Rural Hospital: DISCUSSION
Implementation of the CAP guidelines was found to improve the quality of care by increasing the proportion of patients receiving an appropriate antibiotic and decreasing the time between the ordering and administration of these antibiotics in a rural community hospital. These improvements contributed to the one-day decreased LOS, which consequently resulted in the reduction in the average charge per patient. These results were consistent with previous studies that assessed the impact of the CAP guideline implementation.
In a multicenter, randomized, controlled clinical trial conducted in Canada, Marrie and coworkers found a 1.7-day reduction in LOS when the CAP guidelines were implemented. Fine and coworkers indicated that each one-day reduction in LOS resulted in $680 in cost savings per patient, ranging from $534 to $822, depending on the institution. In this study, a reduction of $829 per patient was achieved, primarily as a result of the one-day decrease in LOS. The decreased costs resulted mainly from a reduction in corresponding room charges and pharmacy charges. When Fine and coworkers evaluated the relationship between LOS and CAP-related charges, most of the savings were associated with a reduction in the average room cost, providing further support for these findings.
discount drugs canda
In this study, costs were defined as the amount charged for services because this is often most relevant for payers. Charges are generally more relevant when payers reimburse providers on a fee-for-service basis. However, reimbursements for most CAP inpatient stays were fixed on a per-visit basis; that is, the payer provided a set dollar amount to the hospital to cover all expenses regardless of LOS or services used. Therefore, differences in charges highlighted in this study may not be considered accurate savings to patients or to LRGH.
Although it is difficult to extrapolate accurate savings to patients, savings to LRGH were assessed by applying the institution’s cost-to-charge ratio to charges during both study periods. Results of this process indicated that actual costs to LRGH were reduced by $607.25 per patient admitted with a diagnosis of CAP after implementation of the intervention.
Marrie and colleagues also found a reduced rate of hospitalization among less severely ill patients because of the CAP guideline implementation, similar to the results seen in this study (even though the reductions in this study were not statistically significant). The fact that the less severely ill patients were admitted is consistent with the focus of the CAP guidelines, considering that these patients should be treated with alternative management options, leaving the more severely ill patients to undergo aggressive inpatient therapy.
The systematic application of the CAP guidelines should also assist physicians in making therapy selections based on specific clinical circumstances, thus reducing treatment variability while increasing the appropriateness of empirical antibiotic therapy. Previous studies have established improved survival with the selection of appropriate empirical antibiotics for CAP therapy, thereby reinforcing the value of the CAP guidelines.
Implementing the CAP guidelines at LRGH resulted in the increased use of fourth-generation fluoroquinolones, specifically moxifloxacin and gatifloxacin (Tequin®, Bristol-Myers Squibb), which were advocated as first-line therapy in patients regardless of the severity of their illness.
Meehan and associates found that giving patients appropriate antibiotics within the first eight hours of arrival also improved survival. Given the stricter criteria of antibiotic administration within two hours at LRGH, coupled with the higher proportion of patients receiving appropriate antibiotics, it is expected that the overall survival of patients with CAP at LRGH will improve. However, such an increase has not been confirmed, because patient survival was not directly assessed. prescription drugs online canada
Although the results are promising, the study does have certain limitations. The study design lacked the rigor to conclude causality with confidence, although the use of multivariate techniques increased the robustness of this analysis. If significant changes in hospital policy (other than the implementation of the CAP guidelines) occurred, the results of this analysis cannot be directly related to the implementation of the guidelines. However, attributing the decrease in charges and the reduced hospital LOS to the implementation of the CAP guidelines is tenable, given that LRGH clinicians and administrators are confident that this was the only policy change over this period of time, and similar results were found in randomized clinical trials.
Missing data also could have substantially influenced the results of this analysis. Patients with missing data were assigned to the most conservative Fine classification. However, the designation of appropriate treatment was directly related to the Fine score classification, which consistently resulted in underestimation of the severity of patients’ infections, and thus may have caused overestimation of the appropriate use of antibiotics.
The analysis was also limited to one institution, which could impose the potential for practice and patient variation that might not be representative of the general population; however, these results have been reproducible in other inpatient settings.
CONCLUSION
The implementation of CAP guidelines at a rural hospital resulted in improved patient care and economic savings. This study supports existing research regarding the clinical and economic impact of employing treatment guidelines and demonstrates the value of broader implementation of the CAP guidelines in the hospital setting.
