The effects of an institutional care map on the admission rates and medical costs in women with acute pyelonephritis

Objectives: There are no disposition guidelines for the management of acute pyelonephritis (APN) in women. Recent studies have demonstrated considerable variation in admission rates for women with APN. The authors evaluated the effect of a predetermined, written protocol for the management of APN on the admission rates and medical costs in adult women with APN. Methods: From January 2006 to December 2006, women presenting to an emergency department (ED) with APN (the after group) were prospectively enrolled. Patients were managed using a predetermined, written protocol that included intravenous ciprofloxacin, antipyretics, antiemetics, and hydration. After a 6-hour observation, patients were reevaluated and discharged on oral medications if they met prede-fined discharge criteria. Data from all APN patients who presented from May 2003 to December 2005 (before the written protocol was adopted) were also collected for comparative analysis (the before group). These two groups were compared in terms of admission rates, rates of revisits to the ED within 7 days, ultimate admission rate, and medical costs incurred. Mean costs of admission and outpatientbased APN management were determined by analyzing the hospital cost database of the before group. Results: There were 388 and 139 patients in the before and after groups, respectively. The initial admission rate of the after group was significantly lower than that of the before group (15.1% vs. 47.7%, p < 0.01). However, no significant difference was observed between the two groups with respect to ED revisit rates after initial discharge (11.9% vs. 15.1%, p = 0.38). For initially discharged patients, 8.5% of the before group and 5.8% of the after group were later admitted, which was not significantly different (p = 0.42). Mean direct medical costs (in U.S. dollars) for initially hospitalized and discharged patients in the before group were $1,520 and $263 (p < 0.001). With the price rise during the study period, it was not reasonable to sum and calculate the mean cost with all before and after protocol costs. Conclusions: Use of a standardized written protocol reduced the admission rates and medical costs in women presenting to the ED with APN.