sputum gram stain, culture and sensitivity (71.8%). More than hal f of the study population was already given the initial hospital antibiotic before collection o f specimen for blood cultures (Table 3). Among the 21 patients stratified as high risk, none we re admitted to the ICU. Table 3. Performance of quality indicators Quality Indicator Q/I % Correct risk stratification based on CPG 65/85 76.5 ICU admission 0/21 Appropriateness of empiric therapy given 8/85 9.4 Performance of sputum g/s 61/85 71.8 MQIS quality indicators used by Meehan Blood culture collection before initial hospital antibiotic 33/85 38.8 Blood culture collection within 24 hours of hospital arrival 36/85 42.2 Oxygenation assessment within 24 hours of hospital arrival 68/85 80.0 Antibiotic administration within 8 hours of hospital arrival 30/85 35.3 Discharge planning Appropriateness of home medications 50/53 94.3 Immunizations for selected patients 0/26 Discharge planning for patients who were sent home improved yielded high QI for appropriateness of home medications given (94.3%). Patients who were at risk of recurrent pneumonia were not advised pneumococcal and/or influenza immunization upon disch arge. The most common complication noted was septic shock followed by respiratory fail ure. There was one patient who developed hospital-acquired pneumonia (Table 4). Table 4. Frequency of complications of CAP during the clinical course Complication Frequency Died Discharged improved

N % N % Respiratory failure 8/85 7 8.2 1 1.2 Hospital-acquired pneumonia 1/85 1 1.2 0 Septic shock 9/85 6 7.1 1 1.2 The mean duration of hospitalization is 7.3 days. Sixty two percent of the patie nts were discharged improved. The rates of complication and mortality were the same (20%) (Table 5). More deaths occurred among patients with high-risk stratification. Majority of p atients who went HAMA and home per request had severe pneumonia. The primary reason for going home was economics. There was no mortality noted in low risk patients though one patient went home per request (Table 6).

Table 5. Summary of outcomes Outcome Q/I % Complication rate 17/85 20 Mean duration of hospitalization 7.3 days Mortality rate 17/85 20 Discharged improved 53/85 62.4 Others 15/85 17.7 Table 6. Summary of outcomes by risk stratification Outcome Risk stratification Discharged improved HAMA HPR THC Expired Total Low risk 8 0 1 0 0 9 Moderate risk 40 5 2 2 6 55 High risk 5 5 0 0 11 21 Total (%) 53 (62.4) 10 (11.8) 3 (3.%) 2 (2.4) 17 (20) 85 Table 7 shows the relationship of performance of process of care to in-hospital mortality. Failure of initial antibiotic administration within 8 hours of hospital arrival and assessment of oxygenation within 24 hours of hospital arrival were significantly associated wi th increased inhospital mortality. Table 7. Relationship of performance of QI (%) to in-hospital mortality MQIS quality indicators used by Meehan Mortality Discharged/Improved p value QI % QI % Blood culture collection before initial hospital antibiotic 15/32 46.9 18/53 34. 0 0.213 Blood culture collection within 24 hours of hospital arrival 17/32 53.1 19/53 35 .8 0.054 Oxygenation assessment within 24 hours of hospital arrival 29/32 90.6 38/53 71.7 0.0252* Antibiotic administration within 8 hours of hospital arrival 2/32 6.25 28/53 52. 8 0.00002* *Significant DISCUSSION Out of the 153 patients initially abstracted, only 85 subjects were used in this study. The disqualified subjects included 41 patients who did not meet the case confirmatio n criteria set by ICD-9 CM code. This result implies that several patients are being treated as a case of pneumonia without proper confirmation, giving us the impression that this disease entity i s being over-

diagnosed. The clinical characteristics of subjects in this study differ in some degree fro m that of Sandoval. The most common co-morbid illness in this study is congestive heart fa ilure (12.9%) while neoplasm was the most common in Sandoval.7 In this study, the quality indicator performance was low when compared to that o f Meehan.6 The most commonly accomplished process of care was oxygenation assessme nt within 24 hours of hospital arrival. The performance of quality indicator was poor in b lood cultures before antibiotic administration, blood cultures within 24 hours of hospital arr ival, and antibiotic administration within 8 hours of hospital arrival. This is critical because fail ure to perform the last two QI's was proven to be associated with increased mortality.6 This is a good a rea for improvement in the performance of residents, nurses and laboratory personnel. Th e hospital laboratory has an inconsistent policy regarding blood culture collection at the emergency room. For the quality indicators based on the Philippine clinical practice guidelines, the performance was generally poor. Conformity with CPG s has been low as shown in pre vious

studies.7,8,9 For this study, the only quality indicators with good performance were risk stratification and appropriateness of home medications. Performance of sputum st udies was comparable to the study made by Sandoval (71.8% vs. 74%),7 though the latest gui delines do not recommend its routine use.5 Performance of one quality indicator did not predict performance of the others. This is evident by the correct risk stratification of the majority o f patients (76.5%) but only 9.4% (8 patients) received appropriate empiric antibiotic therapy. Majority of high-risk patients were given ceftazidime intravenously (IV) and an oral macrolide. This i s in contrast with the recommendation of the guidelines that these patients should receive IV macro lide (e.g. erythromycin). This is primarily due to the unavailability of IV macrolide in th e hospital pharmacy. No patient was admitted to the medical intensive care unit (MICU). This is due t o the Medicine Department policy that MICU admission should prioritize cardiac and not infectious cases. The medical ICU has only 5 beds with 1 or 2 nurse/s on duty per 8-hour sh ift. The rate of complication parallels that of in-hospital mortality (20% vs. 20%). Majority of patients who had complications expired (15 of 17 patients). Fifteen patients (17.7%) went HAMA, home per request, transferred to other hospital or absconded. The main rea son for going home was economics. Indigent or charity patients in our institution are alloted five thousand pesos each. This amount however is not enough to sustain the expenses for the en tire duration of hospitalization. Pneumococcal and/or influenza immunization was not given nor advised to appropri ate patients upon discharge. There was however, good performance of process of care regarding appropriateness of home medication given. This brings into question the resident s knowledge of pneumonia prevention as recommended by the guidelines. Upon analysis, there was a significant association between failure of antibiotic administration within 8 hours of hospital arrival, oxygenation assessment within 24 hours of hospital arrival and increased in-hospital mortality. These results emphasize th e importance of early antibiotic administration to patients' improvement, and confirmed the find ing in the study of Meehan.6 The decision of performing oxygenation assessment by pulse oximetry or arterial blood gas (ABG) lies on the resident's clinical judgement. Mortality rate increases wi th oxygenation

assessment. This result implies that medical residents performed ABG or pulse ox imetry to those patients whom they think were in need of oxygen supplementation and therefore hi gh risk. CONCLUSION This study showed poor performance of the following quality indicators: 1. 2. 3. 4. 5. 6. Appropriateness of empiric antibiotic therapy. ICU admission when indicated. Blood cultures before initial hospital antibiotic. Blood cultures within 24 hours of hospital arrival. Antibiotic administration within 8 hours of hospital arrival. Immunization for selected patients (e.g. pneumococcal and influenza vaccine).

Good performance was noted in the following quality indicators: 1. Sputum studies 2. Risk stratification based on CPG. 3. Appropriateness of home medications. 4. Oxygenation assessment within 24 hours of hospital arrival. Failure to administer initial antibiotics within 8 hours of hospital arrival and oxygenation assessment within 24 hours of hospital arrival was associated with i ncreased mortality.

RECOMMENDATIONS 1. Medical residents should have good knowledge of the Philippine clinical practice guidelines on the diagnosis, empiric management and prevention of community-acquired pneumo nia in immunocompetent adults. 2. A reevaluation of the currently available antibiotics in the hospital pharmacy b e undertaken by the therapeutics committee taking into account the recommended antibiotics in the guidelines. 3. More beds in the medical intensive care unit (MICU) are necessary to accommodate high-risk pneumonia patients. A separate medical ICU for non-coronary patients may then be a better option to reduce the risk of transmission of infectious agents. 4. More studies assessing quality of care to CAP patients involving more subjects i s recommended. REFERENCES 1. Garibaldi RA. Epidemiology of community-acquired respiratory tract infection in adults: incidence, etiology and impact. Am J Med 1985; 78: 32-37. 2. From the Philippine Health Statistics, Department of Health, 1994. 3. From the Dr. Jose R. Reyes Memorial Medical Center - Department of Medicine Reco rds, 1999. 4. Jenks SF, Wilensky GR. The health care quality improvement initiative. JAMA 1992 ; 268: 900-903. 5. Task Force on Community-acquired Pneumonia. The Philippine Clinical Practice Guidelines on the Diagnosis, Empiric Management and Prevention of Community-Acquired Pneumonia in Immunocompetent Adults, 1999. 6. Meehan TP, Fine MJ, Krumholz HM, et al. Quality of care, process and outcomes in elderly patients with pneumonia. JAMA 1997; 278: 2080-2084. 7. Sandoval J, Soriano A. Quality of care for patients with community-acquired p neumonia at the Philippine General Hospital Department of Medicine, 2000. Book of Abstracts, Philippine Col lege of Physicians 31st Annual Convention, 95:89. 8. Pereyna JL, Sison EO. Assessment of quality of care given to elderly patients with community acquired pneumonia in Philippine General Hospital, 2000. (Unpublished) 9. Panaligan MM, Alcantara MF, Pea AC. Management of community-acquired pneumonia among in-patients in a teaching hospital: Adherence to the American Thoracic Society Guidelines. P hil J Microbiol Infect Dis 1998; 27:55-61. 10. Fine MJ, Singer DE, Hanusa BH, Lave JR, Kappor WN. Validation of pneumonia p

rognostic index using the medisgroups comparative hospital database. Am J Med 1993; 94:153-159. 11. Fine MJ. Process and outcomes of care for patients with community-acquired p neumonia. Arch Intern Med 1999; 159: 970-980. 12. Blumenthal D. Quality of health care, part I: Quality of health care - What is it? N Engl Med 1996; 335:891893.