Life In The Slower Lane

Here is the PICO analysis for the article:

Full Article Title:

Treatment Decisions for Infections Occurring in Nursing Home Residents

Authors: Peter D. Mott, MD; William H. Barker, MD

Journal: Journal of the American Geriatrics Society (JAGS) (1988); 36(9):820–824

DOI: 10.1111/j.1532-5415.1988.tb04266.x

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✅ PICO Analysis

Type of Study:

Retrospective cohort study evaluating medical decision-making guided by care category assignments over a 7-year period

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P – Population

• Setting:One skilled nursing facility (SNF) in Rochester, New York, managed by a consistent group of five internists
• Participants:
  • 110 nursing home residents followed for 3,172 patient-months
  • Median age, comorbidity, and functional status not explicitly reported but described as similar to national SNF norms
  • Residents were prospectively assigned to one of four medical care categories:
    1. Maximum care (full hospital and intensive care access)
    2. Intermediate care (hospitalisation but avoiding intensive care)
    3. Intermediate, less aggressive care (antibiotics allowed, hospital avoided)
    4. Comfort care only (no hospitalisation or curative treatment; antibiotics for comfort only)

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I – Intervention

• Structured care plan assignment used to guide decisions about hospitalisation and antibiotic treatment in the event of acute infection
• Assignments made through patient-family-clinician consensus and updated at each visit
• Clinical decisions aligned with care category: e.g., antibiotic use and hospitalisation for pneumonia guided by the category designation

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C – Comparison

• Implicit comparison between residents in different care categories:
  • Maximum care vs comfort care
  • Intermediate groups with partial treatment privileges
  • Outcomes for infections treated in SNF vs hospital, and with vs without antibiotics

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O – Outcomes

Person-Centred Outcomes:

• Mortality:
  • Overall 7-year mortality: 65% (72/110)
  • Infection-related deaths: 63% of total deaths
  • Pneumonia was the most common cause of death (44%)
  • Comfort care group had 87% mortality, with 85% dying in the nursing home

Process Outcomes:

From Tables 1–4:

• Acute medically attended problems:
  • 522 total episodes; 54% due to infection
  • Infections caused 48% of hospitalisations
  • Among comfort care patients, 77% of all acute problems were infections (vs 49% for maximum care)
  • Antibiotic use for pneumonia in SNF:
    • Maximum care: 97% treated
    • Comfort care: 50% treated
  • Antibiotic use for UTI in SNF:
    • Maximum care: 100%
    • Comfort care: 62%
  • Antibiotic use for skin infections:
    • Maximum care: 100%
    • Comfort care: 57%

Health System Outcomes:

• Hospitalisation for infection:
  • Comfort care patients were hospitalised much less (e.g., 13% of pneumonia cases vs 48% for maximum care)
  • Overall, 31% of respiratory infections and 28% of UTIs were managed in hospital across all care levels
• Communication and continuity challenges:
  • Hospitalisation decisions were influenced by advance directives and physician familiarity
  • Covering physicians were more likely to hospitalise or treat aggressively if unfamiliar with care plan 

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Summary Conclusion

This early and insightful study demonstrated that structured advance care planning in nursing homes, categorising residents by treatment preference (from maximum to comfort care), significantly influenced rates of hospitalisation and antibiotic use for infection. While infection remained a major cause of death, comfort care residents received significantly fewer interventions, aligning with pre-defined goals of care. The study underscores the impact of proactive, patient-informed treatment planning on clinical outcomes in aged care settings and the complexity of managing infections in the context of person-centred goals .

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