A controlled trial of a critical pathway for treatment of community-acquired pneumonia. CAPITAL Study Investigators. Community-Acquired Pneumonia Intervention Trial Assessing Levofloxacin

JAMA. 2000 Feb 9;283(6):749-55. doi: 10.1001/jama.283.6.749.


Context: Large variations exist among hospitals in the use of treatment resources for community-acquired pneumonia (CAP). Lack of a common approach to the diagnosis and treatment of CAP has been cited as an explanation for these variations.

Objective: To determine if use of a critical pathway improves the efficiency of treatment for CAP without compromising the well-being of patients.

Design: Multicenter controlled clinical trial with cluster randomization and up to 6 weeks of follow-up.

Setting: Nineteen teaching and community hospitals in Canada.

Patients: A total of 1743 patients with CAP presenting to the emergency department at 1 of the participating institutions between January 1 and July 31, 1998.

Intervention: Hospitals were assigned to continue conventional management (n = 10) or implement the critical pathway (n = 9), which consisted of a clinical prediction rule to guide the admission decision, levofloxacin therapy, and practice guidelines.

Main outcome measures: Effectiveness of the critical pathway, as measured by health-related quality of life on the Short-Form 36 Physical Component Summary (SF-36 PCS) scale at 6 weeks; and resource utilization, as measured by the number of bed days per patient managed (BDPM).

Results: Quality of life and the occurrence of complications, readmission, and mortality were not different for the 2 strategies; the 1-sided 95% confidence limit of the between-group difference in the SF-36 PCS change score was 2.4 points, which was within a predefined 3-point boundary for equivalence. Pathway use was associated with a 1.7-day reduction in BDPM (4.4 vs 6.1 days; P = .04) and an 18% decrease in the admission of low-risk patients (31% vs 49%; P = .01). Although inpatients at critical pathway hospitals had more severe disease, they required 1.7 fewer days of intravenous therapy (4.6 vs 6.3 days; P = .01) and were more likely to receive treatment with a single class of antibiotic (64% vs 27%; P<.001).

Conclusion: In this study, implementation of a critical pathway reduced the use of institutional resources without causing adverse effects on the well-being of patients.

Publication types

  • Clinical Trial
  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Anti-Infective Agents / therapeutic use
  • Canada
  • Community-Acquired Infections / therapy
  • Critical Pathways*
  • Female
  • Hospitalization / statistics & numerical data
  • Humans
  • Levofloxacin
  • Male
  • Middle Aged
  • Ofloxacin / therapeutic use
  • Outcome Assessment, Health Care
  • Pneumonia / complications
  • Pneumonia / diagnosis
  • Pneumonia / mortality
  • Pneumonia / therapy*
  • Sickness Impact Profile
  • Statistics, Nonparametric


  • Anti-Infective Agents
  • Levofloxacin
  • Ofloxacin