Original Studies
The Cost of Treating Pneumonia in the Nursing Home Setting

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Objective

To determine the costs of treating pneumonia in the nursing home setting and explore what factors are most responsible for that cost with a view to reducing cost.

Setting

Thirty-six Missouri nursing homes participating in the study from April 1997 through September 1998.

Participants

Nursing home residents with pneumonia who were not hospitalized (n = 502). We included residents evaluated in the emergency department (ED) and returned to the nursing home without admission.

Measurements

Residents were evaluated by project nurses. Examination findings, diagnostic testing, and treatment information for 30 days following evaluation were abstracted from medical records. Bills were obtained for individuals evaluated in the ED.

Results

There was significant variation in the cost of treating pneumonia in nursing homes. Episode costs were higher for residents seen in the ED of a hospital, residents with decubitus ulcers, black residents, and residents in larger facilities. Although total episode costs were related to illness severity, most of the variation in cost is not explained by resident or illness characteristics. The average cost for treating an episode of pneumonia in the nursing home, over and above usual care, was $458.

Conclusions

There is wide variation in treatment for residents with similar clinical presentations. For residents at low risk of mortality, using less expensive antibiotics and reducing ED evaluation could result in cost reductions, although the effect on outcomes is unknown.

Section snippets

Subjects

Subjects of this cost study were identified from residents of 36 central Missouri and St. Louis area nursing homes (approximately 4000 beds) who developed symptoms compatible with an LRI between April 1, 1997 and September 30, 1998. The patients were part of a larger study focusing on outcomes of LRI (predominantly pneumonia) in nursing home residents (the Missouri LRI Study). Details concerning resident identification and evaluations have been presented elsewhere. 13, 14 Briefly, project

Subjects

From April 1997 through September 1998, we evaluated 1341 residents for 2010 potential episodes of LRI (Figure 1). Of these, 1119 episodes met the LRI study definition. X-ray reports indicated possible, probable, or definite pneumonia (hereafter pneumonia) in 760 episodes. The sample for this study comprised the 502 pneumonia episodes (66%) involving residents who were not admitted to the hospital during the 30 days following evaluation. These episodes represent 444 individuals. Most

Discussion

The mean incremental cost for treating an episode of pneumonia in the nursing home was $427; if ED costs are included, mean episode cost increased to $458. In a study of acute medical conditions in incontinent residents of three California nursing homes, Alessi et al. 29 calculated mean nursing home costs for pneumonia treatment were $575. Their estimates included treatments and services not included in our analysis, such as all routine and as needed medications, nurse-administered treatments,

Conclusion

There is a wide range of costs of treating pneumonia in residents of nursing homes. Most of that variation is unrelated to illness severity. Decreasing the variability in treatment processes could likely reduce the cost of treating pneumonia in nursing home residents. In particular, sending only the sickest residents to the ED for evaluation and avoiding use of the most expensive antibiotics are two of the most likely ways of reducing cost. Any plans for reducing cost must also consider the

Acknowledgments

We gratefully acknowledge the support of the many individuals who made this project possible. We received the support and cooperation of the many attending physicians and the administration and staff of the 36 nursing homes that contributed subjects to this study. Karen Davenport provided crucial administrative support. Dr. Clive Levine, our project radiologist, reread over 200 X-rays to help us make final determination on pneumonia status. Dr. Richard Madsen helped with the statistical

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    Supported by grant HS08551 from the Agency for Healthcare Research and Quality and Dr. Mehr's Robert Wood Johnson Foundation Generalist Physician Faculty Scholars award. Dr. Kruse was supported by Institutional National Research Service Award number PE10038 from the Health Resources and Services Administration.

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