A controlled trial of a critical pathway for treatment of community-acquired pneumonia

Context Large variations exist among hospitals in the use of treatment resources for community-acquired pneumonia (CAP). Lack of a common approach to the diagnosis and treatment of CAP has been cited as an explanation for these variations. Objective To determine if use of a critical pathway improves the efficiency of treatment for CAP without compromising the well-being of patients. Design Multicenter controlled clinical trial with cluster randomization and up to 6 weeks of follow-up. Setting Nineteen teaching and community hospitals in Canada. Patients A total of 1743 patients with CAP presenting to the emergency departmental 1 of the participating institutions between January 1 and July 31, 1998. Intervention Hospitals were assigned to continue conventional management (n = 10) or implement the critical pathway (n = 9), which consisted of a clinical prediction rule to guide the admission decision, levofloxacin therapy, and practice guidelines. Main Outcome Measures Effectiveness of the critical pathway, as measured by health-related quality of life on the Short-Form 36 Physical Component Summary (SF-36 PCS) scale at 6 weeks; and resource utilization, as measured by the number of bed days per patient managed (BDPM). Results Quality of life and the occurrence of complications, readmission, and mortality were not different for the 2 strategies; the 1-sided 95% confidence limit of the between-group difference in the SF-36 PCS change score was 2.4 points, which was within a predefined 3-point boundary for equivalence. Pathway use was associated with a 1.7-day reduction in BDPM (4.4 vs 6.1 days; P = .04) and an 18% decrease in the admission of low-risk patients (31 % vs 49 %; P = .01). Although inpatients at critical pathway hospitals had more severe disease, they required 1.7 fewer days of intravenous therapy (4.6 vs 6.3 days; P = .01) and were more likely to receive treatment with a single class of antibiotic (64% vs 27%; P < .001). Conclusion In this study, implementation of a critical pathway reduced the use of institutional resources without causing adverse effects on the well-being of patients.