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Articles: Jordi Carratalà, Núria Fernández-Sabé, Lucía Ortega, Xavier Castellsagué, Beatriz Rosón, Jordi Dorca, Ana Fernández-Agüera, Ricard Verdaguer, Joaquín Martínez, Frederic Manresa, and Francesc Gudiol Outpatient Care Compared with Hospitalization for Community-Acquired Pneumonia: A Randomized Trial in Low-Risk Patients Ann Intern Med 2005; 142: 165-172 [Abstract] [Full text] [PDF]

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Use of the Pneumonia Severity Index to Determine Site of Care

John H. Kvasnicka   (8 March 2005)

Use of the Pneumonia Severity Index to Determine Site of Care 8 March 2005
John H. Kvasnicka, M. D. St. Joseph's Hospital, St. Paul, MN Send rapid response to journal: Re: Use of the Pneumonia Severity Index to Determine Site of Care jkvasnicka{at}healtheast.org John H. Kvasnicka	As noted by Carratalà, et. al.(1), “The Pneumonia Severity Index (PSI) has been advocated as an objective measure of risk stratification to help determine the initial site of treatment for patients with community- acquired pneumonia.” Unfortunately this study does little to test that hypothesis. Fully 47% of PSI class II or III patients were excluded prior to randomization because they were judged to be too sick to manage as outpatients or were otherwise not suitable for outpatient therapy. Thus this study actually tested a combined approach of using the PSI along with several additional criteria devised by the investigators. This finding is remarkably consistent with prior studies of attempts to apply the PSI to actual decisions to treat patients with pneumonia as outpatients. Fine, et.al.(2) validated the PSI criteria in the Pneumonia Patient Outcomes Research Team (PORT) cohort. In this cohort, 24% of PSI class I patients, 49% of class II patients, and 78% of class III patients were treated initially as inpatients. Marrie, et.al.(3) studied a critical pathway that included PSI scoring for pneumonia patients. In the intervention arm, 31% of class I-III patients were admitted. In all these studies, the PSI was augmented by additional criteria of some type to determine admission criteria. The concept of using the PSI to determine treatment decisions in an unselected population remains an untested hypothesis. Carratalà, et. al. used the PSI in a very highly selected group of already low-risk patients. It would be a mistake to conclude that this study validates use of the PSI to determine treatment decisions in other populations of patients. (1) J. Carratalà, N. Fernández-Sabé, L. Ortega, X. Castellsagué, B. Rosón, J. Dorca, A. Fernández-Agüera, R. Verdaguer, J. Martínez, F. Manresa and F. Gudiol. Outpatient Care Compared with Hospitalization for Community-Acquired Pneumonia: A Randomized Trial in Low-Risk Patients. Ann Intern Med 2005; 165-172. (2) Fine, Michael J., Auble, Thomas E., Yealy, Donald M., Hanusa, Barbara H., Weissfeld, Lisa A., Singer, Daniel E., Coley, Christopher M., Marrie, Thomas J., Kapoor, Wishwa N. A Prediction Rule to Identify Low-Risk Patients with Community-Acquired Pneumonia. N Engl J Med 1997; 336: 243- 250. (3) Thomas J. Marrie; Catherine Y. Lau; Susan L. Wheeler; Cindy J. Wong; Margaret K. Vandervoort; Brian G. Feagan; for the CAPITAL Study Investigators. A Controlled Trial of a Critical Pathway for Treatment of Community-Acquired Pneumonia. JAMA 2000; 283: 749-755 Conflict of Interest: None declared