Volume 184 - Issue 3
Safety of hospital in the home
Authors: Les J Toop, Michael J Epton, Graham R B McGeoch, G Ian Town, Simon M H Wynn-Thomas, Robin D Dawson, Michael C Hlavac, Anja M Werno and Paul D Abernethy
Med J Aust 2006; 184 (3): 142-144.
Published online: 6 February 2006
Published online: 6 February 2006
Dee A Mangin (née Richards),* Les J Toop,† Michael J Epton,‡ Graham R B McGeoch,§ G Ian Town,¶ Simon M H Wynn-Thomas,** Robin D Dawson,†† Michael C Hlavac,‡‡ Anja M Werno,§§ Paul D Abernethy¶¶
* Senior Lecturer, † Head, †† Research Fellow, Department of Public Health and General Practice, ‡ Senior Lecturer, ¶ Dean, ‡‡ Research Fellow, Department of Medicine, Christchurch School of Medicine and Health Services, Otago University, PO Box 4345, Christchurch, New Zealand; § Director, Community Care, ** Medical Director, Extended Care @ Home, ¶¶ Manager, Health Services, Pegasus Health Independent Practitioners Association, Christchurch, NZ; §§ Community Patholgist, Canterbury Health Laboratories, Christchurch, NZ. derelie.manginATchmeds.ac.nz
In reply: Thank you for the opportunity to reply to the letter from Cheng et al. The mortality figures we cited are correct.1 The cited article by Lim et al supports our statement that “Patients with a CURB-65 score of 0–2 have a low mortality (0.7%–9.2%)” (Table 4 shows mortality for CURB-65 score 0 is 0.7% and for score 2 is 9.2%).2 The 3% figure in the abstract is a summary measure obscuring the difference across the CURB 0–2 range — important information for anyone considering community management of community-acquired pneumonia where, we agree, safety is paramount. The rate of 1.7% cited by Cheng et al is for a modified CURB-65 score, which adds a further point, and thus is for the equivalent of CURB-65 scores of < 1.3
Cheng et al correctly observe our study was not powered to detect mortality differences. As explained in our discussion, mortality was not a primary outcome measure. With low mortality, large numbers are required to detect a statistically significant difference — the base rate of 3% in the validation study would require 10 602 patients in a randomised controlled trial to detect a 33% relative (1% absolute) increase in mortality. The study did provide for informed consent (including the possibility of readmission) and the ability to summon urgent attention.
Careful patient selection, routine twice-daily nurse and daily doctor visits, along with a highly trained nurse available by telephone 24 hours a day who can dispatch a doctor or nurse immediately, provides a structure that should match hospital care. Careful patient monitoring will detect failure to respond as expected.
It is important to treat in hospital those who will benefit, but not feasible to admit all with potential mortality risk (nor is there evidence of benefit). Hospitalisation also has risks. With this tool for predicting accurately who will suffer worse outcomes, it could be argued there has to be good evidence that better outcomes will result from continuing inpatient treatment of mild to moderate community-acquired pneumonia.
These wider issues are worthy of debate. There is an assumption by some professionals and consumers that hospital-sanctioned death is more acceptable, that everything possible has been done, and that community-based death implies unsatisfactory management. As a counterpoint to this, there is a clear patient preference for treatment in the home where possible. Avian influenza may, of course, drastically redefine our expectations about locus of care and of death.
References
- Richards DA, Toop LJ, Epton MJ, et al. Home management of mild to moderately severe community-acquired pneumonia: a randomised controlled trial. Med J Aust 2005; 183: 235-238.
- Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003; 58: 377-382. 0_CHDFHGCA
- Aujesky D, Auble TE, Yealy DM, et al. Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia. Am J Med 2005; 118: 384-392. 0_i1091554