Principal Diagnosis Of Pneumonia Research Articles

Etiology, Treatments, and Outcomes of Patients With Severe Community-Acquired Pneumonia in a Large U.S. Sample.

Compare the clinical practice and outcomes in severe community-acquired pneumonia (sCAP) patients to those in non-sCAP patients using guideline-defined criteria for sCAP. Retrospective observational cohort study. One hundred seventy-seven U.S. hospitals within the Premier Healthcare Database. Hospitalized adult (≥ 18 yr old) patients with pneumonia. Adult patients (≥ 18 yr old) with a principal diagnosis of pneumonia or a secondary diagnosis of pneumonia paired with a principal diagnosis of sepsis or respiratory failure were included. Patients with at least one guideline-defined major criterion for severe pneumonia were compared with patients with nonsevere disease. Among 154,799 patients with pneumonia, 21,805 (14.1%) met criteria for sCAP. They had higher organ failure scores (1.9 vs 0.63; p < 0.001) and inpatient mortality (22.0 vs 5.0%; p < 0.001), longer lengths of stay (8 vs 5 d; p < 0.001), and higher costs ($20,046 vs $7,543; p < 0.001) than those with nonsevere disease. Patients with sCAP had twice the rate of positive blood cultures (10.0% vs 4.5%; p < 0.001) and respiratory cultures (34.2 vs 21.1%; p < 0.001) and more often had isolates resistant to first-line community-acquired pneumonia antibiotics (10% of severe vs 3.1% of nonsevere; p < 0.001). Regardless of disease severity, Streptococcus pneumoniae was the most common pathogen recovered from blood cultures and Staphylococcus aureus and Pseudomonas species were the most common pathogens recovered from the respiratory tract. Although few patients with sCAP had cultures positive for a resistant organism, 65% received vancomycin and 42.8% received piperacillin-tazobactam. sCAP patients had worse outcomes and twice the rate of culture positivity. S. aureus and S. pneumoniae were the most common organisms in respiratory and blood specimens, respectively. Although only recommended for sCAP patients, nearly all pneumonia patients received blood cultures, a quarter of nonsevere patients received sputum cultures, and treatment with broad-spectrum agents was widespread, indicating fertile ground for antimicrobial and diagnostic stewardship programs.

The Impact of Principal Diagnosis on Readmission Risk among Patients Hospitalized for Community-Acquired Pneumonia.

Coding variation distorts performance/outcome statistics not eliminated by risk adjustment. Among 1596 community-acquired pneumonia patients hospitalized from 1998 to 2012 identified using an evidence-based algorithm, the authors measured the association of principal diagnosis (PD) with 30-day readmission, stratified by Pneumonia Severity Index risk class. The 152 readmitted patients were more ill (Pneumonia Severity Index class V 38.8% versus 25.8%) and less likely to have a pneumonia PD (52.6% versus 69.9%). Among patients with PDs of pneumonia, respiratory failure, sepsis, and aspiration, mortality/readmission rates were 3.9/8.5%, 28.8/14.0%, 24.7/19.6%, and 9.0/15.0%, respectively. The nonpneumonia PDs were associated with a greater risk of adjusted 30-day readmission: respiratory failure odds ratio (OR) 1.89 (95% confidence interval [CI], 1.13-3.15), sepsis OR 2.54 (95% CI, 1.52-4.26), and possibly aspiration OR 1.73 (95% CI, 0.88-3.41). With increasing use of alternative PDs among pneumonia patients, quality reporting must account for variations in condition coding practices. Rigorous risk adjustment does not eliminate the need for accurate, consistent case definition in producing valid quality measures.

Association between Air Pollution and Risk of Hospital Admission for Pediatric Pneumonia in a Tropical City, Kaohsiung, Taiwan

Recent evidences have shown that particulate matter (PM) and other air pollutants are associated with pulmonary and systemic inflammation; however, the relationship between air pollutants and the risk of admission for pediatric pneumonia has not been well surveyed. This study aimed to estimate the hazards of air pollutants on the risk of pediatric pneumonia emergency department (ED) visits and hospitalization. Data on PM2.5 (PM with an aerodynamic diameter smaller than 2.5 μm), PM10 (PM with an aerodynamic diameter smaller than 10 μm), sulfur dioxide (SO2), nitrogen dioxide (NO2), and ozone (O3) in each of the 11 air monitoring stations in Kaohsiung city were collected. The medical records of non-traumatic patients under 17 years of age who had visited the ED between 2008 to 2013, with a principal diagnosis of pneumonia were extracted. We evaluated the relationship between air pollutant exposure and the risk of admission and length of hospital stay (LOS). An interquartile range increments of PM2.5 (odds ratio [OR]: 1.677, 95% confidence interval [CI]: 1.381–2.041), PM10 (OR: 1.568, 95% CI: 1.312–1.880), NO2 (OR: 1.383, 95% CI: 1.179–1.625), SO2 (OR: 1.261, 95% CI: 1.170–1.361), and O3 (OR: 1.182, 95% CI: 1.024–1.366) were statistically significantly associated with the risk of pediatric pneumonia hospitalization on lag 0–3. In the two-pollutant model, after adjusting for NO2 (OR: 1.534, 95% CI: 1.206–1.958), SO2 (OR: 1.534, 95% CI: 1.206–1.958), or O3 (OR: 1.741, 95% CI: 1.385–2.196), PM2.5 was still statistically significantly associated with pediatric pneumonia hospitalization. Furthermore, higher PM2.5 concentration (> 45 μg/m3) was associated with prolonged hospital LOS (OR: 0.217, 95% CI: 0.03–0.404, P = 0.023), especially for younger children (≤ 5 years). In conclusion, we found that PM2.5, PM10, and SO2 exposure were risk factors for hospitalization due to pediatric pneumonia.

1314. Descriptive Epidemiology of 30-day Readmissions among Survivors of Hospitalization with Bacterial Nosocomial Pneumonia in the US, 2012-2019

BackgroundNosocomial pneumonia (NP) remains associated with excess morbidity and mortality. The effect of NP on other measures of outcome and quality, such as re-admission at 30 days, remains unclear. Moreover, differing types of NP may have varying impacts on re-admissions.MethodsWe conducted a multicenter retrospective cohort study within the Premier Research database, a source containing administrative, pharmacy, and microbiology data. The rate of rehospitalization at 30 days following the index discharge served as our primary endpoint. We compared NP patients readmitted with pneumonia (RaP) as the principal diagnosis to those readmitted for other reasons (RaO). We also compared readmission rates as function of the type of NP: ventilator-associated bacterial pneumonia (VABP), ventilated hospital-acquired bacterial pneumonia (vHABP), and non-ventilated HABP (nvHABP).ResultsAmong 17,819 patients with NP, 14,123 (79.3%) survived to discharge, of whom 2,151 (15.2%) required an acute readmission within 30 days of index discharge. Of these, 106 (4.9%) were RaP, and the remainder were RaO. At index hospitalization, RaP patients were older (mean age (SD) 67.4 (13.9] vs. 63.0 (15.2) years), more likely medical (44.3% vs. 36.7%), and less chronically ill (median [IQR] Charlson scores (3 [2-5] vs. 4 [2-5]) than persons with RaO. Bacteremia (10.4% vs. 17.5%), need for vasopressors (15.1% vs. 20.0%), dialysis (9.4% vs. 16.5%), and/or sepsis (9.4% vs. 16.5%) or septic shock 14.2% vs. 17.1%) occurred less frequently in the RaP group. With respect to NP type, nvHABP was most common in RaP (47.2%) and VABP in RaO (38.1%). ConclusionOne in seven survivors of a hospitalization complicated by NP requires an acute rehospitalization within 30 days. However, few of these readmissions had a principal diagnosis of pneumonia, irrespective of NP type. This suggests that short-term readmission does not capture the quality of care initially delivered to patients for their NP. Of the 5% of NP subjects with RaP, the plurality initially suffered from nvHABP. Disclosures Marya Zilberberg, MD, MPH, Cleveland Clinic (Consultant)J&J (Shareholder)Lungpacer (Consultant, Grant/Research Support)Merck (Grant/Research Support)scPharma (Consultant)Sedana (Consultant, Grant/Research Support)Spero (Grant/Research Support) Brian Nathanson, PhD, Lungpacer (Grant/Research Support)Merck (Grant/Research Support)Spero (Grant/Research Support) Laura A. Puzniak, PhD, Merck & Co., Inc. (Employee) Andrew F. Shorr, MD, MPH, MBA, Merck (Consultant)

Association between Particulate Matter Exposure and Short-term Prognosis in Patients with Pneumonia

ABSTRACT Particulate matter (PM) and other air pollutants are reportedly associated with both lung and systemic inflammation; however, an association between air pollutants and pneumonia outcomes has not been well established. Therefore, we evaluated the effect of air pollutants on the short-term outcomes of emergency department patients with pneumonia. We collected data on PM2.5 (aerodynamic diameter 17 years who had visited the emergency department with a principal diagnosis of pneumonia. In-hospital mortality and the association of air pollutant exposure with the need for invasive respiratory and/or vasopressor support (IRVS) within 72 h were evaluated. Interquartile range (IQR) increments of PM2.5 and PM10 were associated with an increased IRVS risk with odds ratios (ORs) of 1.211 (95% confidence interval [CI], 1.031–1.419) and 1.194 (95% CI, 1.020–1.394) on lag 1, respectively, and per-IQR increments of NO2 were associated with an increased IRVS risk with an OR of 1.146 (95% CI, 1.004–1.308) on lag 2. IQR increments of PM2.5 and NO2 were associated with an increased in-hospital mortality risk with ORs of 1.202 (95% CI, 1.100–1.429) and 1.175 (95% CI, 1.014–1.360), respectively. During the warm season, IQR increments of PM2.5, PM10, and NO2 corresponded with an increased IRVS risk, with ORs of 1.333 (95% CI, 1.078–1.644), 1.348 (95% CI, 1.090–1.665), and 1.321 (95% CI, 1.101–1.585), respectively. For patients with pneumonia, PM2.5, PM10, and NO2 exposures were risk factors for a poor prognosis. Exposure effects appeared to be greater during the warm season. Regulations focused on PM2.5, PM10, and NO2 levels should be considered to improve patient outcomes.

Thirty-Day Spending and Outcomes for an Episode of Pneumonia Care Among Medicare Beneficiaries

Recent policy initiatives aim to improve the value of care for patients hospitalized with pneumonia. It is unclear whether higher 30-day episode spending at the hospital level is associated with any difference in patient mortality among fee-for-service Medicare beneficiaries. This retrospective cohort study assessed the association between hospital-level spending and patient-level mortality for a 30-day episode of care. The study used data for Medicare fee-for-service beneficiaries hospitalized at an acute care hospital with a principal diagnosis of pneumonia from July 2011 to June 2014. Analysis was conducted by using Medicare payment data made publicly available by the Centers for Medicare & Medicaid Services on the Hospital Compare website combined with Medicare Part A claims data to identify patient outcomes. A total of 1,017,353 Medicare fee-for-service beneficiaries were hospitalized for pneumonia across 3,021 US hospitals during the study period. Mean ± SD 30-day spending for an episode of pneumonia care was $14,324 ± $1,305. The observed 30-day all-cause mortality rate was 11.9%. After adjusting for patient and hospital characteristics, no association was found between higher 30-day episode spending at the hospital level and 30-day patient mortality (adjusted OR, 1.00 for every $1,000 increase in spending; 95%CI, 0.99-1.01). Higher hospital-level spending for a 30-day episode of care for pneumonia was not associated with any difference in patient mortality.

Ambient air pollution is associated with pediatric pneumonia: a time-stratified case\u2013crossover study in an urban area

BackgroundPneumonia, the leading reason underlying childhood deaths, may be triggered or exacerbated by air pollution. To date, only a few studies have examined the association of air pollution with emergency department (ED) visits for pediatric pneumonia, with inconsistent results. Therefore, we aimed to elucidate the impact of short-term exposure to particulate matter (PM) and other air pollutants on the incidence of ED visits for pediatric pneumonia.MethodsPM2.5, PM10, and other air pollutant levels were measured at 11 air quality-monitoring stations in Kaohsiung City, Taiwan, between 2008 and 2014. Further, we extracted the medical records of non-trauma patients aged ≤17 years and who had visited an ED with the principal diagnosis of pneumonia. A time-stratified case–crossover study design was employed to determine the hazard effect of air pollution in a total of 4024 patients.ResultsThe single-pollutant model suggested that per interquartile range increment in PM2.5, PM10, nitrogen dioxide (NO2), and sulfur dioxide (SO2) on 3 days before the event increased the odds of pediatric pneumonia by 14.0% [95% confidence interval (CI), 5.1–23.8%], 10.9% (95% CI, 2.4–20.0%), 14.1% (95% CI, 5.0–24.1%), and 4.5% (95% CI, 0.8–8.4%), respectively. In two-pollutant models, PM2.5 and NO2 were significant after adjusting for PM10 and SO2. Subgroup analyses showed that older children (aged ≥4 years) were more susceptible to PM2.5 (interaction p = 0.024) and children were more susceptible to NO2 during warm days (≥26.5 °C, interaction p = 0.011).ConclusionsShort-term exposure to PM2.5 and NO2 possibly plays an important role in pediatric pneumonia in Kaohsiung, Taiwan. Older children are more susceptible to PM2.5, and all children are more susceptible to NO2 during warm days.

Association between Particulate Matter Air Pollution and Hospital Emergency Room Visits for Pneumonia with Septicemia: A Retrospective Analysis

Pneumonia is an inflammatory condition of the lungs caused by infection, which may be triggered and exacerbated by particulate matter (PM) exposure. We aimed to estimate the effect of PM on emergency department (ED) visits in pneumonia patients with septicemia after controlling for gaseous pollutants. Measurements on PM2.5, PM10, and other air pollutants at each of the 11 air-quality monitoring stations in Kaohsiung City, Taiwan, were collected between 2007 and 2013. The medical records of non-trauma patients who were over 17 years old and had visited the ED with a principal diagnosis of pneumonia were extracted. Poisson models were used to examine the relationship between air pollutants and daily ED visits for pneumonia with septicemia. Interquartile increments in the levels of PM2.5, PM10, and NO2 at lag 0 were associated with increments of 25.5%, 21.61%, and 21.97%, respectively, in the number of ED visits for pneumonia with septicemia during the warm season. The effect estimates of PM2.5 were robust after adjusting for PM10 and NO2 in the two-pollutant model. PM2.5 had stronger associations with ED visits in the cases of pneumonia with septicemia in relatively healthy patients, such as those without comorbid hypertension, diabetes, stroke, liver cirrhosis, respiratory disease, or malignancy. In conclusion, although the existing evidence already supports a causal relationship between PM2.5 and pulmonary dysfunction, we propose that PM2.5 may also play an important role in emergency visits for pneumonia with septicemia during the warm season in southern Taiwan after adjusting for PM10 and NO2, especially among relatively healthy residents.

Association Between Outdoor Air Pollution Levels and Inpatient Outcomes in Pediatric Pneumonia Hospitalizations, 2007 to 2008

ObjectivePneumonia is a leading cause of pediatric admissions. Although air pollutants are associated with poor outcomes, few national studies have examined associations between pollutant levels and inpatient pediatric pneumonia outcomes. We examined the relationship between ozone (O3) and fine particulate matter with a diameter ≤2.5 µm (PM2.5) and outcomes related to disease severity. MethodsIn this cross-sectional study, we obtained discharge data from the 2007 to 2008 Nationwide Inpatient Sample and pollution data from the Air Quality System. Patients ≤18years with a principal diagnosis of pneumonia were included. Discharge data were linked to O3 and PM2.5 levels (predictors) from the patient's ZIP Code (not publicly available) from day of admission. Outcomes were mortality, intubation, length of stay (LOS), and total costs. We calculated weighted national estimates and performed multivariable analyses adjusting for sociodemographic and hospital factors. ResultsThere were a total of 57,972 (278,871 weighted) subjects. Median PM2.5 level was 9.5 (interquartile range [IQR] 6.8–13.4) µg/m3. Median O3 level was 35.6 (IQR 28.2–45.2) parts per billion. Mortality was 0.1%; 0.75% of patients were intubated. Median LOS was 2 (IQR 2–4) days. Median costs were $3089 (IQR $2023–$5177). Greater levels of PM2.5 and O3 were associated with mortality, longer LOS, and greater costs. Greater O3 levels were associated with increased odds of intubation. ConclusionsGreater levels of O3 and PM2.5 were associated with more severe presentations of pneumonia. Future work should examine these relationships in more recent years and over a longer time period.

Pneumonia-Associated Hospitalizations, New York City, 2001-2014.

Death certificate data indicate that the age-adjusted death rate for pneumonia and influenza is higher in New York City than in the United States. Most pneumonia and influenza deaths are attributed to pneumonia rather than influenza. Because most pneumonia deaths occur in hospitals, we analyzed hospital discharge data to provide insight into the burden of pneumonia in New York City. We analyzed data for New York City residents discharged from New York State hospitals with a principal diagnosis of pneumonia, or a secondary diagnosis of pneumonia if the principal diagnosis was respiratory failure or sepsis, during 2001-2014. We calculated mean annual age-adjusted pneumonia-associated hospitalization rates per 100 000 population and 95% confidence intervals (CIs). We examined data on pneumonia-associated hospitalizations by sociodemographic characteristics and colisted conditions. During 2001-2014, a total of 495 225 patients residing in New York City were hospitalized for pneumonia, corresponding to a mean annual age-adjusted pneumonia-associated hospitalization rate of 433.8 per 100 000 population (95% CI, 429.3-438.3). The proportion of pneumonia-associated hospitalizations with in-hospital death was 12.0%. The mean annual age-adjusted pneumonia-associated hospitalization rate per 100 000 population increased as area-based poverty level increased, whereas the percentage of pneumonia-associated hospitalizations with in-hospital deaths decreased with increasing area-based poverty level. The proportion of pneumonia-associated hospitalizations that colisted an immunocompromising condition increased from 18.7% in 2001 to 33.1% in 2014. Sociodemographic factors and immune status appear to play a role in the epidemiology of pneumonia-associated hospitalizations in New York City. Further study of pneumonia-associated hospitalizations in at-risk populations may lead to targeted interventions.

Pneumococcal Urinary Antigen Testing in US Hospitals: Underutilized and Rarely Acted Upon

BackgroundThe IDSA guideline for CAP recommends Pneumococcal urinary antigen testing (UAT) in addition to blood and sputum cultures for patients with severe CAP. In controlled settings, UAT is 50–80% sensitive and >90% specific; however, its utility and performance on a large-scale in real-world use has not been assessed. It is unclear whether UAT is clinically useful or whether the results impact prescribing behavior.MethodsRetrospective cohort study of adult patients admitted with CAP or HCAP from 2010 to 2015 at 170 US hospitals that submit data to Premier. Date and time-stamped administrative and microbiologic data were assessed. Patients with a principal diagnosis of pneumonia, or sepsis with a secondary diagnosis of pneumonia plus a CXR and antibiotics within the first 24 hours, were included if they had a UAT plus either a blood or respiratory culture within the first 48 hours of admission.ResultsOf 159,894 eligible pneumonia patients, 24,757 (15.5%) had UAT plus either blood or respiratory cultures performed. Of 1,797 (7%) who had a positive UAT, 457 (25%) also grew S. pneumoniae (SP) from blood or respiratory cultures, 1,240 (69%) had negative cultures, and 100 (6%) an organism other than SP, with S. aureus, Pseudomonas spp., and E.coli being the most common pathogens, predominantly from respiratory cultures. Among 22,960 patients with a negative UAT, 429 (2%) had a positive blood or respiratory culture for SP and 2,653 (12%) had a culture positive for another organism. UAT was performed among 18.4% of patients admitted to the ICU, and 15.3% of those admitted to wards. Among patients empirically started on broad-spectrum antibiotics, 35% who had a positive UAT were de-escalated by Day 5, compared with 49% who grew SP in blood cultures and 24% in respiratory cultures.ConclusionIn a large representative US inpatient database, there was poor concordance between UAT and cultures for SP. A positive UAT decreased the probability of having a non-SP pathogen. Antibiotic de-escalation occurred more often in association with a positive blood culture for SP than for UAT or positive respiratory culture, but occurred in less than half the patients with these markers of pneumococcal pneumonia. Overall, UAT is underutilized and does not appear to have a substantial impact on clinical care.Disclosures S. Haessler, AHRQ: Investigator, Research grant; P. C. Yu, AHRQ: Investigator, Research grant; M. Rothberg, AHRQ: Investigator, Research grant

Trends in Antibiotic Use and Nosocomial Pathogens in Hospitalized Veterans With Pneumonia at 128 Medical Centers, 2006-2010.

In 2005, pneumonia practice guidelines recommended broad-spectrum antibiotics for patients with risk factors for nosocomial pathogens. The impact of these recommendations on the ability of providers to match treatment with nosocomial pathogens is unknown. Among hospitalizations with a principal diagnosis of pneumonia at 128 Department of Veterans Affairs medical centers from 2006 through 2010, we measured annual trends in antibiotic selection; initial blood or respiratory cultures positive for methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, and Acinetobacter species; and alignment between antibiotic coverage and culture results for MRSA and P. aeruginosa, calculating sensitivity, specificity, and diagnostic odds ratio using a 2 × 2 contingency table. In 95 511 hospitalizations for pneumonia, initial use of vancomycin increased from 16% in 2006 to 31% in 2010, and piperacillin-tazobactam increased from 16% to 27%, and there was a decrease in both ceftriaxone (from 39% to 33%) and azithromycin (change from 39% to 36%) (P < .001 for all). The proportion of hospitalizations with cultures positive for MRSA decreased (from 2.5% to 2.0%; P < .001); no change was seen for P. aeruginosa (1.9% to 2.0%; P = .14) or Acinetobacter spp. (0.2% to 0.2%; P = .17). For both MRSA and P. aeruginosa, sensitivity increased (from 46% to 65% and 54% to 63%, respectively; P < .001) and specificity decreased (from 85% to 69% and 76% to 68%; P < .001), with no significant changes in diagnostic odds ratio (decreases from 4.6 to 4.1 [P = .57] and 3.7 to 3.2 [P = .95], respectively). Between 2006 and 2010, we found a substantial increase in the use of broad-spectrum antibiotics for pneumonia despite no increase in nosocomial pathogens. The ability of providers to accurately match antibiotic coverage to nosocomial pathogens remains low.

Hospitals with the highest intensive care utilization provide lower quality pneumonia care to the elderly.

Quality of care for patients admitted with pneumonia varies across hospitals, but causes of this variation are poorly understood. Whether hospitals with high ICU utilization for patients with pneumonia provide better quality care is unknown. We sought to investigate the relationship between a hospital's ICU admission rate for elderly patients with pneumonia and the quality of care it provided to patients with pneumonia. Retrospective cohort study. Two thousand eight hundred twelve U.S. hospitals. Elderly (age≥65 years) fee-for-service Medicare beneficiaries with either a (1) principal diagnosis of pneumonia or (2) principal diagnosis of sepsis or respiratory failure and secondary diagnosis of pneumonia in 2008. None. We grouped hospitals into quintiles based on ICU admission rates for pneumonia. We compared rates of failure to deliver pneumonia processes of care (calculated as 100-adherence rate), 30-day mortality, hospital readmissions, and Medicare spending across hospital quintile. After controlling for other hospital characteristics, hospitals in the highest quintile more often failed to deliver pneumonia process measures, including appropriate initial antibiotics (13.0% vs 10.7%; p<0.001), and pneumococcal vaccination (15.0% vs 13.3%; p=0.03) compared with hospitals in quintiles 1-4. Hospitals in the highest quintile of ICU admission rate for pneumonia also had higher 30-day mortality, 30-day hospital readmission rates, and hospital spending per patient than other hospitals. Quality of care was lower among hospitals with the highest rates of ICU admission for elderly patients with pneumonia; such hospitals were less likely to deliver pneumonia processes of care and had worse outcomes for patients with pneumonia. High pneumonia-specific ICU admission rates for elderly patients identify a group of hospitals that may deliver inefficient and poor-quality pneumonia care and may benefit from interventions to improve care delivery.

Is High ICU Utilization a Quality Measure for Pneumonia Care

Admission rates to the intensive care unit (ICU) for patients with pneumonia differ widely among hospitals. Such variance is related to patient characteristics but may also be a quality-of-care indicator. To investigate this issue, researchers reviewed discharge records for all acute care hospitalizations among Medicare beneficiaries aged ≥65 with either a principal diagnosis of pneumonia or a principal diagnosis …

Poor clinical outcomes among pneumonia patients with depressive disorder.

BackgroundSome studies suggested that psychological stress may be associated with the severity and duration of infectious diseases. In this population-based study, we investigated associations between depressive disorder (DD) and pneumonia outcomes in Taiwan with a large-scale database from the National Health Insurance.MethodsOur study defined 112,198 patients who were hospitalized with a principal diagnosis of pneumonia. We defined their admission date for treatment of pneumonia as the index date. Subsequently, we selected 2,394 patients with DD within 3 years prior to their index date and 11,970 matched patients without DD. We carried out separate conditional logistic regressions to explore the association of clinical pneumonia treatment outcome (ICU admission, use of mechanical ventilation, acute respiratory failure and in-hospital death) with previously diagnosed DD.ResultsPatients with DD had a significantly higher probability of an intensive care unit admission (18.1% vs. 12.9%; p<0.001), need for mechanical ventilation (21.9% vs. 18.1%; p<0.001) and in-hospital death (10.4% vs. 9.0%; p = 0.025) than patients without DD. The study showed that pneumonia patients with DD were respectively 1.41- (95% CI: 1.25∼1.59, p<0.001), 1.28- (95% CI: 1.14∼1.43, p<0.001), and 1.17- times (95% CI: 1.01∼1.36, p = 0.039) greater odds of being admitted to the ICU, need for mechanical ventilation, and in-hospital death than patients without DD after adjusting for monthly income, urbanization level, geographic region and Charlson Comorbidity Index score.ConclusionsIn conclusion, we found that pneumonia patients with DD were associated with poor treatment outcomes compared to patients without DD.

Variation in diagnostic coding of patients with pneumonia and its association with hospital risk-standardized mortality rates: a cross-sectional analysis.

Most U.S. hospitals publicly report 30-day risk-standardized mortality rates for pneumonia. Rates exclude severe cases, which may be assigned a secondary diagnosis of pneumonia and a principal diagnosis of sepsis or respiratory failure. By assigning sepsis and respiratory failure codes more liberally, hospitals might improve their reported performance. To examine the effect of the definition of pneumonia on hospital mortality rates. Cross-sectional study. 329 U.S. hospitals. Adults hospitalized for pneumonia (as a principal diagnosis or secondary diagnosis paired with a principal diagnosis of sepsis or respiratory failure) between 2007 and 2010. Proportion of patients with pneumonia coded with a principal diagnosis of sepsis or respiratory failure and risk-standardized mortality rates excluding versus including a principal diagnosis of sepsis or respiratory failure. When the definition of pneumonia was limited to patients with a principal diagnosis of pneumonia, the risk-standardized mortality rate was significantly better than the mean in 4.3% of hospitals and significantly worse in 6.4%. When the definition was broadened to include patients with a principal diagnosis of sepsis or respiratory failure, this rate was better than the mean in 11.9% of hospitals and worse in 22.8% and the outlier status of 28.3% of hospitals changed. Among hospitals in the highest quintile of proportion of patients coded with a principal diagnosis of sepsis or respiratory failure, outlier status under the broader definition improved in 7.6% and worsened in 40.9%. Among those in the lowest quintile, 20.0% improved and none worsened. Only inpatient mortality was studied. Variation in use of the principal diagnosis of sepsis or respiratory failure may bias efforts to compare hospital performance regarding pneumonia outcomes. Agency for Healthcare Research and Quality.

Mortality Reduction among Pneumonia Patients Still Substantial despite the Impact of Coding Changes

BackgroundAccounting for changes in coding practices may be important in analyzing trends based on administrative data. Several studies have demonstrated large reductions in mortality over time among pneumonia patients. However, a recent study suggested that this reduction may have been an artifact of case definition because more of the highest-risk patients were being coded under alternative principal diagnoses in recent years. MethodsUsing the National Inpatient Sample from 1993 to 2005, we selected hospitalizations with a principal diagnosis of pneumonia or a secondary diagnosis of pneumonia and a principal diagnosis of sepsis or respiratory failure. We performed logistic regression, estimating the likelihood of in-hospital mortality in each year, adjusting for age, sex, and comorbidities. ResultsOver time, there was a substantial increase in the frequency of sepsis and respiratory failure as a principal diagnosis. Length of stay decreased in all 3 principal diagnosis groups. By 2005, the adjusted odds ratio (OR) of death among principal diagnosis pneumonia and respiratory failure hospitalizations decreased to 0.50 (95% confidence interval [CI], 0.49-0.51) and 0.62 (95% CI, 0.58-0.66), respectively, compared with 1993. With all 3 groups combined, there was still a substantial, albeit attenuated, reduction in the risk of mortality (OR2005 0.70; 95% CI, 0.69-0.72). ConclusionsSurvival of patients with community-acquired pneumonia has improved greatly over time. However, interpretation of such findings based on administrative data must be made with caution and careful attention to case definition and coding trends.

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Introduction: Nationally, 93% of patients with community-acquired pneumonia (CAP) receive guideline-concordant therapy. Severe CAP, defined as CAP treated in the ICU, accounts for up to 35% of CAP. Early initiation of antibiotic treatment is extremely important for these patients, but the proportion of patients that receive guideline-concordant therapy is unknown. Hypothesis: Not all patients with severe CAP receive guideline-concordant care. Methods: Using a large national database, we included patients who were discharged between 7/07-6/10; had a principal diagnosis of pneumonia or a principal diagnosis of sepsis or respiratory failure combined with a secondary diagnosis of pneumonia; and, by the second hospital day, had been admitted to the ICU, undergone a chest radiograph, and were treated with antibiotics. We excluded patients with health care-associated pneumonia and those in whom pneumonia was not present on admission. Initial treatment regimens were defined as guideline-concordant if, during the first two days of hospitalization, the patient received coverage for typical and atypical CAP pathogens. Results: 20,704 patients at 346 hospitals met inclusion criteria. Inpatient mortality was 14.1%. Mechanical ventilation was initiated by day 2 in 8,069 (39%) and on day 3 or later in 1,385 (7%). Most patients (85%) were initially treated with guideline-concordant therapy. Among 17,639 patients who received guideline-concordant regimens, 4028 (23%) received coverage for typical and atypical CAP organisms but not Methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas; 1,080 (6%) received additional coverage for MRSA; 6,219 (35%) received coverage for Pseudomonas; and 6,312 (36%) received coverage for both MRSA and Pseudomonas. Among 3,065 patients who initially received guideline-discordant therapy, most (2,925, 95%) received no coverage for atypical organisms. Conclusions: There is variation in initial antibiotic choice for severe CAP. Although most patients received guideline-concordant regimens, about 15% received no initial coverage for atypical organisms.

Disparity of Risk-Adjusted Inpatient Outcomes among African American and White Patients Hospitalized with Community-Acquired Pneumonia

The objectives of this study were to examine the associations between inpatient pneumonia outcomes, health care factors, and sociodemographics with an emphasis on race. African American and white patients from the 2008 National Hospital Discharge Survey who were admitted to nonprofit and for-profit hospitals with a principal diagnosis of pneumonia were sampled (n=1924). Three outcomes were measured: length of hospital stay, discharge to home, and deceased at discharge. Length of hospital stay was measured with negative binomial regression including incidence rate ratios (IRRs), while the remaining 2 outcomes were measured with logistic regression including odds ratios (ORs). Patients with longer hospital stays relative to peers were likely older (IRR=1.01, 95% confidence interval [CI]=1.01-1.01, P<0.001) and African American (IRR=1.19, 95% CI=1.10-1.30, P<0.001), but had fewer comorbidities (IRR=0.97, 95% CI=0.94-0.99, P=0.016). Patients were less likely to be discharged to home if they were older (OR=0.96, 95% CI=0.95-0.96, P<0.001), African American (OR=0.68, 95% CI=0.52-0.90, P=0.006), and had government insurance (OR=0.59, 95% CI=0.44-0.79, P<0.001). Patients deceased at discharge were more likely to be older (OR=1.03, 95% CI=1.01-1.05, P=0.001), African American (OR=1.97, 95% CI=1.10-3.53, P=0.023), and to have fewer comorbidities (OR=0.71, 95% CI=0.57-0.88, P=0.002). African Americans with pneumonia experience inequitable inpatient pneumonia-related outcomes relative to whites. Hospital interventions addressing equity are needed.

Hospital‐reported Data on the Pneumonia Quality Measure “Time to First Antibiotic Dose” Are Not Associated With Inpatient Mortality: Results of a Nationwide Cross‐sectional Analysis

Significant controversy exists regarding the Centers for Medicare & Medicaid Services (CMS) "time to first antibiotics dose" (TFAD) quality measure. The objective of this study was to determine whether hospital performance on the TFAD measure for patients admitted from the emergency department (ED) for pneumonia is associated with decreased mortality. This was a cross-sectional analysis of 95,704 adult ED admissions with a principal diagnosis of pneumonia from 530 hospitals in the 2007 Nationwide Inpatient Sample. The sample was merged with 2007 CMS Hospital Compare data, and hospitals were categorized into TFAD performance quartiles. Univariate association of TFAD performance with inpatient mortality was evaluated by chi-square test. A population-averaged logistic regression model was created with an exchangeable working correlation matrix of inpatient mortality adjusted for age, sex, comorbid conditions, weekend admission, payer status, income level, hospital size, hospital location, teaching status, and TFAD performance. Patients had a mean age of 69.3 years. In the adjusted analysis, increasing age was associated with increased mortality with odds ratios (ORs) of >2.3. Unadjusted inpatient mortality was 4.1% (95% confidence interval [CI] = 3.9% to 4.2%). Median time to death was 5 days (25th-75th interquartile range = 2-11). Mean TFAD quality performance was 77.7% across all hospitals (95% CI = 77.6% to 77.8%). The risk-adjusted OR of mortality was 0.89 (95% CI = 0.77 to 1.02) in the highest performing TFAD quartile, compared to the lowest performing TFAD quartile. The second highest performing quartile OR was 0.94 (95% CI = 0.82 to 1.08), and third highest performing quartile was 0.91 (95% CI = 0.79 to 1.05). In this nationwide heterogeneous 2007 sample, there was no association between the publicly reported TFAD quality measure performance and pneumonia inpatient mortality.