Wednesday, December 28, 2005

More on community acquired pneumonia and guidelines

The Dec. 20, 2005 issue of the Annals of Internal medicine published an article evaluating various implementation strategies for pneumonia guideline implementation.This was a RCT but not a trial to see how effective or safe the Pneumonia Severity Index (PSI) is but to determine the preferred method to implement the guidelines based on the PSI. It did not go unnoticed that one of the authors is Dr. MJ Fine who is credited with the Fine PSI.The authors concluded that a "high intensity" intervention increased the proportion of "low-risk"patients with pneumonia who were treated as outpatients. A key outcome of interest was the number treated as a outpatient.Importantly they listed numerous contraindications to outpatient treatment.These conditions trumped the PSI.Many of the reasons that inpatient treatment was opted for were the reasons that clinicians used to hospitalize patients in the study quoted in a earlier posting.The trump list included:frailty,serious comorbid conditions,extreme abnormalities in vital signs or laboratory values,clinical or psychosocial factors that could compromise the outpatient use of oral antibiotics.Viewed in this light,the PSI is a much more limited tool.It is useful unless any of the above list applies.Most of the items in the list require clinical judgment.How frail is the patient,how seriously abnormal the lab finding, etc.etc.The authors tout the value of the PSI and for them apparently the only issue is how best to implement it.However, the PSI is only a part of the assessment process as they implicitly admit by recognizing the many clinical factors that override its use. I find the importance placed on proportion of patients treated as outpatients somewhat disturbing.
While we do not want to needlessly hospitalize patients the basic doctoring mission is to do the right thing for patients and in that regard to measure success at what we do in terms of how many patients did we send home with pneumonia seem to miss the main point of what physicians do.The AJM article previously blogged about pointed out the importance of clinical judgment, the Annals article seemed narrowly confined to how to minimize hospitalizations by determining the best method of implementing the PSI and seems to ignore the importance of clinical judgment .Dr. Robert E. Siegel from the Mount Sinai School of Medicine in an editorial in the American Journal of Medicine (Amer. J. Med. 118:1311,dec.2005) said of the PSI ,"formulas, points and classes, no matter how helpful are no substitute for experience and judgment."A similar view was expressed by the American Thoracic Society in their 2001 paper on CAP when they spoke of the admission decision as an "art of medicine" decision and said that no rule by itself can determine the need for hospitalization.

No comments: