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Abstract & commentary
Synopsis: Among hospitalized patients with community-acquired pneumonia, major cost savings accrued from early hospital discharge, rather than from other interventions such as changing from the intravenous to the oral route of antibiotic administration.
Source: Fine MJ, et al. Relation between length of hospital stay and
costs of care for patients with community-acquired pneumonia.
Am J Med 2000;109:378-385.
Fine and colleagues report economic and outcomes in-formation for patients treated at three different hospitals for community-acquired pneumonia. The data come from the Pneumonia Patient Outcomes Research Team (PORT) studies and were collected at two university hospitals (1 in Pittsburgh, the other in Boston) and a community hospital (in Pittsburgh). Nine hundred eighty-two patients were enrolled. Of those, 863 were included after the outliers were eliminated (those who died or spent > 30 days in the hospital). Fifty-five percent of patients were 65 years of age or older. Charge information was obtained from bills submitted to Medicare.
The mean stay in the hospital was seven days with an average charge of $5492, or $836 per day. Further analysis indicated the first day was the most expensive, largely because of the pharmacy, laboratory, and radiology services. Emergency department services were also included in the overall charges. The median hospital room charge for the three hospitals was $491, or 59% of total charges. The room rates varied from $398 to $540 (both university hospitals). Nonroom charges included $122 per day for laboratory tests, $67 per day for pharmacy and intravenous (IV) solutions, $48 per day for radiology tests and procedures, $65 for "other" services, and $43 for the emergency department services.
The university teaching hospital in Pittsburgh had the highest charges ($7341) whereas the private hospital was $5397 even though the stay was a little longer (mean, 9.4 vs 8.4 days; median, 8 vs 7 days). Patient populations and outcomes were the same. The patterns of medical evaluation and treatment were similar among the institutions. The differences in charges suggest there are opportunities to make the care of community-acquired pneumonia more cost-efficient in some hospitals.
When Fine et al examined actual billed charges they found an average of $680 could be saved if patients were discharged one day earlier and $1408 if it was two days earlier. Since the patients were a low-risk group for 30-day mortality, it was concluded that efforts should be made to save money through shortening hospital stay.
COMMENT by Alan D. Tice, MD, FACP
The PORT investigators continue to mine their data and have come up with some interesting information, even though it is getting less relevant. The seven-day hospital stay from 1991-1994 is no longer acceptable. Hospital stays have fallen substantially since then. A recent study suggests two or three days of hospital care is all that is needed to reach clinical stability and that earlier discharge can be achieved without a reduction in clinical outcome.1-3
The first day in the hospital is clearly the most expensive with a cost equivalent to nearly three other days. The cost benefits of earlier hospital discharge are clear, although they diminish with each additional day. Any progress that can be made to avoid hospitalization altogether would certainly be a cost savings as well. Fine et al have already reported some of the advantages of avoiding admission—including a more rapid return to work and activities of daily living—but it has been reported only in abstract form.4
It is also interesting to note what the hospital charges for the care of pneumonia are. The majority are not for medical evaluation (17% of charges) or treatment (7% of charges), but rather housing, at a rate of $491 per day. This is more than an ocean view room at the Hilton Hawaii ($340/d) with a king-sized bed during peak season. While the Hilton may not be appropriate for the patients with severe disease or at high risk for 30-day mortality by Fine et al’s criteria, it may be for the low-risk patients.
The report brings to light how much money can be saved by treating patients with community-acquired pneumonia as outpatients rather than inpatients. Fine et al have previously analyzed why the opportunities for outpatient care have not been better used. The reasons they have found responsible for unnecessary admissions and unneeded hospital stays have included a lack of available home and ambulatory care IV antibiotic therapy resources in the community, delayed diagnostic services in the hospital, and slow discharge planning.5,6 On the other hand, patients are quite happy to avoid hospital stays and prefer home care.7
The concept of outpatient parenteral antimicrobial therapy for community-acquired pneumonia has also seemed to elude the recently published IDSA guidelines for community-acquired pneumonia, which suggest the route of antibiotic therapy should be based on whether the patient needs to be hospitalized, not the severity of illness or the infection being treated.8
These figures also challenge the usual focus on the costs of IV antibiotics—which commonly comprise less than 10% of the average daily charges—and bring into question the value of in-hospital switch to oral antibiotics, compared with shortening hospital stay by a day ($836) or even an hour ($34.83), if charges are strictly accounted for by time.
The major fault in the article and in the design of the study is that only billed Medicare charges were examined. The thought that these reflect actual costs is unrealistic. That they reflect actual payments for services is even more remote. Charges and payments for private insurers and Medicaid would be different. It is, nevertheless, helpful to see some actual dollar figures related to care in the medical literature and to get an idea of the relative costs and charges for different aspects of care. The actual charges of a day in the hospital in a standard room are more likely on the order of $1000 per day (American Hospital Association says $1063/d for an average bed as of 1998).
The PORT team again brings us useful, practical, and insightful information from the huge database they have developed. They have previously documented the value of outpatient therapy and the reluctance of doctors to prescribe it, and the interest in patients in receiving it. We look forward to more of their information and insight.
1. Halm EA, et al. Time to clinical stability in patients hospitalized with community-acquired pneumonia. JAMA 1998;279:1452-1457.
2. Siegel RE, et al. A prospective randomized study of inpatient intravenous antibiotics for community-acquired pneumonia: The optimal duration of therapy. Chest 1996;105:1109-1115.
3. McCormick D, et al. Variation in length of hospital stay and its relation to medical outcomes in patients with community-acquired pneumonia. Am J Med 1999;107:5-12.
4. Fine MJ, et al. Medical outcomes of ambulatory and hospitalized low risk patients with community-acquired pneumonia. J Gen Int Med 1994;9(suppl 2):29A.
5. Fine MJ, et al. The hospital admission decision for patients with community-acquired pneumonia. Arch Intern Med 1997;157:36-44.
6. Fine MJ, et al. The hospital discharge decision for patients with community-acquired pneumonia. Arch Intern Med 1997;157:47-56.
7. Coley MC, et al. Preferences for home vs. hospital care among low-risk patients with community-acquired pneumonia. Arch Intern Med 1996;156:1565-1571.
8. Bartlett JG, et al. Practice guidelines for the management of community-acquired pneumonia in adults. Clin Infect Dis 2000;31(2):347-382.