Comparative Evaluation of the Effectiveness of Treatment of Patients with Community-Acquired Pneumonia in Inpatient, Day-Care, and Outpatient Settings

The dissertation is devoted to a comparative evaluation of the clinical, social, and economic effectiveness of treatment of patients with community-acquired pneumonia under three forms of organization of medical care: a 24-hour inpatient hospital, a day-care hospital, and a polyclinic. The work analyzes epidemiological data, etiology, and modern approaches to the diagnosis of the disease, as well as existing consensus recommendations on its management. Particular attention is paid to hospital-replacing technologies as a way of optimizing expenditures while maintaining the quality of treatment.

The methodological basis is formed by clinical, socio-hygienic, and statistical methods, including discriminant and multiple regression analyses. On the basis of the data obtained, criteria for choosing the optimal form of medical care were developed and indications for referring patients to treatment in the day-care hospital were determined. It is shown that the day-care hospital has advantages in clinical, social, and economic respects, while the combination of clinical and social factors makes it possible to predict the course and outcomes of community-acquired pneumonia.

Relevance of the Problem

Despite the continuous improvement of diagnostic and treatment methods, pneumonia remains a pressing problem of contemporary healthcare because of its high morbidity and mortality, as well as substantial direct and indirect costs of treatment.

The incidence of pneumonia is 3.6–16.0 per 1000 adults, and this rate shows no tendency to decrease. A significant proportion of cases (74.4%) are persons of working age (Krylov A.A., 1994). In the structure of respiratory diseases, pneumonia accounts for more than 60.0% of cases, which ensures its stable 1st place (Chuchalin A.G., 2004). Delayed initiation of treatment, irrational choice of antibacterial drugs (ABDs) and of the organizational form of medical care reduce the effectiveness of therapy and lead to adverse medical and social consequences: a protracted course, an increase in severe forms and complications of the disease, and death. In industrially developed countries, pneumonia ranks 6th among all causes of death and 1st among causes of mortality from nosocomial infections (Avdeev S.N., Chuchalin A.G., 2001; Goldstein R.J. et al., 1997).

Most clinical practice guidelines recommend hospitalizing patients only in cases of severe pneumonia (Fine M.J. et al., 1997; Woodhead M.A., 2002). In Western Europe and North America, up to 80.0% of patients with community-acquired pneumonia (CAP) are treated on an outpatient basis. In the Russian Federation, the diagnosis of pneumonia has long served as an indication for hospitalization. At the same time, analysis of the activity of medical institutions shows that in 20.0–50.0% of cases patients are hospitalized on relative indications (Kovalenko A.N., 2001).

Therefore, the adaptation of modern international recommendations on the choice of the place of treatment for patients with CAP to the existing conditions of functioning of national healthcare is currently of particular relevance, which is especially important under conditions of underfunding of the sector (Kalininskaya A.A., Shlyafer S.I., 2000; Ostrovsky A.N., 2000). Of growing interest in this context are hospital-replacing forms, in particular the day-care hospital (DCH), the application of which is advisable when it is difficult to carry out the necessary scope of diagnostic and treatment measures in outpatient-polyclinic settings. The effectiveness of the DCH as a form of organization of medical care for a number of diseases, including CAP, has been noted by a number of researchers (Alekseev N.A. et al., 2000; Galkin R.A. et al., 2000; Starodubov V.I. et al., 2001). However, the data available in the literature on the treatment of patients with CAP in the DCH do not constitute a comprehensive assessment. Publications reflecting the possibilities of the DCH in the treatment of CAP compared with traditional forms of organization of medical care — the inpatient hospital and the polyclinic — are absent.

In this regard, a comparative analysis of the effectiveness of treatment of patients with CAP under different forms of organization of medical care and the development of algorithms for choosing the optimal form are relevant and promising, which determined the topic of the present study.

Aim of the Study

To develop recommendations for choosing the optimal form of organization of medical care for patients with community-acquired pneumonia.

Objectives of the Study

1. Comparative evaluation of the clinical effectiveness of treatment of patients with community-acquired pneumonia in a 24-hour inpatient hospital, a day-care hospital, and a polyclinic.

2. Analysis of the social and economic effectiveness of treatment of patients in a 24-hour inpatient hospital, a day-care hospital, and a polyclinic. Determination of patients' social satisfaction with the organization of medical care in medical institutions.

3. Study of living conditions, medical activity, hygienic literacy, and psychological status of patients with community-acquired pneumonia.

4. Identification of socio-hygienic and medical factors influencing the effectiveness of treatment of patients under different conditions.

5. Substantiation of criteria for choosing the optimal form of organization of medical care for patients with community-acquired pneumonia. Determination of indications for treatment of patients in the day-care hospital.

Scientific Novelty

For the first time, a comprehensive comparative analysis of the effectiveness of treatment of patients with CAP under different forms of organization of medical care — inpatient hospital, DCH, polyclinic — has been carried out. The state of the psychoemotional status has been studied in relation to the place of treatment of patients. For the first time, on the basis of discriminant and multiple regression analyses, the degree of influence of clinical, biomedical, and social factors on the course and outcomes of CAP has been determined under different conditions of patient treatment. Criteria for choosing the place of treatment of patients with CAP have been developed, and indications for referring patients to treatment in the DCH have been determined.

Practical Significance

The application of the developed recommendations on the choice of the optimal form of organization of medical care for patients with CAP in the work of therapists will ensure an improvement in the quality of treatment of this category of patients. The results of the study of the psychoemotional status, lifestyle, medical activity, and hygienic literacy of patients with CAP can be used by physicians of preventive departments when organizing preventive and health-promoting measures. Treatment of patients with CAP in the DCH will make it possible to obtain a socio-economic effect through a reduction in direct and indirect costs and a decrease in the volume of expensive inpatient care.

Main Provisions Submitted for Defense

1. Rational empirical antibacterial therapy of non-severe community-acquired pneumonia, based on epidemiological, biomedical, and clinical criteria, leads to recovery of patients regardless of the form of organization of medical care.

2. The day-care hospital as a form of organization of medical care for patients with community-acquired pneumonia has a number of advantages in clinical, social, and economic aspects compared with the 24-hour inpatient hospital and the polyclinic.

3. Medical activity, hygienic literacy, and social status of patients influence the course and outcomes of community-acquired pneumonia. The combination of clinical and social factors makes it possible to predict the characteristics of the course of the disease and to choose the optimal form of organization of medical care.

Approval of the Work

The main provisions of the work were reported and discussed at interregional conferences of young researchers "Postgraduate Readings" (Samara, 2002, 2006), at the symposium "Development of State Medicine in Russia" (Moscow, 2003), at the VII Pacific Scientific and Practical Conference of Students and Young Scientists with International Participation (Vladivostok, 2006), at the V All-Russian University Scientific and Practical Conference of Young Scientists and Students in Medicine (Tula, 2006), at the I International Pirogov Scientific Medical Conference (Moscow, 2006), and at inter-university scientific conferences of young scientists and students (Izhevsk, 2004, 2005).

Publications

On the topic of the dissertation, 11 scientific works and an information letter "Modern Tactics of Management of Patients with Community-Acquired Pneumonia," approved by the Ministry of Health of the Udmurt Republic, have been published.

Implementation into Practice

The results of the study have been implemented into the practice of medical care for patients with CAP in the day-care hospitals of Municipal Healthcare Institution City Polyclinic No. 2, Municipal Healthcare Institution City Polyclinic No. 3 of the city of Izhevsk and of the Federal State Healthcare Institution "Medical Unit of the Ministry of Internal Affairs of the Udmurt Republic." The main provisions of the present study are used in teaching at the Departments of Public Health, Economics and Management of Healthcare of the Faculty of Professional Development and Retraining and of Propaedeutics of Internal Diseases with a Course in Nursing of the Izhevsk State Medical Academy.

Structure and Volume of the Dissertation

The work consists of an introduction, five chapters, a conclusion, findings, a list of references, and appendices. The dissertation is set out on 194 pages of typewritten text, contains 65 tables, and 21 figures. The bibliography includes 194 domestic and 55 foreign sources.