Quality of Care and Outcomes of Healthcare-Associated Pneumonia

描述（由申请人提供）：医疗获得性肺炎（HCAP）是一种新认识的临床实体，其发病率和死亡率高于社区获得性肺炎（CAP）。HCAP患者由于既往的医疗暴露（如近期住院、疗养院和透析单位）而面临多重耐药微生物的风险，并且往往具有较高的共病负担。2005年美国胸科学会/美国传染病学会指南建议诊断为HCAP的患者最初使用3种广谱抗生素治疗;然而，这些建议背后的证据来自几项小型观察性试验。这些研究表明，与CAP患者相比，HCAP患者的死亡率更高，并且更有可能接受不适当的初始抗生素治疗，但目前尚不清楚广泛使用几种广谱药物是否会改善患者的结局。由于这些抗生素可能会引起严重的副作用，而且通常价格昂贵，因此在没有更多证据证明其相对有效性的情况下，医生可能会犹豫是否根据指南开具处方。我们将使用Perspective数据仓库（PREMIER Healthcare Inc.）中包含的非常详细的患者级别声明和微生物学数据进行回顾性队列研究。从2007年1月1日到2008年12月31日，来自美国550家参与医院。我们将检查年龄≥ 18岁的诊断为肺炎的住院患者的数据。本研究的目的是确定因HCAP住院的患者的结局是否比因CAP住院的患者差，结局的差异是否是由于共病或耐药微生物，以及接受ATS-IDSA指南推荐的经验性抗生素治疗的HCAP患者是否有更好的结局（死亡率更低，并发症更少，住院时间更短，费用更低）。我们的研究将使用复杂的统计方法，包括逻辑回归，倾向匹配和工具变量方法的适应，以调整患者之间的治疗前差异，并比较不同抗生素方案的有效性。我们的研究结果将有助于指导医生治疗个别患者，并帮助专家制定循证临床实践指南。我们发现的关于医生实践模式的信息也将帮助质量官员和政策制定者确定在这种常见和致命疾病的护理中需要改进的领域。 公共卫生相关性：“医疗保健相关性肺炎的护理质量和结局”将为每年护理多达30万名医疗保健相关性肺炎（HCAP）患者的医生所面临的临床困境提供重要见解。这项研究将评估HCAP患者是否接受与美国胸科学会和美国传染病学会制定的指南中的建议一致的治疗，以及根据指南治疗的患者是否比接受其他抗生素治疗的患者有更好的结果。这些结果将帮助临床医生平衡推荐抗生素的潜在益处与抗生素副作用，未来抗生素耐药性和增加成本的潜在危害。如果推荐的治疗是有益的，但未得到充分利用，这些结果将提醒质量改进官员和政策制定者，这是一个重要的机会，以改善对常见和致命疾病的患者护理。

DESCRIPTION (provided by applicant): Health-care acquired pneumonia (HCAP) is a newly-recognized clinical entity which has a higher morbidity and mortality than community acquired pneumonia (CAP). Patients with HCAP are at risk for multi-drug resistant organisms due to past healthcare exposures such as recent hospitalizations, nursing homes, and dialysis units, and tend to have a high burden of co-morbid illnesses. The 2005 American Thoracic Society/Infectious Diseases Society of America guidelines recommend that patients diagnosed with HCAP be treated initially with 3 broad- spectrum antibiotics; however, the evidence behind these recommendations comes from several small observational trials. These studies show that compared to patients with CAP, patients with HCAP have higher mortality and are more likely to be treated with inappropriate initial antibiotic therapy, but it is not known whether widespread use of several broad-spectrum agents will improve patient outcomes. Because these antibiotics can cause serious side effects and are often expensive, physicians may be hesitant to prescribe according to the guidelines without more evidence of their comparative effectiveness. We will conduct a retrospective cohort study using highly detailed patient-level claims and microbiological data contained in the Perspective data warehouse (PREMIER Healthcare Inc.) from January 1, 2007 to December 31, 2008 from 550 participating hospitals in the United States. We will examine data from hospitalized patients = 18 years of age who were admitted with a diagnosis of pneumonia. The aim of our study is to determine whether patients hospitalized for HCAP have worse outcomes than those admitted for CAP, whether differences in outcome are due to co-morbid illnesses or to resistant organisms, and whether HCAP patients who are treated with the empiric antibiotic regimen recommended by the ATS-IDSA guidelines have better outcomes (lower mortality, fewer complications, shorter length-of stay and lower costs) than patients treated with other antibiotics. Our study will use sophisticated statistical methods, including logistic regression, propensity matching and an adaptation of the instrumental variable approach, to adjust for pre- treatment differences between patients and compare the effectiveness of different antibiotic regimens. Our results will help to guide physicians in the treatment of individual patients and aid experts in developing evidence-based clinical practice guidelines. Information we discover about physician practice patterns will also help quality officers and policy-makers identify areas for improvement in the care of this common and deadly illness. PUBLIC HEALTH RELEVANCE: "Quality of Care and Outcomes of Healthcare-Associated Pneumonia" will provide important insight into a clinical dilemma faced by physicians who care for as many as 300,000 patients each year with Healthcare-Associated pneumonia (HCAP). This study will assess whether patients with HCAP are receiving care consistent with the recommendations found in guidelines developed by the American Thoracic Society and the Infectious Disease Society of America, and whether those treated according to the guidelines have better outcomes than patients who are treated with other antibiotics. These results will help clinicians balance the potential benefits of the recommended antibiotics against the potential harms of antibiotic side effects, future antibiotic resistance, and increased costs. If recommended therapy is beneficial but underutilized, these results will alert quality improvement officers and policy makers to an important opportunity to improve patient care for a common and deadly illness.