Increasing outpatient treatment of mild community-acquired pneumonia: systematic review and meta-analysis

In order to identify, synthesise and interpret the evidence relating to strategies to increase the proportion of low-risk patients with community-acquired pneumonia treated in the community, we conducted a systematic review of intervention studies conducted between 1981-2010. Articles were included if they compared strategies to increase outpatient care with usual care. Outcomes were: the proportion of patients treated as outpatients, mortality, hospital re-admissions, health related quality of life, return to usual activities and patient satisfaction with care. The main analysis included six studies. The interventions in these studies were generally complex, but all involved the use of a severity score to identify low-risk patients. Overall, a significantly larger numbers of patients were treated in the community with these interventions (OR 2.31, 95% CI 2.03-2.63). The interventions appear safe, with no significant differences in mortality (OR 0.83, 95% CI 0.59-1.17), hospital readmissions (OR 1.08, 95% CI 0.82-1.42) or patient satisfaction with care (OR 1.21, 95% CI 0.97-1.49) between the intervention and control groups. There was insufficient data regarding quality of life or return to usual activities. All studies had significant limitations. The available evidence suggests that interventions to increase the proportion of patients treated in the community are safe, effective and acceptable to patients.