Marked Reduction in 30-Day Mortality Among Elderly Patients with Community-acquired Pneumonia

doi:10.1016/j.amjmed.2010.08.019

The American Journal of Medicine

Volume 124, Issue 2, February 2011, Pages 171-178.e1

https://doi.org/10.1016/j.amjmed.2010.08.019 Get rights and content

Abstract

Background

Community-acquired pneumonia is the most common infectious cause of death in the US. Over the last 2 decades, patient characteristics and clinical care have changed. To understand the impact of these changes, we quantified incidence and mortality trends among elderly adults.

Methods

We used Medicare claims to identify episodes of pneumonia, based on a validated combination of diagnosis codes. Comorbidities were ascertained using the diagnosis codes located on a 1-year look back. Trends in patient characteristics and site of care were compared. The association between year of pneumonia episode and 30-day mortality was then evaluated by logistic regression, with adjustment for age, sex, and comorbidities.

Results

We identified 2,654,955 cases of pneumonia from 1987-2005. During this period, the proportion treated as inpatients decreased, the proportion aged ≥80 years increased, and the frequency of many comorbidities rose. Adjusted incidence increased to 3096 episodes per 100,000 population in 1999, with some decrease thereafter. Age/sex-adjusted mortality decreased from 13.5% to 9.7%, a relative reduction of 28.1%. Compared with 1987, the risk of mortality decreased through 2005 (adjusted odds ratio, 0.46; 95% confidence interval, 0.44-0.47). This result was robust to a restriction on comorbid diagnoses assessing for the results' sensitivity to increased coding.

Conclusions

These findings show a marked mortality reduction over time in community-acquired pneumonia patients. We hypothesize that increased pneumococcal and influenza vaccination rates as well as wider use of guideline-concordant antibiotics explain a large portion of this trend. © 2011 Elsevier Inc. All rights reserved.

Section snippets

Data Source and Study Subjects

Our analyses used all claims (1987-2005) for a random 20% sample of Medicare patients aged ≥65 years from the Centers for Medicare & Medicaid Services Research Identifiable Files. Cases of community-acquired pneumonia were identified by the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 CM)¹⁴ code combinations as either: a principal diagnosis of pneumonia (codes 481-487) or a principal diagnosis of respiratory distress (code 786) or respiratory failure

Characteristics of the Study Subjects and Incidence Trends

The total sample of 2,654,955 community-acquired pneumonia subjects included 1,130,919 outpatients and 1,524,036 inpatients. The Table shows the characteristics of the study subjects for the periods 1987-1989 and 2003-2005. From the early period to the recent period, the proportion of patients aged ≥80 years increased from 42.5% to 47.5% (P <.001), while the proportion of subjects treated as inpatients decreased from 62.6% to 55.7% (P <.001). Most of this shift in site of care had occurred by

Discussion

Our findings reveal a substantial mortality reduction in elderly pneumonia patients from 1987 to 2005, over which time the relative risk of mortality fell by 28%, and, after comorbidity adjustment, 54%. Our data demonstrate a 13.5% mortality rate in 1987 that decreased markedly over the period studied. However, even this initial mortality rate reflects a decrease during the 1980s. A Lancet report studying community-acquired pneumonia patients with a mean age of 51 years in 1980 and 1981 showed

Acknowledgment

We thank Daniel E. Singer, David Blumenthal, and Lisa I. Iezzoni for their mentorship, advice, and critical review of the manuscript. We thank Douglas M. Norton for his programming assistance.

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Pneumonia represents a public health problem of substantial health and economic burden. However, the evidence on the burden of adult pneumonia is limited in China.
The China Kadoorie Biobank recruited 512,725 participants aged 30–79 years from five urban and five rural areas during 2004–2008. The current analyses included 506,086 participants who were alive in 2009. Pneumonia hospitalizations were ascertained through the health insurance system until December 31, 2017. Generalized linear models were used to examine the secular trends and regional and population variations in pneumonia hospitalization rate, mean length of hospital stay (LOS), and 30-day case fatality rate (CFR).
A total of 27,879 participants with 36,567 pneumonia hospitalizations were identified with a mean follow-up time of 8·9 years. The unadjusted hospitalization rate was 8·4 (95% confidence interval [CI]: 8·3, 8·6) per 1000 person-years, with an increase of 15·5% annually from 4·2 (3·9, 4·4) in 2009 to 10·9 (10·6, 11·3) in 2017, after adjusting for age, sex, study area. The mean LOS was 8·8 (95% CI: 8·7, 8·9) days, with a slight decrease of 1·0% annually from 2009 to 2017. The average 30-day CFR remained practically unchanged at 2·4 (95% CI: 2·2, 2·5) deaths per 100 admissions. A clear seasonal pattern of pneumonia hospitalization rate was observed, and the hospitalization rate and CFR differed across regions and subpopulations of different ages and underlying conditions.
There was an increasing hospitalization burden of pneumonia in Chinese adults, especially for adults aged ≥60 years or those with underlying conditions.
The National Natural Science Foundation of China, the Kadoorie Charitable Foundation, the National Key R&D Program of China, the Chinese Ministry of Science and Technology.
Rates of hospitalization for community-acquired pneumonia among US adults: A systematic review
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Community-acquired pneumonia (CAP) is associated with significant disease burden in adults but has not been measured uniformly. Reconciling differences across studies is critical for understanding the true burden of CAP.
We performed a systematic literature review of the incidence of hospitalized CAP among US adults and described the impact of key study characteristics on these estimates.
After review of 8361 articles as of January 31, 2019, we identified 28 studies with 41 unique estimates of hospitalized CAP incidence. Among adults ≥65 years of age, annual rates of hospitalized CAP ranged from 847 to 3500 per 100,000 persons with median = 1830. Rates were lower in studies that excluded patients with healthcare-associated (but community-onset) pneumonia (HCAP; median = 2003 vs 1286; P = 0.02) or immunocompromising conditions (median = 1895 vs 1409; P = 0.27) compared to those that did not. Rates of CAP were also lower in studies that used more restrictive criteria for diagnosing pneumonia (eg, pneumonia coded in any diagnosis position [median = 2270] vs pneumonia coded in the first position only [median = 1375] in studies of administrative claims; P = 0.02). For adults <65 years of age, rates of CAP were lower (range: 89 to 1138 per 100,000; median = 199).
CAP causes a significant disease burden among adults, particularly among those ≥65 years of age. Commonly-applied exclusion criteria (eg, persons with HCAP or immunocompromising conditions) or restrictive case definitions (eg, only including pneumonias coded in the primary diagnosis position) have led to systematic underestimation of CAP incidence in many previous studies. In studies that did not apply these restrictive criteria, the rate of hospitalization was approximately 2000 per 100,000 annually. Understanding the true burden of adult CAP is critical for highlighting the ongoing need for expanded prevention programs, including vaccination.
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The epidemiology of pneumonia has likely evolved in recent years, reflecting an aging population, changes in population immunity, and socioeconomic disparities.
Using the National (Nationwide) Inpatient Sample, estimated numbers and rates of pneumonia-associated hospitalizations for 2001-2014 were calculated. A pneumonia-associated hospitalization was defined as one in which the discharge record listed a principal diagnosis of pneumonia or a secondary diagnosis of pneumonia if the principal diagnosis was respiratory failure or sepsis.
There were an estimated 20,361,181 (SE, 95,601) pneumonia-associated hospitalizations in the United States during 2001-2014 (average annual age-adjusted pneumonia-associated hospitalization rate of 464.8 per 100,000 population [95% CI, 462.5-467.1]). The average annual age-adjusted pneumonia-associated hospitalization rate decreased over the study period (P < .0001). In-hospital death occurred in 7.4% (SE, 0.03) of pneumonia-associated hospitalizations. Non-Hispanic American Indian/Alaskan Natives and non-Hispanic blacks had the highest average annual age-adjusted rates of pneumonia-associated hospitalization of all race/ethnicities at 439.2 (95% CI, 415.9-462.5) and 438.6 (95% CI, 432.5-444.7) per 100,000 population, respectively. During 2001-2014, the proportion of pneumonia-associated hospitalizations colisting an immunocompromising condition increased from 18.7% (SE, 0.2) in 2001 to 29.9% (SE, 0.2) in 2014. Total charges for pneumonia-associated hospitalizations in 2014 were over $84 billion.
Pneumonia is a major cause of morbidity and mortality in the United States. Differences in rates and outcomes of pneumonia-associated hospitalizations between sociodemographic groups warrant further investigation. The immunocompromised population has emerged as a group experiencing a disproportionate burden of pneumonia-associated hospitalizations.
Declining mortality among hospitalized patients with community-acquired pneumonia
2016, Clinical Microbiology and Infection
Little information is available on the changes over time in community-acquired pneumonia (CAP) management and their impact on 30-day mortality in hospitalized patients. We performed a prospective, observational study of non-severely immunosuppressed hospitalized adults with CAP from 1995 to 2014. A total of 4558 patients were included. Thirty-day mortality decreased from 9.6% in the first study period (1995–99) to 4.1% in the last period (2010–14); with a progressive downward trend (–0.2% death/year; p for trend = 0.003). Over time, patients were older (p 0.02), had more co-morbidities (p 0.037), more frequently presented severe illness according to the Pneumonia Severity Index (p <0.001) and septic shock (p <0.001), and more often required intensive care unit admission (p <0.001). Combination antibiotic therapy (p <0.001) and fluoroquinolone use (p <0.001) increased. Factors independently associated with 30-day mortality were increasing age (OR 1.04; 95% CI 1.03–1.05), co-morbidities (OR 1.48; 95% CI 1.04–2.11), shock at admission (OR 4.95; 95% CI 3.49–7.00), respiratory failure (OR 1.89; 95% CI 1.42–2.52), bacteraemia (OR 2.16; 95% CI 1.58–2.96), Gram-negative bacilli aetiology (OR 4.79; 95% CI 2.52–9.10) and fluoroquinolone use (OR 0.45; 95% CI 0.29–0.71). When we adjusted for a propensity score to receive fluoroquinolones, the protective effect of fluoroquinolone use was not confirmed. In conclusion, 30-day mortality decreased significantly over time in hospitalized patients with CAP in spite of an upward trend in patient age and other factors associated with poor outcomes. Several changes in the management of CAP and a general improvement in global care over time may have caused the observed outcomes.
Outcomes in patients with community-acquired pneumonia admitted to the intensive care unit
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Severe community-acquired pneumonia (CAP) portends a serious prognosis. The temporal trend in outcome of severe CAP is not well established. We evaluated the temporal trends in the outcomes of severe CAP.
This is a secondary analysis of 800 patients with severe CAP enrolled in the Community-Acquired Pneumonia Organization International Cohort. Severe CAP was defined as CAP requiring admission to the intensive care unit. Only patients admitted to the ICU upon hospital admission were included in this study. We assessed the trend in outcomes of these patients during three time periods: Period I (June 2001 to April 2004), Period II (May 2004 to January 31 2008), and Period III (February 2008 to February 2013).
After adjustment for other variables, mortality was higher for patients admitted during Period II compared with Period I (RR: 1.46; 95% CI: 1.002 to 2.14; P value = 0.049), and for Period III compared with Period I (RR: 1.70; 95% CI: 1.15 to 2.50; P value = 0.008). No significant difference in length of stay or time to clinical stability was found among the three periods.
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: Funding: This work was supported by unrestricted grants P01 AG31098, P30 AG12810, and P01AG005842 from the National Institute on Aging. It also was supported by an institutional Ruth L. Kirschstein National Research Service Award (T32 HP11001) from the Health Resources and Services Administration of the Department of Health and Human Services, the Division of General Internal Medicine at the Massachusetts General Hospital, and grant F32 HS016948-01 from the Agency for Healthcare Research and Quality. The supporters had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

: Conflict of Interest: The authors confirm the absence of potential conflicts of interest, financial or otherwise.

: Authorship: All authors had access to the data and a role in writing the manuscript. Dr. Ruhnke had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

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Clinical research studyMarked Reduction in 30-Day Mortality Among Elderly Patients with Community-acquired Pneumonia

Abstract

Background

Methods

Results

Conclusions

Section snippets

Data Source and Study Subjects

Characteristics of the Study Subjects and Incidence Trends

Discussion

Acknowledgment

Infect Dis Clin North Am

Am J Med

Lancet

Lancet

Am J Med

Chest

A prediction rule to identify low-risk patients with community-acquired pneumonia

N Engl J Med

Trends in hospitalizations for pneumonia among persons aged 65 years or older in the United States, 1988-2002

JAMA

Increasing hospital admissions for pneumonia, England

Emerg Infect Dis

Sex differences in mortality after acute myocardial infarction: changes from 1994 to 2006

Arch Intern Med

Type 2 diabetes and pneumonia outcomes: a population-based cohort study

Diabetes Care

Community-acquired pneumonia: defining quality care

J Hosp Med

Combination antibiotic therapy lowers mortality among severely ill patients with pneumococcal bacteremia

Am J Respir Crit Care Med

Monotherapy may be suboptimal for severe bacteremic pneumococcal pneumonia

Arch Intern Med

Quality of care, process, and outcomes in elderly patients with pneumonia

JAMA

Processes and outcomes of care for patients with community-acquired pneumonia: results from the Pneumonia Patient Outcomes Research Team (PORT) cohort study

Arch Intern Med

Patient and hospital characteristics associated with recommended processes of care for elderly patients hospitalized with pneumonia: results from the medicare quality indicator system pneumonia module

Arch Intern Med

International Classification of Diseases, Ninth Revision, Clinical Modification

Community-acquired pneumonia: can it be defined with claims data?

Am J Med Qual

Effect of increasing the intensity of implementing pneumonia guidelines: a randomized, controlled trial

Ann Intern Med

Comorbidity measures for use with administrative data

Med Care

Clinical research study
Marked Reduction in 30-Day Mortality Among Elderly Patients with Community-acquired Pneumonia