Implementing a Standardized Order Set for Community-acquired Pneumonia: Impact on Mortality and Cost

Background: Order sets have shown some success in improving compliance with clinical guidelines, as well as patient and financial outcomes. Baylor Health Care System (BHCS) deployed a standardized adult pneumonia order set throughout its eight acute care hospitals in 2006.

Methods: All non-comfort care adult patients admitted with community-acquired pneumonia who met The Joint Commission definition of pneumonia and were discharged from an acute care BHCS hospital for a 30-month period (March 1, 2006-August 31, 2008) were included. Mortality, core measures compliance, and direct cost were compared for patients who did and did not receive the order set.

Results: Some 4,454 patients met study inclusion criteria. Significant variation in use between hospitals, however, persisted. Unadjusted analysis showed significant reductions in inhospital mortality, 30-day mortality, and direct cost and a significant increase in core measures compliance. Following risk adjustment, the difference in core measures compliance was retained (relative risk [95% confidence interval (C.I.)] 1.08 [1.03, 1.12]). Inhospital mortality and 30-day mortality reductions both approached significance (hazard ratios [95% C.I.] of 0.73 [0.51,1.02] and 0.79 [0.62, 1.00], respectively). Mean (standard error) benefits of order set use in in-hospital mortality and costs were estimated at 1.67 (0.62)% and $383 (207). The incremental cost-effectiveness ratio point estimate was -$22,882 per life saved, with an upper 95% confidence limit of$1,278 per life saved.

Discussion: Widespread adoption of the order set was achieved, with use consistently at or above 75% across all BHCS acute care hospitals since February 2007. The reductions in mortality observed with order set use, in combination with the favorable estimate of cost-effectiveness, make standardized evidence-based order sets an attractive improvement methodology for improving quality of pneumonia care.