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Management of Pneumonia in the Nursing Home
CHEST
Topics in Practice Management
Management of Pneumonia in the Nursing Home Ali A. El-Solh, MD, FCCP; Mike S. Niederman, MD, FCCP; and Paul Drinka, MD
Pneumonia is a major cause of morbidity and mortality among nursing home residents. The approach to managing these patients has lacked uniformity because of the paucity of clinical trials, complexity of underlying comorbid diseases, and heterogeneity of administrative structures. The decision to hospitalize nursing home patients with pneumonia varies among institutions depending on staffing level, availability of diagnostic testing, and laboratory support. In the absence of comparative studies, choice of empirical antibiotic therapy continues to be based on expert opinion. Validated prognostic scoring models are needed for risk stratification. Pneumococcal and influenza vaccination are the primary prevention measures. As of January 2010, Medicare no longer pays for consultation codes; thus, practitioners must instead use existing evaluation and management service codes when providing these services. CHEST 2010; 138(6):1480–1485 Abbreviations: BTS 5 British Thoracic Society; CAP 5 community-acquired pneumonia; CMS 5 Centers for Medicare & Medicaid Services; CPT 5 current procedural terminology; LTCF 5 long-term-care facility; NHAP 5 nursing homeacquired pneumonia; PSI 5 Pneumonia Severity Index
important demographic changes of the past Thecentury and the prolonged life expectancy related to the tremendous development of the medical sciences and technologies contributed to the exponential increase in elderly patients residing in nursing homes. It is estimated that the number of older people who will require nursing home care will reach 5.3 million in 2030.1 Assuming that the incidence of pneumonia in this population remains constant, the total cases of nursing home-acquired pneumonia
Manuscript received May 2, 2010; revision accepted June 14, 2010. Affiliations: From the Division of Pulmonary, Critical Care, and Sleep Medicine (Dr El-Solh), Veterans Affairs Western New York Healthcare System, and Department of Medicine (Dr El-Solh), University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY; Department of Medicine (Dr Niederman), Winthrop-University Hospital, Mineola, NY; Department of Medicine (Dr Niederman), SUNY Stony Brook School of Medicine, Stony Brook, NY; Department of Internal Medicine/Geriatrics (Dr Drinka), University of Wisconsin, Madison, WI; and Medical College of Wisconsin (Dr Drinka), Milwaukee, WI. Correspondence to: Ali El-Solh, MD, FCCP, Division of Pulmonary, Critical Care, and Sleep Medicine, Veterans Affairs Western New York Healthcare System, 3495 Bailey Ave, Buffalo, NY 14215-1199; [email protected] © 2010 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/ site/misc/reprints.xhtml). DOI: 10.1378/chest.10-1135 1480
(NHAP) will approach 1.9 million episodes annually. Currently, the incidence of NHAP varies from 0.3 to 2.3 episodes per 1,000 resident care days.2 The variation in incidence is related to differences in multiple methodologic approaches used in the various studies, including differences in study design, number of facilities evaluated (one vs multiple), intensity of surveillance, case mix, and facility affiliation (US Veterans Affairs vs community nursing homes). According to the latest statistics, nursing home residents account for 10% to 18% of all patients hospitalized for pneumonia, with an average hospital charge of approximately $10,000 per admission.3 This article reviews practical issues that physicians caring for nursing home residents with pneumonia frequently confront. Rather than trying to provide an exhaustive review of the general issues regarding hospitalized patients with NHAP, the article focuses on practice management in which the approach to pneumonia in nursing home settings generates significant controversies.
Diagnosis of Nursing Home Pneumonia The diagnosis of pneumonia in nursing home residents can be challenging. Clinical assessment is Topics in Practice Management
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hampered by impaired communication, nonlocalizing symptoms, and chronic respiratory diseases that compromise accurate diagnosis of any infection in this population. With radiology and laboratory facilities usually off site, limited access to diagnostic tests also compromises evaluation. Even when available, the results of the diagnostic tests are subject to conflicting interpretations. Chest radiographs may be nondiagnostic because of chronic changes or delayed radiographic manifestations. Sputum specimens frequently are contaminated with gram-negative flora colonizing the upper airway, and peripheral leukocyte count may be normal despite bacterial infection. For the evaluation of nursing home residents with suspected lower-respiratory tract infection, the recent guidelines of the Infectious Diseases Society of America recommend using physical examination, pulse oximetry for patients with a respiratory rate . 25 breaths/min, and chest radiography for residents with hypoxia.4 A peripheral WBC count and sputum Gram stain also are recommended, although the validity and utility of diagnostic tests for lower-respiratory tract infection in these settings have not been rigorously evaluated. One classic scenario underlying the diagnostic dilemma in the nursing home is that of aspiration syndromes. Nursing home residents are at an increased risk of aspiration due to decreased host defenses; dysphagia; and impaired swallowing reflex caused by degenerative neurologic diseases, tube feeding, and sedative-hypnotic drug use. Although the difference between aspiration pneumonia and aspiration pneumonitis is established pathologically, the distinction between these two entities on clinical grounds is not always straightforward. The classic assumption that gastric content is sterile and that bacterial pneumonia after gastric aspiration occurs as a secondary superinfection may not be factual in a nursing home setting. Aspiration of nonacidified gastric contents may easily include viable endogenous flora when regurgitated into a colonized oral pharynx before entering the trachea. In the absence of a sensitive biomarker that would separate the two aspiration syndromes,5 the decision to withhold antibiotics in suspected aspiration pneumonitis remains an exercise in academic rather than routine practice. Cytokine profiling in animal models of gastric aspiration has identified a specific lung injury signature.6 The validity of this approach in a clinical scenario has not yet been tested.
most widely studied severity prediction rules were developed as a means of stratifying patients with community-acquired pneumonia (CAP) according to their risk of mortality. The Pneumonia Severity Index (PSI) developed by Fine et al7 was set to identify patients at low risk for death within 30 days of presentation. The model incorporated 20 variables that encompassed demographic, physical examination, laboratory, and radiographic findings. The PSI was not specifically designed for the institutionalized elderly population, and it may in fact be partially skewed against patients residing in nursing homes. The single investigation that used PSI in nursing home patients with pneumonia successfully stratified low- and high-risk groups for 30-day mortality; however, the study was limited by the exclusion of many patients for whom information required to calculate the prognostic index was missing from their medical records.8 An alternative severity assessment tool proposed by the British Thoracic Society (BTS) relies on four clinical features as a means of identifying patients with severe CAP at high risk of mortality.9,10 The BTS rule and its derivatives were never assessed in a nursing home setting. In addition, factors such as raised urea or low diastolic pressure that commonly portend poor outcome in community dwellers may be a transient derangement in nursing home patients. A novel prognostic system, SOAR (systolic BP, oxygenation, age, and respiratory rate),11 was introduced recently to counter the impact of variables thought to discriminate poorly in predicting mortality in old age. The new system is performed similarly to the BTS-recommended rules in patients with CAP,11 but it is yet to be validated in NHAP. One common limitation to all these scoring models is that none account for social needs or take into consideration the functional status of nursing home residents. The Missouri Lower Respiratory Tract Infection Project Risk Score is the only prognostic model that was derived from nursing home residents with lower-respiratory tract infections.2 The model is derived from eight factors that independently predict pneumonia without the need to obtain a chest radiograph. The predicted 30-day mortality ranges from 2.4% to 61.6%. The authors acknowledged that the model needs large-scale validation. Its significance in determining the appropriate level of care and guiding antibiotic treatment has not yet been determined.
Risk Stratification
The decision of when to transfer a nursing home patient with pneumonia to an acute care facility continues to be a matter of debate. The recognition of the high risk of adverse outcomes during hospitalization challenges the dogma of hospitalizing every elderly
Severity assessment is a key element in determining not only patient prognosis but also site of treatment and intensity of medical therapy. The www.chestpubs.org
Decision to Hospitalize
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nursing home resident with pneumonia. Hospitalized older patients are at high risk of developing complications such as falls, delirium, and loss of mobility. In the absence of impending respiratory failure, hypothermia, hemodynamic instability, or renal failure, there is little evidence that hospitalization for NHAP improves outcomes.12,13 More importantly, not only do the two sites of therapy produce about the same immediate events, the functional status of those patients treated in the nursing home setting is more preserved, and total mortality in the 2 months following the acute pneumonia is less compared with a hospitalized cohort.14 In one cluster-randomized trial of 680 residents of long-term-care facilities (LTCFs) with radiographically proven pneumonia, Loeb and colleagues15 demonstrated that a clinical pathway that allowed for oral quinolone therapy reduced the hospitalization rate by 12% and resulted in a cost savings of at least $1,000 per patient without affecting mortality or health-related quality of life. Similarly, a Medicare demonstration project that involved payment to nursing homes to manage sicker residents without hospital transfer did not show a substantial increase in mortality when a variety of conditions were treated in the nursing home.16 Addressing the challenges of providing care to this population requires greater availability of registered nurses and primary-care clinicians who can recognize acute changes in clinical conditions of frail elderly patients, better access to diagnostic and treatment services on site, and increased use of practice guidelines and tools to assist nursing home staff in managing residents’ health conditions.17,18 Hence, specialized nursing home facilities adequately staffed and equipped with onsite chest radiographic and laboratory capabilities are less likely to transfer patients to hospitals for acute episodes of pneumonia. An expert committee of the Infectious Diseases Society of America has proposed the following criteria as a guide for NHAP hospitalization19: 1. The resident is clinically unstable, and the patient’s or the family’s goals indicate that aggressive medical therapy should be urgently initiated. 2. Critical diagnostic tests are not available in the LTCFs. 3. A required or necessary therapy is not available in the facility, or the frequency and intensity of monitoring therapy are beyond the capacity of the LTCF staff. 4. Comfort measures cannot be ensured in the LTCF. 5. Specific infection control measures are not available in the LTCF. Although the committee revised the clinical practice guidelines in 2009, it did not address the criteria 1482
for hospital transfer.4 The Hutt and Kramer20 guideline advanced parallel recommendations (Table 1), but in the absence of standardized criteria for hospital admission, interpretation and comparison of outcome studies remain problematic. Other factors that enter into consideration for transfer to an acute care facility include financial incentive that precludes nursing homes from adequate reimbursement for an acute episode of pneumonia. In a study of nursing homes in 10 states, Intrator and Mor21 found that homes in states with higher Medicaid reimbursement have lower hospitalization rates, controlling for confounding factors and the competing risk of death. A $10 higher daily Medicaid rate was found to be associated with a 9% reduction in the odds of hospitalization. Medicare is beginning a demonstration of a value-based purchasing initiative that will reward nursing homes based in part on lower rates of potentially avoidable hospitalizations.22 In addition, Medicare is exploring bundling payments for 30-day episodes of care for acute conditions, including NHAP. If enacted into law, hospitals and nursing homes would have a mutual financial incentive to collaborate and coordinate their activity to avoid hospitalization of nursing home residents whenever safe and feasible. Nevertheless, both strategies are fraught with pitfalls23,24 and could be counterproductive if support for the infrastructure to manage sicker residents within the nursing home is not available.
Antimicrobial Management Prescription of antimicrobial therapy for NHAP remains a highly contested issue driven by a disagreement on how the condition should be approached Table 1—Proposed Guidelines for Hospitalizing Nursing Home Patients With Pneumonia Guideline
Description
1. Oxygen saturation , 90% on room air at sea level 2. Systolic BP , 90 mm Hg or 20 mm Hg , baseline 3. Respiratory rate . 30 breaths/min or 10 breaths/min . baseline 4. Increase oxygen requirement by 3 L/min or more than baseline 5. Uncontrolled COPD, congestive heart failure, or diabetes mellitus 6. Altered mental status 7. New or increased agitation Transfer to a hospital if the Vital sign assessment every 4 h facility cannot provide:a Laboratory access Parenteral hydration Two licensed nurses per shift Presence of any two symptoms
a
If any one of the listed symptoms warrant it. Topics in Practice Management
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and treated. Should NHAP be recognized as CAP, health-care-associated pneumonia, or hospital-acquired pneumonia? The arguments for and against the inclusion of NHAP in these classifications are beyond the context of this review. Despite the fact that respiratory tract infections remain the primary cause for use of antimicrobial therapy in nursing homes,25 the lack of randomized trials has been a continuous problem for expert panels developing guidelines. The two guidelines that have addressed treatment of pneumonia in the nursing home setting have been consistent in their approach to antibiotic therapy.26,27 The choices for empirical coverage include oral antipneumococcal quinolone alone, amoxicillin/clavulanic acid, or a second-generation oral cephalosporin plus a macrolide other than erythromycin. For residents who develop NHAP not amenable to oral treatment, oncedaily IM therapy with ceftriaxone vs cefepime has been examined in a double-blind study with similar efficacy.28 However, in the absence of outcome data pointing to a superiority of one regimen over another, the choice of treatment depends on knowing the potential pathogens, likelihood of antibiotic resistance, ease of administration, and adverse effect profiles of various agents. Modifying risk factors suggestive of multidrug-resistant organisms include a history of resistant pathogens, antibiotic therapy in the past 3 months, foreign bodies, chronic wounds, recent hospitalization, and dependency on or need for contact care.29,30 One study noted that the 75th percentile for duration of therapy of NHAP within the nursing home was 10 days,31 but the optimal duration of antibiotic treatment is unknown. The prescription of antibiotic therapy for NHAP when it occurs as an expected terminal event has been questioned recently. Limited observational studies25,32,33 have failed to demonstrate that antimicrobial treatment achieves life prolongation in this frail population. There is also increased uncertainty about whether antimicrobial therapy promotes symptomatic relief beyond what can be achieved by high-quality palliative treatment with more conservative modalities. A study by van der Steen and colleagues33 found that the level of discomfort was not different in residents dying of pneumonia whether antimicrobial therapy was prescribed or not. Further, the level of discomfort that occurred at the onset of pneumonia among those residents who survived and were not treated returned to baseline within 1 week in most cases. The tendency of relying on IV therapy in the United States compared with oral antibacterial agents in The Netherlands imposes further burden on these frail patients, including the need to institute physical restraints to avoid patient removal of IV catheters and to obtain frequent blood samples to monitor for toxicity. This difference in approach to NHAP treatwww.chestpubs.org
ment in patients with late dementia reflects a divergence in attitudes of physicians and families with regard to aggressive intervention.34 As emphasized by van der Steen et al,35 optimal care of NHAP includes “prudent consideration of curative treatment, treatment to relieve discomfort, and supportive treatment in view of expected and desirable outcomes.”
Prevention Current US strategies to prevent pneumonia among institutionalized older adults include recommending immunization with pneumococcal polysaccharide vaccine and annual influenza vaccinations.36 However, the effectiveness of these vaccines decreases with increasing age and among individuals with comorbid conditions. It has been suggested that the presumed benefit of the influenza vaccine in the reduction of mortality from pneumonia might have been overestimated.37,38 Various methods to minimize such residual confounding have been applied in various observational studies, leaving little scope for unmeasured confounders, including, for example, the use of laboratory-confirmed influenza as an outcome, restriction of the analyzed population, multivariable regression to adjust for confounders, propensity scores, and others.39 Yet, even after taking such unmeasured confounding into account, influenza vaccination still is associated with substantial reduction in mortality risk.40 The 23-valent pneumococcal polysaccharide vaccine also has been shown to confer protection against all-cause pneumonia and pneumonia-related mortality in nursing home residents, although the protective efficacy of the vaccine did not translate into a reduction in all-cause mortality.41 Standing-order programs have been linked to increase vaccination rates in ambulatory and hospital settings. However, a 2005 survey showed that only 9% of LTCFs use such programs.42 The greatest use of such programs was in government-owned, nonprofit, dual-certified (ie, by both Medicare and Medicaid), and independent LTCFs and in facilities with a lower index of disease acuity. Reducing bacterial colonization of the oropharynx is considered another potential target for the prevention of NHAP. Limited observational studies of aggressive oral care among elderly nursing home patients have uniformly shown a reduced risk of pneumonia in the intervention group.43-45 These studies involved a range of intervention from daily mechanical brushing to weekly professional cleaning. However, the comparison group in the majority of these investigations was left to self-care or no oral care. Such a design would invariably favor the CHEST / 138 / 6 / DECEMBER, 2010
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intervention arm. To that end, any future randomized controlled trials should incorporate daily brushing and flossing as the standard of care before any claim of superiority is made. Meanwhile, the implementation of an oral-care program at each nursing facility ought to become a quality improvement project supported by local and governmental agencies. Billing and Coding Changes There are many unresolved issues with regard to NHAP. At the present level, the health-care system is ill prepared to deal with what promises to be a major public health problem unless medically sound, costeffective strategies for the evaluation, management, and prevention of NHAP are implemented. A conservative Congressional Budget Office estimate suggests that total long-term-care expenditures will increase at a rate of 2.6% per year above inflation over the next 30 years to $195 billion in 2020 and a staggering $270 billion in 2030.46 As a result, changes in administrative and billing procedures have taken the lead. In the 2010 final Medicare Physician Fee Schedule, the Centers for Medicare & Medicaid Services (CMS) announced that Medicare will no longer recognize consultation codes (current procedural terminology [CPT] 99251-99254) for Medicare Part B fee-forservice payment.47 CMS directs providers to report other evaluation management codes for nursing homes (CPT 99304-99310, 99318) in lieu of the consultation codes. These codes recognize the time physicians spend on chart review, documentation, and communication with the patient’s family while at the facility. There are instances when a prolonged service code (CPT 99356-99357) also may be appropriately added. To counter the loss of consultation code revenues, CMS increased the work relative value units for initial nursing facility visits and incorporated the increased use of these visits into the practice expense and malpractice calculations. Subsequent consultations are reported as subsequent visit codes (CPT 99231-99233). The principal physician of record is to append modifier “AI Principal Physician of Record” to the evaluation management code when billed. This modifier will identify the physician who oversees the patient’s care from all other physicians who may be furnishing specialty care.
Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Niederman has received honoraria or consulted for Bayer, Ceragenix, Abbott, Schering-Plough, Merck, Pfizer, Johnson and Johnson, and Nektar and has received grants from Nektar and Bayer. Drs El-Solh and Drinka have reported to CHEST that no potential conflicts of 1484
interest exist with any companies/organizations whose products or services may be discussed in this article.
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17. Intrator O, Zinn J, Mor V. Nursing home characteristics and potentially preventable hospitalizations of long-stay residents. J Am Geriatr Soc. 2004;52(10):1730-1736. 18. Ouslander JG, Lamb G, Perloe M, et al. Potentially avoidable hospitalizations of nursing home residents: frequency, causes, and costs: [see editorial comments by Drs Jean F. Wyman and William R. Hazzard, pp 760-761]. J Am Geriatr Soc. 2010;58(4):627-635. 19. Bentley DW, Bradley S, High K, Schoenbaum S, Taler G, Yoshikawa TT; American Geriatrics Society; Gerontological Society of America, Clinical Medicine Section; Infectious Diseases Society of America; Society for Healthcare Epidemiology of America. Practice guideline for evaluation of fever and infection in long-term care facilities. Clin Infect Dis. 2000;31(3):640-653. 20. Hutt E, Kramer AM. Evidence-based guidelines for management of nursing home-acquired pneumonia. J Fam Pract. 2002;51(8):709-716. 21. Intrator O, Mor V. Effect of state Medicaid reimbursement rates on hospitalizations from nursing homes. J Am Geriatr Soc. 2004;52(3):393-398. 22. Department of Health & Human Services, Centers for Medicare and Medicaid Services. Medicare Nursing Home Value-Based Purchasing Initiative. SMDL #08-009 [letter]. Baltimore, MD: Center for Medicare & Medicaid Services; 2008. 23. Davis K. Paying for care episodes and care coordination. N Engl J Med. 2007;356(11):1166-1168. 24. Medicare Payment Advisory Commission. Chapter 4: a path to bundled payment around a hospitalization. In: Report to the Congress: Reforming the Delivery System. Washington, DC: Medicare Payment Advisory Commission; 2008; 83-103. 25. D’Agata E, Mitchell SL. Patterns of antimicrobial use among nursing home residents with advanced dementia. Arch Intern Med. 2008;168(4):357-362. 26. Mandell LA, Marrie TJ, Grossman RF, Chow AW, Hyland RH; The Canadian Community-Acquired Pneumonia Working Group. Canadian guidelines for the initial management of community-acquired pneumonia: an evidence-based update by the Canadian Infectious Diseases Society and the Canadian Thoracic Society. Clin Infect Dis. 2000;31(2):383-421. 27. Mandell LA, Bartlett JG, Dowell SF, File TM Jr, Musher DM, Whitney C; Infectious Diseases Society of America. Update of practice guidelines for the management of communityacquired pneumonia in immunocompetent adults. Clin Infect Dis. 2003;37(11):1405-1433. 28. Paladino JA, Eubanks DA, Adelman MH, Schentag JJ. Oncedaily cefepime versus ceftriaxone for nursing home-acquired pneumonia. J Am Geriatr Soc. 2007;55(5):651-657. 29. O’Sullivan NP, Keane CT. Risk factors for colonization with methicillin-resistant Staphylococcus aureus among nursing home residents. J Hosp Infect. 2000;45(3):206-210. 30. Drinka PJ, Stemper ME, Gauerke CD, Miller JE, Goodman BM, Reed KD. Clustering of multiple endemic strains of methicillin-resistant Staphylococcus aureus in a nursing home: an 8-year study. Infect Control Hosp Epidemiol. 2005;26(2):215-218. 31. Naughton BJ, Mylotte JM. Treatment guideline for nursing home-acquired pneumonia based on community practice. J Am Geriatr Soc. 2000;48(1):82-88. 32. Morrison RS, Siu AL. Survival in end-stage dementia following acute illness. JAMA. 2000;284(1):47-52. 33. van der Steen JT, Ooms ME, van der Wal G, Ribbe MW. Pneumonia: the demented patient’s best friend? Discomfort
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Topics in Practice Management
Management of Pneumonia in the Nursing Home Ali A. El-Solh, MD, FCCP; Mike S. Niederman, MD, FCCP; and Paul Drinka, MD
Pneumonia is a major cause of morbidity and mortality among nursing home residents. The approach to managing these patients has lacked uniformity because of the paucity of clinical trials, complexity of underlying comorbid diseases, and heterogeneity of administrative structures. The decision to hospitalize nursing home patients with pneumonia varies among institutions depending on staffing level, availability of diagnostic testing, and laboratory support. In the absence of comparative studies, choice of empirical antibiotic therapy continues to be based on expert opinion. Validated prognostic scoring models are needed for risk stratification. Pneumococcal and influenza vaccination are the primary prevention measures. As of January 2010, Medicare no longer pays for consultation codes; thus, practitioners must instead use existing evaluation and management service codes when providing these services. CHEST 2010; 138(6):1480–1485 Abbreviations: BTS 5 British Thoracic Society; CAP 5 community-acquired pneumonia; CMS 5 Centers for Medicare & Medicaid Services; CPT 5 current procedural terminology; LTCF 5 long-term-care facility; NHAP 5 nursing homeacquired pneumonia; PSI 5 Pneumonia Severity Index
important demographic changes of the past Thecentury and the prolonged life expectancy related to the tremendous development of the medical sciences and technologies contributed to the exponential increase in elderly patients residing in nursing homes. It is estimated that the number of older people who will require nursing home care will reach 5.3 million in 2030.1 Assuming that the incidence of pneumonia in this population remains constant, the total cases of nursing home-acquired pneumonia
Manuscript received May 2, 2010; revision accepted June 14, 2010. Affiliations: From the Division of Pulmonary, Critical Care, and Sleep Medicine (Dr El-Solh), Veterans Affairs Western New York Healthcare System, and Department of Medicine (Dr El-Solh), University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY; Department of Medicine (Dr Niederman), Winthrop-University Hospital, Mineola, NY; Department of Medicine (Dr Niederman), SUNY Stony Brook School of Medicine, Stony Brook, NY; Department of Internal Medicine/Geriatrics (Dr Drinka), University of Wisconsin, Madison, WI; and Medical College of Wisconsin (Dr Drinka), Milwaukee, WI. Correspondence to: Ali El-Solh, MD, FCCP, Division of Pulmonary, Critical Care, and Sleep Medicine, Veterans Affairs Western New York Healthcare System, 3495 Bailey Ave, Buffalo, NY 14215-1199; [email protected] © 2010 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/ site/misc/reprints.xhtml). DOI: 10.1378/chest.10-1135 1480
(NHAP) will approach 1.9 million episodes annually. Currently, the incidence of NHAP varies from 0.3 to 2.3 episodes per 1,000 resident care days.2 The variation in incidence is related to differences in multiple methodologic approaches used in the various studies, including differences in study design, number of facilities evaluated (one vs multiple), intensity of surveillance, case mix, and facility affiliation (US Veterans Affairs vs community nursing homes). According to the latest statistics, nursing home residents account for 10% to 18% of all patients hospitalized for pneumonia, with an average hospital charge of approximately $10,000 per admission.3 This article reviews practical issues that physicians caring for nursing home residents with pneumonia frequently confront. Rather than trying to provide an exhaustive review of the general issues regarding hospitalized patients with NHAP, the article focuses on practice management in which the approach to pneumonia in nursing home settings generates significant controversies.
Diagnosis of Nursing Home Pneumonia The diagnosis of pneumonia in nursing home residents can be challenging. Clinical assessment is Topics in Practice Management
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hampered by impaired communication, nonlocalizing symptoms, and chronic respiratory diseases that compromise accurate diagnosis of any infection in this population. With radiology and laboratory facilities usually off site, limited access to diagnostic tests also compromises evaluation. Even when available, the results of the diagnostic tests are subject to conflicting interpretations. Chest radiographs may be nondiagnostic because of chronic changes or delayed radiographic manifestations. Sputum specimens frequently are contaminated with gram-negative flora colonizing the upper airway, and peripheral leukocyte count may be normal despite bacterial infection. For the evaluation of nursing home residents with suspected lower-respiratory tract infection, the recent guidelines of the Infectious Diseases Society of America recommend using physical examination, pulse oximetry for patients with a respiratory rate . 25 breaths/min, and chest radiography for residents with hypoxia.4 A peripheral WBC count and sputum Gram stain also are recommended, although the validity and utility of diagnostic tests for lower-respiratory tract infection in these settings have not been rigorously evaluated. One classic scenario underlying the diagnostic dilemma in the nursing home is that of aspiration syndromes. Nursing home residents are at an increased risk of aspiration due to decreased host defenses; dysphagia; and impaired swallowing reflex caused by degenerative neurologic diseases, tube feeding, and sedative-hypnotic drug use. Although the difference between aspiration pneumonia and aspiration pneumonitis is established pathologically, the distinction between these two entities on clinical grounds is not always straightforward. The classic assumption that gastric content is sterile and that bacterial pneumonia after gastric aspiration occurs as a secondary superinfection may not be factual in a nursing home setting. Aspiration of nonacidified gastric contents may easily include viable endogenous flora when regurgitated into a colonized oral pharynx before entering the trachea. In the absence of a sensitive biomarker that would separate the two aspiration syndromes,5 the decision to withhold antibiotics in suspected aspiration pneumonitis remains an exercise in academic rather than routine practice. Cytokine profiling in animal models of gastric aspiration has identified a specific lung injury signature.6 The validity of this approach in a clinical scenario has not yet been tested.
most widely studied severity prediction rules were developed as a means of stratifying patients with community-acquired pneumonia (CAP) according to their risk of mortality. The Pneumonia Severity Index (PSI) developed by Fine et al7 was set to identify patients at low risk for death within 30 days of presentation. The model incorporated 20 variables that encompassed demographic, physical examination, laboratory, and radiographic findings. The PSI was not specifically designed for the institutionalized elderly population, and it may in fact be partially skewed against patients residing in nursing homes. The single investigation that used PSI in nursing home patients with pneumonia successfully stratified low- and high-risk groups for 30-day mortality; however, the study was limited by the exclusion of many patients for whom information required to calculate the prognostic index was missing from their medical records.8 An alternative severity assessment tool proposed by the British Thoracic Society (BTS) relies on four clinical features as a means of identifying patients with severe CAP at high risk of mortality.9,10 The BTS rule and its derivatives were never assessed in a nursing home setting. In addition, factors such as raised urea or low diastolic pressure that commonly portend poor outcome in community dwellers may be a transient derangement in nursing home patients. A novel prognostic system, SOAR (systolic BP, oxygenation, age, and respiratory rate),11 was introduced recently to counter the impact of variables thought to discriminate poorly in predicting mortality in old age. The new system is performed similarly to the BTS-recommended rules in patients with CAP,11 but it is yet to be validated in NHAP. One common limitation to all these scoring models is that none account for social needs or take into consideration the functional status of nursing home residents. The Missouri Lower Respiratory Tract Infection Project Risk Score is the only prognostic model that was derived from nursing home residents with lower-respiratory tract infections.2 The model is derived from eight factors that independently predict pneumonia without the need to obtain a chest radiograph. The predicted 30-day mortality ranges from 2.4% to 61.6%. The authors acknowledged that the model needs large-scale validation. Its significance in determining the appropriate level of care and guiding antibiotic treatment has not yet been determined.
Risk Stratification
The decision of when to transfer a nursing home patient with pneumonia to an acute care facility continues to be a matter of debate. The recognition of the high risk of adverse outcomes during hospitalization challenges the dogma of hospitalizing every elderly
Severity assessment is a key element in determining not only patient prognosis but also site of treatment and intensity of medical therapy. The www.chestpubs.org
Decision to Hospitalize
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nursing home resident with pneumonia. Hospitalized older patients are at high risk of developing complications such as falls, delirium, and loss of mobility. In the absence of impending respiratory failure, hypothermia, hemodynamic instability, or renal failure, there is little evidence that hospitalization for NHAP improves outcomes.12,13 More importantly, not only do the two sites of therapy produce about the same immediate events, the functional status of those patients treated in the nursing home setting is more preserved, and total mortality in the 2 months following the acute pneumonia is less compared with a hospitalized cohort.14 In one cluster-randomized trial of 680 residents of long-term-care facilities (LTCFs) with radiographically proven pneumonia, Loeb and colleagues15 demonstrated that a clinical pathway that allowed for oral quinolone therapy reduced the hospitalization rate by 12% and resulted in a cost savings of at least $1,000 per patient without affecting mortality or health-related quality of life. Similarly, a Medicare demonstration project that involved payment to nursing homes to manage sicker residents without hospital transfer did not show a substantial increase in mortality when a variety of conditions were treated in the nursing home.16 Addressing the challenges of providing care to this population requires greater availability of registered nurses and primary-care clinicians who can recognize acute changes in clinical conditions of frail elderly patients, better access to diagnostic and treatment services on site, and increased use of practice guidelines and tools to assist nursing home staff in managing residents’ health conditions.17,18 Hence, specialized nursing home facilities adequately staffed and equipped with onsite chest radiographic and laboratory capabilities are less likely to transfer patients to hospitals for acute episodes of pneumonia. An expert committee of the Infectious Diseases Society of America has proposed the following criteria as a guide for NHAP hospitalization19: 1. The resident is clinically unstable, and the patient’s or the family’s goals indicate that aggressive medical therapy should be urgently initiated. 2. Critical diagnostic tests are not available in the LTCFs. 3. A required or necessary therapy is not available in the facility, or the frequency and intensity of monitoring therapy are beyond the capacity of the LTCF staff. 4. Comfort measures cannot be ensured in the LTCF. 5. Specific infection control measures are not available in the LTCF. Although the committee revised the clinical practice guidelines in 2009, it did not address the criteria 1482
for hospital transfer.4 The Hutt and Kramer20 guideline advanced parallel recommendations (Table 1), but in the absence of standardized criteria for hospital admission, interpretation and comparison of outcome studies remain problematic. Other factors that enter into consideration for transfer to an acute care facility include financial incentive that precludes nursing homes from adequate reimbursement for an acute episode of pneumonia. In a study of nursing homes in 10 states, Intrator and Mor21 found that homes in states with higher Medicaid reimbursement have lower hospitalization rates, controlling for confounding factors and the competing risk of death. A $10 higher daily Medicaid rate was found to be associated with a 9% reduction in the odds of hospitalization. Medicare is beginning a demonstration of a value-based purchasing initiative that will reward nursing homes based in part on lower rates of potentially avoidable hospitalizations.22 In addition, Medicare is exploring bundling payments for 30-day episodes of care for acute conditions, including NHAP. If enacted into law, hospitals and nursing homes would have a mutual financial incentive to collaborate and coordinate their activity to avoid hospitalization of nursing home residents whenever safe and feasible. Nevertheless, both strategies are fraught with pitfalls23,24 and could be counterproductive if support for the infrastructure to manage sicker residents within the nursing home is not available.
Antimicrobial Management Prescription of antimicrobial therapy for NHAP remains a highly contested issue driven by a disagreement on how the condition should be approached Table 1—Proposed Guidelines for Hospitalizing Nursing Home Patients With Pneumonia Guideline
Description
1. Oxygen saturation , 90% on room air at sea level 2. Systolic BP , 90 mm Hg or 20 mm Hg , baseline 3. Respiratory rate . 30 breaths/min or 10 breaths/min . baseline 4. Increase oxygen requirement by 3 L/min or more than baseline 5. Uncontrolled COPD, congestive heart failure, or diabetes mellitus 6. Altered mental status 7. New or increased agitation Transfer to a hospital if the Vital sign assessment every 4 h facility cannot provide:a Laboratory access Parenteral hydration Two licensed nurses per shift Presence of any two symptoms
a
If any one of the listed symptoms warrant it. Topics in Practice Management
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and treated. Should NHAP be recognized as CAP, health-care-associated pneumonia, or hospital-acquired pneumonia? The arguments for and against the inclusion of NHAP in these classifications are beyond the context of this review. Despite the fact that respiratory tract infections remain the primary cause for use of antimicrobial therapy in nursing homes,25 the lack of randomized trials has been a continuous problem for expert panels developing guidelines. The two guidelines that have addressed treatment of pneumonia in the nursing home setting have been consistent in their approach to antibiotic therapy.26,27 The choices for empirical coverage include oral antipneumococcal quinolone alone, amoxicillin/clavulanic acid, or a second-generation oral cephalosporin plus a macrolide other than erythromycin. For residents who develop NHAP not amenable to oral treatment, oncedaily IM therapy with ceftriaxone vs cefepime has been examined in a double-blind study with similar efficacy.28 However, in the absence of outcome data pointing to a superiority of one regimen over another, the choice of treatment depends on knowing the potential pathogens, likelihood of antibiotic resistance, ease of administration, and adverse effect profiles of various agents. Modifying risk factors suggestive of multidrug-resistant organisms include a history of resistant pathogens, antibiotic therapy in the past 3 months, foreign bodies, chronic wounds, recent hospitalization, and dependency on or need for contact care.29,30 One study noted that the 75th percentile for duration of therapy of NHAP within the nursing home was 10 days,31 but the optimal duration of antibiotic treatment is unknown. The prescription of antibiotic therapy for NHAP when it occurs as an expected terminal event has been questioned recently. Limited observational studies25,32,33 have failed to demonstrate that antimicrobial treatment achieves life prolongation in this frail population. There is also increased uncertainty about whether antimicrobial therapy promotes symptomatic relief beyond what can be achieved by high-quality palliative treatment with more conservative modalities. A study by van der Steen and colleagues33 found that the level of discomfort was not different in residents dying of pneumonia whether antimicrobial therapy was prescribed or not. Further, the level of discomfort that occurred at the onset of pneumonia among those residents who survived and were not treated returned to baseline within 1 week in most cases. The tendency of relying on IV therapy in the United States compared with oral antibacterial agents in The Netherlands imposes further burden on these frail patients, including the need to institute physical restraints to avoid patient removal of IV catheters and to obtain frequent blood samples to monitor for toxicity. This difference in approach to NHAP treatwww.chestpubs.org
ment in patients with late dementia reflects a divergence in attitudes of physicians and families with regard to aggressive intervention.34 As emphasized by van der Steen et al,35 optimal care of NHAP includes “prudent consideration of curative treatment, treatment to relieve discomfort, and supportive treatment in view of expected and desirable outcomes.”
Prevention Current US strategies to prevent pneumonia among institutionalized older adults include recommending immunization with pneumococcal polysaccharide vaccine and annual influenza vaccinations.36 However, the effectiveness of these vaccines decreases with increasing age and among individuals with comorbid conditions. It has been suggested that the presumed benefit of the influenza vaccine in the reduction of mortality from pneumonia might have been overestimated.37,38 Various methods to minimize such residual confounding have been applied in various observational studies, leaving little scope for unmeasured confounders, including, for example, the use of laboratory-confirmed influenza as an outcome, restriction of the analyzed population, multivariable regression to adjust for confounders, propensity scores, and others.39 Yet, even after taking such unmeasured confounding into account, influenza vaccination still is associated with substantial reduction in mortality risk.40 The 23-valent pneumococcal polysaccharide vaccine also has been shown to confer protection against all-cause pneumonia and pneumonia-related mortality in nursing home residents, although the protective efficacy of the vaccine did not translate into a reduction in all-cause mortality.41 Standing-order programs have been linked to increase vaccination rates in ambulatory and hospital settings. However, a 2005 survey showed that only 9% of LTCFs use such programs.42 The greatest use of such programs was in government-owned, nonprofit, dual-certified (ie, by both Medicare and Medicaid), and independent LTCFs and in facilities with a lower index of disease acuity. Reducing bacterial colonization of the oropharynx is considered another potential target for the prevention of NHAP. Limited observational studies of aggressive oral care among elderly nursing home patients have uniformly shown a reduced risk of pneumonia in the intervention group.43-45 These studies involved a range of intervention from daily mechanical brushing to weekly professional cleaning. However, the comparison group in the majority of these investigations was left to self-care or no oral care. Such a design would invariably favor the CHEST / 138 / 6 / DECEMBER, 2010
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intervention arm. To that end, any future randomized controlled trials should incorporate daily brushing and flossing as the standard of care before any claim of superiority is made. Meanwhile, the implementation of an oral-care program at each nursing facility ought to become a quality improvement project supported by local and governmental agencies. Billing and Coding Changes There are many unresolved issues with regard to NHAP. At the present level, the health-care system is ill prepared to deal with what promises to be a major public health problem unless medically sound, costeffective strategies for the evaluation, management, and prevention of NHAP are implemented. A conservative Congressional Budget Office estimate suggests that total long-term-care expenditures will increase at a rate of 2.6% per year above inflation over the next 30 years to $195 billion in 2020 and a staggering $270 billion in 2030.46 As a result, changes in administrative and billing procedures have taken the lead. In the 2010 final Medicare Physician Fee Schedule, the Centers for Medicare & Medicaid Services (CMS) announced that Medicare will no longer recognize consultation codes (current procedural terminology [CPT] 99251-99254) for Medicare Part B fee-forservice payment.47 CMS directs providers to report other evaluation management codes for nursing homes (CPT 99304-99310, 99318) in lieu of the consultation codes. These codes recognize the time physicians spend on chart review, documentation, and communication with the patient’s family while at the facility. There are instances when a prolonged service code (CPT 99356-99357) also may be appropriately added. To counter the loss of consultation code revenues, CMS increased the work relative value units for initial nursing facility visits and incorporated the increased use of these visits into the practice expense and malpractice calculations. Subsequent consultations are reported as subsequent visit codes (CPT 99231-99233). The principal physician of record is to append modifier “AI Principal Physician of Record” to the evaluation management code when billed. This modifier will identify the physician who oversees the patient’s care from all other physicians who may be furnishing specialty care.
Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Niederman has received honoraria or consulted for Bayer, Ceragenix, Abbott, Schering-Plough, Merck, Pfizer, Johnson and Johnson, and Nektar and has received grants from Nektar and Bayer. Drs El-Solh and Drinka have reported to CHEST that no potential conflicts of 1484
interest exist with any companies/organizations whose products or services may be discussed in this article.
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