The PSI risk class was calculated based on the 20 prognostic variables collected retrospectively during the medical record review. Trained research nurses collected the following baseline data using a medical record review: patient sociodemographics, initial vital signs and mental status, comorbid conditions, medical treatments before presentation, physical examination findings, pertinent laboratory test results, and chest radiography findings from the time of presentation. More specifically, we focused on baseline patient characteristics that are not prognostic factors contained in the PSI, such as preexisting medical treatments, coexisting comorbid illnesses, or medical or psychosocial contraindications to outpatient care. The aim of the present study was to identify the patient, physician, and emergency department characteristics associated with the hospitalization of low-risk patients enrolled in the EDCAP trial. 9, 10 Identifying these factors and understanding whether hospitalized low-risk patients have one or more of these factors at presentation could lead to further improvements in the efficiency of hospital use among patients with pneumonia and improved interventions to guide the initial site of treatment for such patients. Limited data document the risk factors for the hospitalization of low-risk patients with pneumonia. 6 – 8 Despite the implementation of interventions to increase the proportion of low-risk patients treated in the outpatient setting in these trials, the proportion of low-risk patients hospitalized ranged from 31% to 62.5%. 5 Three previous studies, including the recently completed Emergency Department Community-Acquired Pneumonia (EDCAP) trial, demonstrated the effectiveness and safety of using the PSI to reduce the hospitalization of low-risk patients. The Pneumonia Severity Index (PSI) is a validated prediction rule for prognosis that identifies patients with pneumonia at low risk for 30-day mortality and other adverse medical outcomes. Other research has demonstrated that physicians may overestimate the severity of illness in low-risk patients with pneumonia, leading to potentially unnecessary hospitalizations rather than the outpatient treatment that is often preferred by patients. 2 Owing to the large cost differences associated with the site of treatment, increasing outpatient management of low-risk patients is one approach to improve the cost efficiency of care for this illness. 1 The magnitude of resource use for pneumonia is directly related to inpatient treatment, which costs approximately 20 times as much as outpatient care. Community-acquired pneumonia (designated pneumonia) causes 4 million episodes of illness and more than 1 million hospital admissions in the United States each year.
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