Clinical Studies
Variations in Antimicrobial Use and Cost in More Than 2,000 Patients with Community-acquired Pneumonia fn1

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Abstract

PURPOSE: To assess the patterns of antimicrobial use, costs of antimicrobial therapy, and medical outcomes by institution in patients with community-acquired pneumonia.

PATIENTS AND METHODS: The route, dose, and frequency of administration of all antimicrobial agents prescribed within 30 days of presentation were recorded for 927 outpatients and 1328 inpatients enrolled in the Pneumonia Patient Outcomes Research Team (PORT) multicenter, prospective cohort study. Total antimicrobial costs were estimated by summing drug costs, using average wholesale price for oral agents and institutional acquisition prices for parenteral agents, plus the costs associated with preparation and administration of parenteral therapy. Thirty-day outcome measures were mortality, subsequent hospitalization for outpatients, and hospital readmission for inpatients.

RESULTS: Significant variation (P <0.05) in prescribing practices occurred for 17 of the 23 antimicrobial agents used in outpatients across 5 treatment sites, and for 18 of the 20 parenteral agents used in inpatients across 4 treatment sites. The median duration of antimicrobial therapy for treatment site ranged from 11 to 13 days for outpatients (P = 0.01), and from 13 to 15 days for inpatients (P = 0.49). The overall median cost of antimicrobial therapy was $12.90 for outpatients, and ranged from $10.80 to $58.90 among treatment sites (P <0.0001). The overall median cost of antimicrobial therapy was $228.70 for inpatients, and ranged from $183.70 to $315.60 among sites (P <0.0001). Mortality and hospital readmission for inpatients were not significantly different across sites after adjusting for baseline differences in patient demographic characteristics, comorbidity, and illness severity. Although subsequent hospitalization for outpatients differed by site, the rate was lowest for the site with the lowest antimicrobial costs.

CONCLUSION: Variations in antimicrobial prescribing practices by treatment site exist for outpatients and inpatients with community-acquired pneumonia. Although variation in antimicrobial prescribing practices across institutions results in significant differences in antimicrobial costs, patients treated at institutions with the lowest antimicrobial costs do not demonstrate worse medical outcomes.

Section snippets

Methods

This study was conducted as part of the Pneumonia Patient Outcomes Research Team (PORT) multicenter, prospective cohort study of ambulatory and hospitalized patients with community-acquired pneumonia.

Results

Of the 944 outpatients and 1343 inpatients enrolled in the Pneumonia PORT cohort study, 927 (98.2%) outpatients and 1328 (98.9%) inpatients with information on antimicrobial therapy prescribed for the 30 days following presentation were included in this study.

Discussion

This study demonstrated that antimicrobial therapy for patients with community-acquired pneumonia varied markedly by site. These variations in prescribing practices led to large differences in the costs of antimicrobial therapy across treatment sites that were unexplained by differences in patient demographic characteristics, comorbidity, or severity of illness at presentation. It appears that the specific antimicrobial agents prescribed rather than the number of agents prescribed or treatment

Acknowledgements

The authors gratefully acknowledge the assistance of Elmer Holzinger, MD, for coordinating study activities at St. Francis Medical Center; Karen Lahive, MD, for coordinating study activities at the Harvard Community Health Plan; Linda Hough, MPH, project coordinator; Terry Sefcik, MS, data manager; and the following clinical research assistants for cohort study patient enrollment and data collection: Mary Walsh, RN, and Donna Polenik, MPH, in Pittsburgh; Mary Ungaro, RN, Leila Haddad, AB, and

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    fn1

    This work was part of the Pneumonia Patient Outcomes Research Team (PORT) project funded by a grant (R01 HSO6468) from the Agency for Health Care Policy and Research. Dr. Fine was supported as a Robert Wood Johnson Generalist Physician Faculty Scholar.

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