Here is the standardised PICO analysis for the thirty-seventh uploaded article:
Full Title
Effect of a Clinical Pathway to Reduce Hospitalizations in Nursing Home Residents With Pneumonia: A Randomized Controlled Trial
Authors: Mark Loeb, Soo Chan Carusone, Ron Goeree, et al.
Journal: JAMA, 2006; 295(21):2503–2510
Type of Study
Cluster Randomised Controlled Trial across 22 nursing homes in Ontario, Canada
PICO Summary
Population (P)
- 680 residents aged ≥65 years from 22 nursing homes
- Diagnosed with pneumonia or lower respiratory tract infection (LRTI) per standardised criteria
- Exclusions: residents expected to die within 30 days, those with serious allergy to fluoroquinolones, or pre-existing advance directives precluding hospitalisation
Intervention (I)
Clinical pathway for on-site management of pneumonia, including:
- Oral levofloxacin treatment
- Portable chest radiograph within 12 hours
- Pulse oximetry, hydration via hypodermoclysis, and routine vital sign monitoring
- Clear criteria for hospital transfer based on oxygenation, pulse, BP, and ability to eat/drink
- Study nurse support (implementation, monitoring, escalation if criteria not met)
Comparison (C)
- Usual care, in which treatment decisions were made by nursing home physicians
- Typically included off-site hospital transfers and broader physician discretion
Outcomes (O)
Primary outcomes:
- Hospital admissions:
- 10% in the clinical pathway group vs 22% in usual care (weighted mean reduction: 12%, 95% CI 5–18%, p=0.001)
- Hospital days per resident:
- 0.79 vs 1.74 (mean difference: 0.95 days, p=0.004)
Secondary outcomes:
- Mortality: 8% (clinical pathway) vs 9% (usual care); difference not significant (p=0.23)
- Quality of life and functional status: No significant differences
- Emergency department visits (without admission): Similar between groups (1.2% vs 1.6%, p=0.72)
- Adverse events: Low and similar (e.g. nausea, rash, tendinitis)
- Cost: Mean savings of US$1,016 per resident (up to $1,517 using US healthcare cost estimates)
Findings Summary
This study demonstrates that a nurse-led, structured clinical pathway for treating pneumonia and LRTIs on-site in nursing homes:
- Significantly reduces hospitalisations and hospital days
- Achieves comparable clinical outcomes (mortality, quality of life)
- Provides substantial cost savings
- Facilitates timely treatment, reduced disruption, and avoidance of hospital-associated harms
Importantly, this approach is both clinically safe and economically viable, and scalable across long-term care settings, especially with supporting infrastructure and trained staff.
Life In The Slower Lane 
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