Annals of Emergency Medicine
Volume 59, Issue 1 , Pages 35-41, January 2012

Hospital Admission Decision for Patients With Community-Acquired Pneumonia: Variability Among Physicians in an Emergency Department

Presented as an abstract at the American Thoracic Society International Conference, May 2010, New Orleans, LA; and the Society of Academic Emergency Medicine Conference, June 2010, Phoenix, AZ.

  • Nathan C. Dean, MD

      Affiliations

    • Pulmonary and Critical Care Medicine Division at Intermountain Medical Center and the University of Utah, Salt Lake City, UT
    • Corresponding Author InformationAddress for correspondence: Nathan C. Dean, MD
    • ,
  • Jason P. Jones, PhD

      Affiliations

    • Kaiser Permanente Los Angeles, Los Angeles, CA
    • ,
  • Dominik Aronsky, MD, PhD

      Affiliations

    • Vanderbilt Hospital Department of Biomedical Informatics and Emergency Medicine, Nashville, TN
    • ,
  • Samuel Brown, MD, MS

      Affiliations

    • Pulmonary and Critical Care Medicine Division at Intermountain Medical Center and the University of Utah, Salt Lake City, UT
    • ,
  • Caroline G. Vines, MD

      Affiliations

    • Department of Emergency Medicine at the University of Utah, Salt Lake CIty, UT
    • ,
  • Barbara E. Jones, MD

      Affiliations

    • Pulmonary and Critical Care Medicine Division at Intermountain Medical Center and the University of Utah, Salt Lake City, UT
    • ,
  • Todd Allen, MD

      Affiliations

    • Department of Emergency Medicine at the University of Utah, Salt Lake CIty, UT
    • Department of Emergency Medicine at LDS Hospital and Intermountain Medical Center, Salt Lake City, UT

Received 25 January 2011; received in revised form 19 May 2011 and 11 July 2011; accepted 25 July 2011. published online 12 September 2011.

Study objective

We examine variability among emergency physicians in rate of hospitalization for patients with pneumonia and the effect of variability on clinical outcomes.

Methods

We studied 2,069 LDS Hospital emergency department (ED) patients with community-acquired pneumonia who were aged 18 years or older during 1996 to 2006, identified by International Classification of Diseases, Ninth Revision coding and compatible chest radiographs. We extracted vital signs, laboratory and radiographic results, hospitalization, and outcomes from the electronic medical record. We defined “low severity” as PaO2/FiO2 ratio greater than or equal to 280 mm Hg, predicted mortality less than 5% by an electronic version of CURB-65 that uses continuous and weighted elements (eCURB), and less than 3 Infectious Disease Society of America-American Thoracic Society 2007 severe pneumonia minor criteria. We adjusted hospitalization decisions and outcomes for illness severity and patient demographics.

Results

Initial hospitalization rate was 58%; 10.7% of patients initially treated as outpatients were secondarily hospitalized within 7 days. Median age of admitted patients was 63 years; median eCURB predicted mortality was 2.65% (mean 6.8%) versus 46 years and 0.93% for outpatients. The 18 emergency physicians (average age 44.9 [standard deviation 7.6] years; years in practice 8.4 [standard deviation 6.9]) objectively calculated and documented illness severity in 2.7% of patients. Observed 30-day mortality for inpatients was 6.8% (outpatient mortality 0.34%) and decreased over time. Individual physician admission rates ranged from 38% to 79%, with variability not explained by illness severity, time of day, day of week, resident care in conjunction with an attending physician, or patient or physician demographics. Higher hospitalization rates were not associated with reduced mortality or fewer secondary hospital admissions.

Conclusion

We observed a 2-fold difference in pneumonia hospitalization rates among emergency physicians, unexplained by objective data.

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 Supervising editor: Gregory J. Moran, MD

 Author contributions: NCD was involved in all aspects of this study. JPJ performed the statistical analysis. DA conceived the original idea for this study and laid the groundwork for it and has reviewed the data, conclusions, and article extensively. SB and BEJ worked extensively to develop the ED pneumonia database. SB, CGV, BEJ, and TA revised the article. CGV and TA played important roles in interpreting the data and presented the work at the Society of Academic Emergency Medicine Conference. NCD takes responsibility for the paper as a whole.

 Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). This work was supported by a grant from the Deseret Foundation, Salt Lake City, UT. Dr. Brown received NIH career development grant 5K23GM094465.

 Publication date: Available online September 10, 2011.

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 Please see page 36 for the Editor's Capsule Summary of this article.

PII: S0196-0644(11)01404-1

doi:10.1016/j.annemergmed.2011.07.032

Annals of Emergency Medicine
Volume 59, Issue 1 , Pages 35-41, January 2012

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