Resource Utilization of Adults Admitted to a Large Urban Hospital With Community-Acquired Pneumonia Caused by Streptococcus pneumoniae: Summary
Excluding those patients who died, median length of stay was 2 days longer in patients who met our definition of delayed discharge. If patients were discharged within 1 day of meeting our clinical definition and receiving oral antibiotic therapy, the median length of stay for these 88 patients would have been 3 days (range, 2 to 6.75 days), with an estimated savings of approximately $507,000. These potential savings are likely underestimated given there was often a delay between IV-to-oral transition and the first day of stable clinical criteria; furthermore, we conservatively used the later day to define discharge eligibility. Our study was conducted at a single hospital, and while our patient population is likely similar to other large urban hospitals in the United States, one study has documented the distinct differences in clinical criteria used by physicians from institution to institution to determine when patients are stable for discharge, which may have influenced the impact of this variable. Additionally, clinical outcomes have not been adversely affected by decreases in length of stay (ie, discharge once patients are clinically stable without observation), suggesting that patients with CAP admitted to hospitals with historically long lengths of stay might be treated just as effectively with shorter hospital stays. It is important to note the limitations in attempting to define this variable retrospectively.
Although there was no affect of age, comorbid illness, or PSI score, prolonged lengths of stay in these patients may be a reflection of numerous other factors in addition to defervescence, WBC normalization, and time to oral transition. Specifically, social issues and physician preferences, which cannot be accounted for in any severity of illness score, are important factors and difficult to account for given this study design. Nevertheless, given the significant impact that this defined variable had on our model, it will be sensible for us to further evaluate criteria for discharge within our institution and determine if changes in practice or discharge management can be addressed to reduce length of stay for CAP.
In conclusion, at our large, urban hospital, we observed that hospital bed costs accounted for > 50% of the total cost of care for patients admitted with CAP due to S pneumoniae. Admission to an ICU, neoplasm, and an unexplained delay in discharge were independently associated with both total hospital costs and increased length of stay; therefore, focused efforts to reduce total and ICU length of stay, including minimizing prolonged and unnecessary observation of patients, should have the most profound effect on reducing total costs. Finally, in the current era in which more potent antibiotics are empirically utilized to treat CAP, it does not appear that a simple classification of penicillin nonsusceptibility complicates the clinical or economic impact of S pneumoniae infection.