Outcomes/Effectiveness Research

Researchers examine hospital length-of-stay and costs for pneumonia

About 1 million patients are hospitalized for pneumonia each year at a cost exceeding $6 billion. Most of this cost is for hospital room charges and is directly related to length of hospital stay. The Pneumonia Patient Outcomes Research Team (PORT), led by Wishwa N. Kapoor, M.D., M.P.H., of the University of Pittsburgh, and supported by the Agency for Health Care Policy and Research (HS06468), recently published two studies examining length of hospital stay and costs for community-acquired pneumonia (CAP).

The first study found that hospitals varied substantially in their mean lengths of stay for CAP patients, and that outcomes were no worse for patients with shorter stays than they were for patients who were hospitalized longer. The second study calculated that in 1994, the estimated cost of outpatient treatment for a patient with CAP was $264, and inpatient treatment cost $7,500 per patient, with total CAP treatment costs totaling $10 billion that year. These studies are summarized here.

McCormick, D., Fine, M.J., Coley, C.M., and others (1999, July). "Variation in length of hospital stay in patients with community-acquired pneumonia: Are shorter stays associated with worse medical outcomes?" American Journal of Medicine 107, pp. 5-12.

Hospitals vary dramatically in how long they keep patients with CAP. Apparently, patients who stay shorter times have no worse medical outcomes than those who stay longer in the hospital, according to this study, which involved a group of 1,188 adults with CAP who had been admitted to one community and three university teaching hospitals. They compared patients' mean length of stay, deaths, hospital readmissions, return to usual activities and work, and pneumonia-related symptoms.

Patients' mean length of hospital stay ranged from 7.8 to 9.8 days. Patients with the shortest stays were at no higher risk for poor medical outcomes than those admitted for longer stays in mortality (relative risk, RR, 0.7; 1 is equal risk), hospital readmission (RR, 0.8), return to usual activities (RR, 1.1), return to work (RR, 1.2) during the first 14 days after discharge, or in the mean number of pneumonia-related symptoms 30 days after admission. The 95 percent confidence limits for each of these estimates included the null value of 1.0, indicating a nonsignificant association between length of stay and these medical outcomes.

These findings suggest that hospitals that keep CAP patients for longer times may be able to shorten their stays without adversely affecting patient outcomes. Of course, aggressive programs to shorten hospital stays for CAP may eventually introduce unnecessary risk. Future studies are needed to identify the most efficient processes of care for CAP and to determine when patients are sufficiently stable for hospital discharge, conclude the authors.

Lave, J.R., Lin, C.J., Fine, M.J., and Hughes-Cromwick, P. (1999). "The cost of treating patients with community-acquired pneumonia." Seminars in Respiratory and Critical Care Medicine 20(3), pp. 189-197.

This study estimates that in 1994, the cost of treating an outpatient with CAP was $264; inpatient care cost $7,500 (including hospital and physician care and followup care). The total costs associated with treating CAP that year were about $10 billion. The estimated average national cost of an inpatient pneumonia case was $5,711, with a range from $4,259 in Washington to $7,545 in Connecticut. Similar patients were treated differently. The range in average length of stay, a major cost contributor, across States was 4.6 days. Washington had the shortest average length of stay (5.3 days), and New Jersey had the longest (9.9 days). The median cost of antibiotic therapy for an inpatient episode was $228.70, ranging across four hospitals studied from $183.67 to $315.60 for similarly ill patients with similar outcomes.

Across sites, the mean cost per outpatient episode ranged from $264 to $421. Much of this variation was due to the site of the patient's initial visit, with emergency department (ED) visits costing much more than visits to a doctor's office.

The researchers recommend various strategies for decreasing the cost of treating CAP. These include identifying low-risk patients who can safely be treated as outpatients, decreasing length of hospital stays, reducing the use of EDs for initial CAP evaluation, and promoting the use of lower cost antibiotic therapy. The team's findings are based on analysis of six databases: the National Health Interview Survey, the National Hospital Discharge Survey, AHCPR's Healthcare Cost and Utilization Project-3 (HCUP-3), the Pennsylvania MediQal Pneumonia Database of adult patients with CAP discharged from Pennsylvania Hospitals in 1991, the Pennsylvania Medicare Pneumonia Sample, and the Pneumonia PORT Cohort Study (to obtain treatment estimates), which was a multicenter prospective cohort study of outpatient and hospitalized patients with CAP.

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