Preventing mismanagement of community-acquired pneumonia at an urban public hospital: implications for institution-specific practice guidelines.

STUDY OBJECTIVES: To assess institutional performance of key diagnostic and therapeutic interventions and to identify areas amenable to improvement in the management of community-acquired pneumonia (CAP). DESIGN: A chart-based retrospective study. SETTING: Cook County Hospital, a large, urban, public teaching hospital. PATIENTS: Adult inpatients with a hospital discharge diagnosis of CAP. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Fifty hospital admissions were reviewed. Only 25 patients (50%) had two specimens obtained for blood culture, and sputum was sent for Gram's stain and culture for only 11 patients (22%). Approximately one third of the patients had portable anterior-posterior instead of standard posterior-anterior and lateral chest radiographs performed. Physicians in the emergency department (ED) tended to be less likely to note the presence of multilobar infiltrates or pleural effusions than the attending radiologists. The antibiotic regimens employed in the ED and on the inpatient wards were widely variable. The mean time from hospital entry until administration of the first dose of antibiotics was 5.5 h for the 18 patients for whom treatment was initiated in the ED vs 16.1 h for the 27 patients admitted through the ED for whom therapy was deferred until ward admission (p < 0.001, Student's t test). CONCLUSIONS: Institutional variations in the performance of basic diagnostic and therapeutic interventions for patients with CAP may be substantial. The local performance of these key processes of care should be assessed to help direct the formulation of institutional practice guidelines for the management of CAP.

Influenza vaccine use among an elderly population in a community intervention.

A community intervention program was carried out to promote influenza immunization among an elderly population, as part of a demonstration established to estimate the value of including influenza immunization as a Medicare-covered benefit. Potential recipients were informed of reasons for receiving vaccine and its availability at no cost, and physicians and others administering it were provided with educational materials and cost reimbursement. Data collected for annual evaluations of influenza vaccine effectiveness were used to evaluate the impact of the community intervention program on influenza immunization status and to determine the effects of age, gender, chronic health conditions, and smoking status on the likelihood of immunization. Results indicated that the intervention program had a statistically significant impact on increasing the likelihood of immunization among the elderly population living in the targeted area. The existence of certain chronic health conditions also predicted immunization, while the effect of current smoking on immunization was strongly negative. During the three years of vaccine promotion, use in those 65 years and older who resided in the intervention area increased from approximately 40% in 1989-1990 to over 56% in 1991-1992. With various incentives, including cost reimbursement through Medicare, influenza immunization can be markedly increased among elderly beneficiaries.

Hypertension in women: the Women Take Heart project.

Hypertension is an important, modifiable risk for cardiovascular disease. The Women Take Heart study, a prospective, community-based cohort study of risk factors for heart disease, provides an opportunity to examine prevalence, awareness, and control of hypertension specifically in women. In 1992, 5932 women, age 35 and older (mean age, 52.9; 86% white, 9% African American, 5% other) and free of active heart disease symptoms for 3 months, were recruited through Chicago area public announcements, and their baseline examination data analyzed. Overall, 47.6% were hypertensive (systolic blood pressure >or=140 mm Hg or diastolic blood pressure >or=90 mm Hg, or self-report). Only 17.3% reported being hypertensive; in 63.2% of all hypertensive women, the hypertension was undetected or unacknowledged. Blood pressure was controlled to <140/90 mm Hg in 24.1% of self-reported hypertensives. Results from this study and national surveys indicate that hypertension detection and control remain major public health challenges in preventing cardiovascular disease in older women.

Influenza vaccine effectiveness in preventing hospitalization for pneumonia in the elderly.

During the winter of 1989-1990, influenza type A(H3N2) circulated widely, causing excess morbidity and mortality nationwide. From November through April, 1989-1990, hospitalized cases of pneumonia and influenza occurring among noninstitutionalized individuals 65 or more years of age were identified by 20 acute care hospitals in southern lower Michigan. These cases were group matched on age, sex, race, and zip code to randomly sampled, community-based controls from a comprehensive listing of Medicare beneficiaries residing in the study area. Self-reported data were collected from cases and controls on influenza vaccine status for the 1989-1990 season and on a number of other factors which could have influenced vaccination status or outcome. Questionnaires were completed by 1,907 individuals, 449 of whom were cases, resulting in an overall response rate of 76%. A community-based influenza surveillance system was implemented to determine the timing and intensity of viral activity and influenza-like illness. Vaccine effectiveness in preventing overall pneumonia and influenza hospitalizations was estimated by logistic regression. During the 3-month period of surveillance-confirmed peak influenza type A(H3N2) circulation, vaccine effectiveness was 45% (95% confidence interval 14-64, p = 0.009). However, during the 3-month period of low or absent virus activity, identical methodology and model specification resulted in an effectiveness estimate of 21% that was not statistically different from zero (p = 0.36). The effectiveness determined during the peak period of virus circulation is felt to be a conservative estimate, since agents other than influenza are responsible for pneumonia and influenza hospitalizations, even during times of peak influenza activity.