Quality of care delivered by fee-for-service and DRG hospitals in Switzerland in patients with community-acquired pneumonia

PRINCIPLES

Reimbursement for inpatient treatment in Switzerland is in transition. While hospitals in some cantons already use Diagnosis Related Groups (DRG) based systems for hospital financing, others use fee-for-service (FFS) based systems, a situation that provides the opportunity to perform a head-to-head comparison between the two reimbursement systems. The aim of this analysis was to compare reimbursement systems with regard to length of hospital stay (LOS) and patient outcomes in a cohort of community-acquired pneumonia patients from a previous prospective multicentre study in Switzerland.

METHODS

This is a post-hoc analysis of 925 patients with community-acquired pneumonia from a previous randomised-controlled trial. We calculated multivariate regression models adjusted for age, gender, comorbidities and severity of illness (using the Pneumonia Severity Index) and accounting for clustering within hospitals to compare LOS and outcomes between FFS (n = 4) or DRG hospitals (n = 2).

RESULTS

LOS in DRG hospitals was significantly shorter compared to FFS hospitals (8.4 vs 10.3 days, absolute difference 1.9 days [95%CI 0.8-3.1]). This was confirmed in multivariate adjusted Cox models (hazard ratio 1.2 [95% 1.1-1.3]). There were no differences in 30-day and 18-month mortality rates (adjusted odds ratio 1.7 [95% 0.9-3.2] and 1.3 [95% 0.9-1.9]) or recurrence rates within 30 days (adjusted odds ratio 0.8 [95% 0.4-1.7]). Also, no differences were found in the rate of still ongoing clinical symptoms at 30 days, satisfaction with the discharge process and quality of life measures at 30 days of follow-up.

CONCLUSIONS

This study focusing on community-acquired pneumonia patients with different severities found a 20% shorter LOS in hospitals with DRG financing compared to FFS hospitals without apparent harmful effects on patient outcomes, satisfaction with care and different quality of life measures. Further studies are required to validate these findings for other medical and surgical patient populations.

Prohormones for prediction of adverse medical outcome in community-acquired pneumonia and lower respiratory tract infections

INTRODUCTION

Measurement of prohormones representing different pathophysiological pathways could enhance risk stratification in patients with community-acquired pneumonia (CAP) and other lower respiratory tract infections (LRTI).

METHODS

We assessed clinical parameters and five biomarkers, the precursor levels of adrenomedullin (ADM), endothelin-1 (ET1), atrial-natriuretic peptide (ANP), anti-diuretic hormone (copeptin), and procalcitonin in patients with LRTI and CAP enrolled in the multicenter ProHOSP study. We compared the prognostic accuracy of these biomarkers with the pneumonia severity index (PSI) and CURB65 (Confusion, Urea, Respiratory rate, Blood pressure, Age 65) score to predict serious complications defined as death, ICU admission and disease-specific complications using receiver operating curves (ROC) and reclassification methods.

RESULTS

During the 30 days of follow-up, 134 serious complications occurred in 925 (14.5%) patients with CAP. Both PSI and CURB65 overestimated the observed mortality (X2 goodness of fit test: P = 0.003 and 0.01). ProADM or proET1 alone had stronger discriminatory powers than the PSI or CURB65 score or any of either score components to predict serious complications. Adding proADM alone (or all five biomarkers jointly) to the PSI and CURB65 scores, significantly increased the area under the curve (AUC) for PSI from 0.69 to 0.75, and for CURB65 from 0.66 to 0.73 (P < 0.001, for both scores). Reclassification methods also established highly significant improvement (P < 0.001) for models with biomarkers if clinical covariates were more flexibly adjusted for. The developed prediction models with biomarkers extrapolated well if evaluated in 434 patients with non-CAP LRTIs.

CONCLUSIONS

Five biomarkers from distinct biologic pathways were strong and specific predictors for short-term adverse outcome and improved clinical risk scores in CAP and non-pneumonic LRTI. Intervention studies are warranted to show whether an improved risk prognostication with biomarkers translates into a better clinical management and superior allocation of health care resources.

TRIAL REGISTRATION

NCT00350987.

Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections: the ProHOSP randomized controlled trial

CONTEXT

In previous smaller trials, a procalcitonin (PCT) algorithm reduced antibiotic use in patients with lower respiratory tract infections (LRTIs).

OBJECTIVE

To examine whether a PCT algorithm can reduce antibiotic exposure without increasing the risk for serious adverse outcomes.

DESIGN, SETTING, AND PATIENTS

A multicenter, noninferiority, randomized controlled trial in emergency departments of 6 tertiary care hospitals in Switzerland with an open intervention of 1359 patients with mostly severe LRTIs randomized between October 2006 and March 2008.

INTERVENTION

Patients were randomized to administration of antibiotics based on a PCT algorithm with predefined cutoff ranges for initiating or stopping antibiotics (PCT group) or according to standard guidelines (control group). Serum PCT was measured locally in each hospital and instructions were Web-based.

MAIN OUTCOME MEASURES

Noninferiority of the composite adverse outcomes of death, intensive care unit admission, disease-specific complications, or recurrent infection requiring antibiotic treatment within 30 days, with a predefined noninferiority boundary of 7.5%; and antibiotic exposure and adverse effects from antibiotics.

RESULTS

The rate of overall adverse outcomes was similar in the PCT and control groups (15.4% [n = 103] vs 18.9% [n = 130]; difference, -3.5%; 95% CI, -7.6% to 0.4%). The mean duration of antibiotics exposure in the PCT vs control groups was lower in all patients (5.7 vs 8.7 days; relative change, -34.8%; 95% CI, -40.3% to -28.7%) and in the subgroups of patients with community-acquired pneumonia (n = 925, 7.2 vs 10.7 days; -32.4%; 95% CI, -37.6% to -26.9%), exacerbation of chronic obstructive pulmonary disease (n = 228, 2.5 vs 5.1 days; -50.4%; 95% CI, -64.0% to -34.0%), and acute bronchitis (n = 151, 1.0 vs 2.8 days; -65.0%; 95% CI, -84.7% to -37.5%). Antibiotic-associated adverse effects were less frequent in the PCT group (19.8% [n = 133] vs 28.1% [n = 193]; difference, -8.2%; 95% CI, -12.7% to -3.7%).

CONCLUSION

In patients with LRTIs, a strategy of PCT guidance compared with standard guidelines resulted in similar rates of adverse outcomes, as well as lower rates of antibiotic exposure and antibiotic-associated adverse effects.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN95122877.

[Fever, pneumonia and eosinophilia]

We present the case of a 71-year old man with acute eosinophilic pneumonia. By ruling out other common etiologies and by a positive lymphocyte transformation test the non-steroidal anti-inflammatory drug mefenamic acid was identified as the possible causative agent or this potentially life threatening lung disease. The clinical presentation, diagnosis, and treatment of acute eosinophilic pneumonia as a pulmonary manifestation of a drug-induced allergic reaction are discussed.

Characterization of iron and manganese precipitates from an in situ ground water treatment plant

Aquifer samples from the precipitation zone of an in situ iron and manganese removal plant that was operated for 10 years were analyzed for iron and manganese minerals. Measurements were performed by various chemical extraction techniques (5 M HCI, 0.008 M Ti(III)-EDTA, 0.114 M ascorbic acid), X-ray diffraction and Mössbauer spectroscopy. Chemical extractions showed that iron was precipitated as ferric oxides, whereas manganese was not oxidized but deposited as Mn(II) probably within carbonates. The ferric oxides in particular accumulate preferentially in the smaller grain- size fractions. This tendency was observed to a lesser extent for manganese. X-ray diffraction and Mössbauer spectroscopy showed that the ferric oxides were mainly crystalline (goethite, 50% to 100% of the iron). Ferrihydrite was found as well, but only as a minor fraction (< or = 12%). Pure manganese minerals were not found by X-ray diffraction. The precipitated amounts of iron (5 to 27 micromol/g Fe as ferric oxide) and manganese (1 to 4 micromol/g Mn) during 10 years operation of the treatment plant agree with values that were estimated from operational parameters (9 to 31 micromol/g Fe and 3 to 6 micromol/g Mn). Considering the small amounts of precipitated iron and manganese, no long-term risks of clogging of the aquifer are expected.

Community-acquired pneumonia--which patients are hospitalised?

BACKGROUND AND OBJECTIVE

Patients with community-acquired pneumonia can be allocated into low and high-risk mortality groups by simple clinical criteria. We studied the value of the stratification for outcome as proposed by Fine, et al. to guide the decision for in-hospital versus outpatient treatment in the emergency department.

PATIENTS AND METHODS

We studied demographic data, risk group stratification and decision-making for in-hospital versus outpatient treatment in 101 consecutive medical emergency department patients with community-acquired pneumonia. We also analysed predictive factors for hospitalisation of low-risk patients. We obtained complete 30 day follow-up information.

RESULTS

Forty-three of 44 high-risk patients were hospitalised after medical emergency department triage. Twenty-seven (47%) of 57 low-risk patients were hospitalised as well. Based on routine clinical assessment, hospitalisation of low-risk patients was required for poor medical condition or severe pneumonia (67%), for lack of social support (15%) and for relevant comorbidity (18%). In an univariate analysis, age (p = 0.003), C-reactive protein (p = 0.0006), presence of comorbidity (p = 0.0001), Charlson index (p = 0.0001) and active oral steroid treatment (p = 0.028) were significantly correlated with hospitalisation of low-risk patients. The 30-day mortality rate was 32% in patients allocated to the high-risk group at the time of diagnosis in the emergency department, compared to 0% in low-risk patients.

CONCLUSION

Simple clinical criteria distinguish well between low and high 30-day-mortality risk in patients diagnosed with community-acquired pneumonia. Nevertheless, 47% of low-risk patients require in-hospital treatment. Age, C-reactive protein, presence of comorbidity and steroid treatment are significantly correlated with hospitalisation of low-risk patients with community-acquired pneumonia.

Community-acquired pneumonia--which patients are hospitalised?

BACKGROUND AND OBJECTIVE

Patients with community-acquired pneumonia can be allocated into low and high-risk mortality groups by simple clinical criteria. We studied the value of the stratification for outcome as proposed by Fine, et al. to guide the decision for in-hospital versus outpatient treatment in the emergency department.

PATIENTS AND METHODS

We studied demographic data, risk group stratification and decision-making for in-hospital versus outpatient treatment in 101 consecutive medical emergency department patients with community-acquired pneumonia. We also analysed predictive factors for hospitalisation of low-risk patients. We obtained complete 30 day follow-up information.

RESULTS

Forty-three of 44 high-risk patients were hospitalised after medical emergency department triage. Twenty-seven (47%) of 57 low-risk patients were hospitalised as well. Based on routine clinical assessment, hospitalisation of low-risk patients was required for poor medical condition or severe pneumonia (67%), for lack of social support (15%) and for relevant comorbidity (18%). In an univariate analysis, age (p = 0.003), C-reactive protein (p = 0.0006), presence of comorbidity (p = 0.0001), Charlson index (p = 0.0001) and active oral steroid treatment (p = 0.028) were significantly correlated with hospitalisation of low-risk patients. The 30-day mortality rate was 32% in patients allocated to the high-risk group at the time of diagnosis in the emergency department, compared to 0% in low-risk patients.

CONCLUSION

Simple clinical criteria distinguish well between low and high 30-day-mortality risk in patients diagnosed with community-acquired pneumonia. Nevertheless, 47% of low-risk patients require in-hospital treatment. Age, C-reactive protein, presence of comorbidity and steroid treatment are significantly correlated with hospitalisation of low-risk patients with community-acquired pneumonia.

[Progressive muscular weakness due to subacute postinfectious polyradiculitis and myelitis]

In a 67-year-old patient, generalised stable muscular weakness preexisting for several years became rapidly progressive within a few weeks prior to hospitalisation. He died one month after admission from acute cardiocirculatory failure. There was no history of muscular pain, clinical examination showed weak or absent tendon reflexes, hyposensibility of the dorsa of his feet, fasciculations and myocloni of the muscles of the lower limbs as well as a generalised muscular atrophy. Polyneuropathy due to diabetes mellitus and monoclonal IGG-kappa-type gammopathy were preexisting. CSF examination showed inflammatory cerebral fluid changes and further investigations revealed inflammatory polyradiculopathy affecting mainly motor nerve fibres. There was evidence of a reactivated varicella-zoster infection in serum and in the cerebrospinal fluid samples. The search for a tumour, vasculitis or a drug-related cause for this syndrome remained negative. Neuropathological examination at autopsy showed subacute polyradiculitis accompanied by myelitis. The most probable cause of this disorder is immune-mediated polyradiculitis after varicella-zoster infection.

[Prehospital resuscitation in urban conditions--results and prognostic decision criteria]

From 1983 to 1991, 214 patients (age 62 +/- 15 years; 72% male) with out-of-hospital cardiac arrest were resuscitated in the field and transported to the hospital with basic cardiac life support only (manual chest compression, assisted ventilation by bag-air-valve). In 64 patients (30%; 95% confidence interval [CI]: 24-36%) a stable circulation allowing admission to the intensive care unit was restored in the emergency room. 26 patients (12%; CI: 8-17%) survived to hospital discharge. 20 patients showed no or only mild neurological impairment, 4 had moderate cognitive deficits, and 2 patients were in a permanent vegetative state. Multiple logistic regression revealed bystander resuscitation before arrival of the ambulance (odds ratio [OR]: 4.7 [CI: 1.5-14.7]; p < 0.01) and ventricular fibrillation on arrival in the emergency room (OR: 42.8 [CI: 5.2-350]; p = 0.0005) to be statistically significant predictors of survival. These data justify continuation and extension of resuscitation efforts in the emergency room if patients were given only basic cardiac life support in the field and during transport. Patients who arrive in ventricular fibrillation and who were resuscitated by a bystander prior to the arrival of the ambulance team have a realistic chance of survival. Delegation of competence to defibrillate to trained, non-physician ambulance personnel may reduce the duration of cardiac arrest in patients with ventricular fibrillation and thus save lives.

[Cocaine poisoning from transport of the drug in the gastrointestinal tract (the body-packer syndrome)]

Three days after arriving in Switzerland from Bolivia a 35-year-old man presented at a casualty department. He was anxious, agitated and hallucinating, and he expressed delusional ideas of being poisoned. As a general physical examination was without abnormal findings he was thought to suffer from a psychiatric disorder. It was only when he had evacuated in stool a long oval foreign body, packed in plastic sheeting and filled with a dark paste, that cocaine poisoning due to cocaine transport in the gastrointestinal tract (body packer syndrome) was suspected. Plain X-ray of the abdomen revealed numerous regular structures of poor X-ray contrast and the urine contained cocaine metabolites, confirming the tentative diagnosis. As the patient's state of consciousness deteriorated and he had a grand mal seizure, an emergency laparotomy was performed. 78 packages (two of them had opened) were removed by gastro- and caecotomy. Total cocaine weight was 650 g. He was discharged from hospital after 11 days, free of symptoms.

[Thrombolysis in acute myocardial infarct. Initial experiences in a Swiss university hospital]

Preliminary experience with thrombolytic therapy in patients with acute myocardial infarction and its practicability in a CCU of a Swiss university hospital are presented. Out of 674 patients with a transmural or non-transmural infarction, 72 (11%) have been treated with thrombolytic agents since March 1986. 53 of these patients were included in the "European Cooperative Study Group" multicenter trial and treated with recombinant tissue plasminogen activator (rt-PA) or placebo; the other 19 patients received streptokinase i.v. with the same inclusion/exclusion criteria. The results corresponded to the well known effects of early thrombolysis with improvement in infarct size reduction, cardiac performance and early mortality.--The importance of the time factor and the implications regarding information of potential patients and practitioners and organization of rapid hospitalization are outlined. Follow-up (after a mean of 14 months) of our 72 thrombolysis patients revealed a high percentage of patients still dependent on medical care, reduced physical capacity in almost half of the patients and (a favourable result) a large number of patients who stopped smoking after the infarction. --In view of the slight additional stress caused by this therapy for patients, physicians and nursing staff, the use of thrombolytic agents in acute myocardial infarction should (with strict inclusion/exclusion criteria) be rapidly generalized in the hospitals of Switzerland.

Myofibrillar M-line structure in normal and dystrophic hamster muscle

The presence of the specific myofibrillar M-line marker, myomesin , in isolated myofibrils and cryosections of skeletal and heart muscle as well as its appearance during differentiation in skeletal and heart muscle cell cultures of normal and dystrophic hamsters were evaluated. By means of the indirect immunofluorescence technique employing antibodies against chicken M-line proteins, the appearance of antigen localized in the M-line was investigated. No difference could be found between the M-line structure of normal and dystrophic animals. The results suggest that the M-line proteins, apparently relatively stable, are not primarily affected by the disease.