Here is the PICO analysis for the article:
Full Article Title:
Effect of a Clinical Pathway to Reduce Hospitalizations in Nursing Home Residents With Pneumonia: A Randomized Controlled Trial
Authors: Loeb M, Carusone SC, Goeree R, et al.
Journal: JAMA (2006); 295(21):2503–2510
✅ PICO Analysis
Type of Study:
Cluster randomised controlled trial of 22 nursing homes in Ontario, Canada
P – Population
- Setting:22 nursing homes in Hamilton, Ontario, Canada (each with ≥100 beds)
- Participants:
- 680 residents aged ≥65 years with suspected pneumonia or lower respiratory tract infection (LRTI)
- 327 assigned to the clinical pathway group
- 353 assigned to usual care
- Inclusion required ≥2 clinical signs (e.g., new/increased cough, sputum, fever, pleuritic chest pain)
- Exclusion Criteria:Life expectancy <30 days, fluoroquinolone allergy, or advance directive precluding hospital transfer
I – Intervention
Clinical Pathway for On-Site Treatment of Pneumonia in Nursing Homes, including:
- Standardised clinical assessment by research nurses
- Treatment delivered in the nursing home if resident met all stability criteria:
- Pulse ≤100/min
- RR <30/min
- SBP ≥90 mm Hg
- O2 saturation ≥92% (or ≥90% for COPD)
- Able to eat and drink
- Use of:
- Oral levofloxacin (empiric antibiotic)
- Portable chest X-rays
- Oxygen therapy and hypodermoclysis (subcutaneous fluids)
- Close monitoring by study nurses
- Residents were transferred to hospital only if criteria not met or condition deteriorated
C – Comparison
- Usual Care Group:
- Standard physician-directed care
- Decision to hospitalise or initiate treatment was left to physicians and nursing home staff
- Study nurses collected observation data but did not intervene
O – Outcomes
Primary Outcomes:
- Hospitalisation rate:
- Clinical pathway: 10% (34/327)
- Usual care: 22% (76/353)
- 12% absolute reduction in admissions (95% CI, 5–18%; P = .001)
- Hospital days per resident:
- Pathway: 0.79 days
- Usual care: 1.74 days
- Mean difference: 0.95 fewer days per resident (P = .004)
Secondary Outcomes:
- Mortality:
- No significant difference (8% vs 9%, P = .23)
- Health-related quality of life (HRQoL):
- No significant difference at 30 days
- Functional status (Barthel Index):
- No significant difference
- Time to stabilisation of vital signs:
- No significant difference (≈2.5 days both groups)
- Adverse Events:
- No significant differences in nausea, vomiting, diarrhoea, rash
- Cost Analysis (Third-party payer perspective):
- Clinical pathway group saved $1016 per resident (Canadian $ converted to USD)
- Savings driven by reduced hospitalisation, ED visits, and transport costs
- US system cost-savings projected at $1517 per resident
Summary Conclusion
This cluster RCT demonstrated that a structured clinical pathway for on-site treatment of pneumonia in nursing home residents significantly reduced hospitalisation rates and costs without compromising mortality, functional status, or quality of life. These findings suggest that treating stable pneumonia cases in situ using standardised protocols is both safe and cost-effective, with significant potential to reduce health system burden—especially during peak respiratory illness seasons .
Life In The Slower Lane 
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