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Management of Pneumonia in the Prospective Payment Era: A Need for More Clinician and Support Service Interaction

Management of Pneumonia in the Prospective Payment Era: A Need for More Clinician and Support... Abstract • We compared the diagnostic and therapeutic management of pneumonia during 1970 and 1971 with that during 1979 and 1980 in clinically similar populations at The Johns Hopkins Hospital, Baltimore. More patients received aminoglycoside and cephalosporin therapy during 1979 and 1980. Guidelines for the use of chest roentgenograms and cultures were exceeded in 14% to 24% of cases. Patients whose cases were judged to be suboptimally managed had significantly higher charges and length of stay. Aged patients and those requiring thoracentesis also used resources more intensively. Given the technologic explosion, clinicians cannot know the performance characteristics of all tests and medications they can order. To minimize inefficient and ineffective practices, it is essential that clinicians and support service directors develop guidelines for testing and antibiotic use. Deviations should trigger timely interventions. Management under prospective payment will also require identifying specific patient subgroups to verify appropriate utilization and to assure equitable reimbursement. (Arch Intern Med 1984;144:1392-1397) References 1. Kinzer D, Warner M: The effect of case-mix adjustment on admission-based reimbursement. Health Ser Res 1983;18:209-225. 2. Fetter RB, Shin Y, Freeman JL, et al: Case-mix definition by diagnosis-related groups. Med Care 1980;18( (suppl) ):1-53. 3. Moore MA, Merson MH, Charache P, et al: The characteristics and mortality of outpatient-acquired pneumonia. Johns Hopkins Med J 1977;140:9-14. 4. White RJ, Blainey AD, Harrison KJ, et al: Causes of pneumonia presenting to a district general hospital. Thorax 1981;36:566-570.Crossref 5. Sullivan RJ, Dowdle WR, Marine WM, et al: Adult pneumonia in a general hospital etiology and host risk factors. Arch Intern Med 1972;129:935-942.Crossref 6. Ebright JR, Rytel MW: Bacterial pneumonia in the elderly. J Am Geriatr Soc 1980;28:220-223. 7. Mufson MA, Chang V, Gill V, et al: The role of viruses, mycoplasmas and bacteria in acute pneumonia in civilian adults. Am J Epidemiol 1967;86:526-544. 8. Dorff GJ, Rytel MW, Farmer SG, et al: Etiologies and characteristic features of pneumonias in a municipal hospital. Am J Med Sci 1973;266: 349-358.Crossref 9. Fiala M: A study of the combined role of viruses, mycoplasmas and bacteria in adult pneumonia. Am J Med Sci 1969;257:44-51.Crossref 10. MacFarlane JT, Finch RG, Ward MJ, et al: Hospital study of adult community-acquired pneumonia. Lancet 1982;2:255-258.Crossref 11. Rein MF, Gwaltney JM Jr, O'Brien WM, et al: Accuracy of Gram's stain in identifying pneumococci in sputum. JAMA 1978;239:2671-2673.Crossref 12. Merrill CW, Gwaltney JM Jr, Hendley JO, et al: Rapid identification of pneumococci, gram stain vs the quellung reaction. N Engl J Med 1973;288: 510-512.Crossref 13. Barrett-Connor E: The nonvalue of sputum culture in the diagnosis of pneumococcal pneumonia. Am Rev Respir Dis 1971;103:845-848. 14. Thorsteinsson SB, Musher DM, Fagan T: The diagnostic value of sputum culture in acute pneumonia. JAMA 1975;233:894-895.Crossref 15. Drew WL: Value of sputum culture in diagnosis of pneumococcal pneumonia. J Clin Microbiol 1977;6:62-65. 16. Gerding DN: Etiologic diagnosis of acute pneumonia in adults a growing challenge. Pneumonia Diag 1981;69:136-150. 17. Dans PE: The establishment of a university-based venereal disease clinic: I. Description of the clinic and its population. J Am Venereol Dis Assoc 1974;1:70-78. 18. Heineman HS, Chawla JK, Lofton WM: Misinformation from sputum cultures without microscopic examination. J Clin Microbiol 1977;6:518-527. 19. Murray PR, Washington II JA: Microscopic and bacteriologic analysis of expectorated sputum. Mayo Clin Proc 1975;50:339-344. 20. Jay SJ, Johanson WG, Pierce AK: The radiographic resolution of Streptococcus pneumoniae pneumonia. N Engl J Med 1975;293:798-801.Crossref 21. Neu HC: Clinical uses of cephalosporins. Lancet 1982;2:252-255.Crossref 22. Donowitz GR, Mandell GL: Empiric therapy for pneumonia. Rev Infect Dis 1983;5( (suppl) ):S40-S54.Crossref 23. Weisholtz SJ, Hartman BJ, Roberts RB: Effect of underlying disease and age on pneumococcal serotype distribution. Am J Med 1983;75:199-205.Crossref 24. Wong ET, Lincoln TL: Ready! fire!... aim! An inquiry into laboratory test ordering. JAMA 1983;250:2510-2513.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Management of Pneumonia in the Prospective Payment Era: A Need for More Clinician and Support Service Interaction

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Publisher
American Medical Association
Copyright
Copyright © 1984 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1984.00350190076014
Publisher site
See Article on Publisher Site

Abstract

Abstract • We compared the diagnostic and therapeutic management of pneumonia during 1970 and 1971 with that during 1979 and 1980 in clinically similar populations at The Johns Hopkins Hospital, Baltimore. More patients received aminoglycoside and cephalosporin therapy during 1979 and 1980. Guidelines for the use of chest roentgenograms and cultures were exceeded in 14% to 24% of cases. Patients whose cases were judged to be suboptimally managed had significantly higher charges and length of stay. Aged patients and those requiring thoracentesis also used resources more intensively. Given the technologic explosion, clinicians cannot know the performance characteristics of all tests and medications they can order. To minimize inefficient and ineffective practices, it is essential that clinicians and support service directors develop guidelines for testing and antibiotic use. Deviations should trigger timely interventions. Management under prospective payment will also require identifying specific patient subgroups to verify appropriate utilization and to assure equitable reimbursement. (Arch Intern Med 1984;144:1392-1397) References 1. Kinzer D, Warner M: The effect of case-mix adjustment on admission-based reimbursement. Health Ser Res 1983;18:209-225. 2. Fetter RB, Shin Y, Freeman JL, et al: Case-mix definition by diagnosis-related groups. Med Care 1980;18( (suppl) ):1-53. 3. Moore MA, Merson MH, Charache P, et al: The characteristics and mortality of outpatient-acquired pneumonia. Johns Hopkins Med J 1977;140:9-14. 4. White RJ, Blainey AD, Harrison KJ, et al: Causes of pneumonia presenting to a district general hospital. Thorax 1981;36:566-570.Crossref 5. Sullivan RJ, Dowdle WR, Marine WM, et al: Adult pneumonia in a general hospital etiology and host risk factors. Arch Intern Med 1972;129:935-942.Crossref 6. Ebright JR, Rytel MW: Bacterial pneumonia in the elderly. J Am Geriatr Soc 1980;28:220-223. 7. Mufson MA, Chang V, Gill V, et al: The role of viruses, mycoplasmas and bacteria in acute pneumonia in civilian adults. Am J Epidemiol 1967;86:526-544. 8. Dorff GJ, Rytel MW, Farmer SG, et al: Etiologies and characteristic features of pneumonias in a municipal hospital. Am J Med Sci 1973;266: 349-358.Crossref 9. Fiala M: A study of the combined role of viruses, mycoplasmas and bacteria in adult pneumonia. Am J Med Sci 1969;257:44-51.Crossref 10. MacFarlane JT, Finch RG, Ward MJ, et al: Hospital study of adult community-acquired pneumonia. Lancet 1982;2:255-258.Crossref 11. Rein MF, Gwaltney JM Jr, O'Brien WM, et al: Accuracy of Gram's stain in identifying pneumococci in sputum. JAMA 1978;239:2671-2673.Crossref 12. Merrill CW, Gwaltney JM Jr, Hendley JO, et al: Rapid identification of pneumococci, gram stain vs the quellung reaction. N Engl J Med 1973;288: 510-512.Crossref 13. Barrett-Connor E: The nonvalue of sputum culture in the diagnosis of pneumococcal pneumonia. Am Rev Respir Dis 1971;103:845-848. 14. Thorsteinsson SB, Musher DM, Fagan T: The diagnostic value of sputum culture in acute pneumonia. JAMA 1975;233:894-895.Crossref 15. Drew WL: Value of sputum culture in diagnosis of pneumococcal pneumonia. J Clin Microbiol 1977;6:62-65. 16. Gerding DN: Etiologic diagnosis of acute pneumonia in adults a growing challenge. Pneumonia Diag 1981;69:136-150. 17. Dans PE: The establishment of a university-based venereal disease clinic: I. Description of the clinic and its population. J Am Venereol Dis Assoc 1974;1:70-78. 18. Heineman HS, Chawla JK, Lofton WM: Misinformation from sputum cultures without microscopic examination. J Clin Microbiol 1977;6:518-527. 19. Murray PR, Washington II JA: Microscopic and bacteriologic analysis of expectorated sputum. Mayo Clin Proc 1975;50:339-344. 20. Jay SJ, Johanson WG, Pierce AK: The radiographic resolution of Streptococcus pneumoniae pneumonia. N Engl J Med 1975;293:798-801.Crossref 21. Neu HC: Clinical uses of cephalosporins. Lancet 1982;2:252-255.Crossref 22. Donowitz GR, Mandell GL: Empiric therapy for pneumonia. Rev Infect Dis 1983;5( (suppl) ):S40-S54.Crossref 23. Weisholtz SJ, Hartman BJ, Roberts RB: Effect of underlying disease and age on pneumococcal serotype distribution. Am J Med 1983;75:199-205.Crossref 24. Wong ET, Lincoln TL: Ready! fire!... aim! An inquiry into laboratory test ordering. JAMA 1983;250:2510-2513.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Jul 1, 1984

References