Longterm mortality in hospitalized patients with community acquired pneumonia

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Long-term mortality in hospitalized patients with
community acquired pneumonia

• AYNNA YEE M.D.
• UCSF- Fresno Internal Medicine
• May 24, 2003

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Introduction

• The Pneumonia Severity Index algorithm (PSI) was
  designed to predict short term mortality for
  hospitalized patients
• Fine MJ et al. A prediction rule to identify
  low risk patients with community acquired
  pneumonia. NEJM 3364243-50.
• This was derived and validated as part of the
  Pneumonia Patient Outcomes Research Team (PORT)
  and MedisGroup cohorts

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Introduction

• MedisGroup derivation cohort
• MedisGroup validation cohort
• Pneumonia Patient Outcomes Research Team (PORT)
  prospective cohort

4
Introduction

• Some studies have investigated long term
  mortality in patients hospitalized for CAP
• Kaplan et al report almost half of all elderly
  patients admitted die within the subsequent year
• Brancati et al report 1 in 4 CAP hospital
  survivors died within the following year

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Objective

• To determine whether the use of the pneumonia
  severity index (PSI) prediction rule could
  predict long-term mortality of hospitalized
  patients with community acquired pneumonia

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Methods

• Retrospective chart review
• Patients admitted to VA Medical Center from
  12/28/00 7/30/02
• Principal diagnosis of CAP using ICD-09 codes
• Chart review of all patients included
  confirmation by CXR and/or gram stain sputum and
  culture results

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Methods

• On initial admission
• PSI calculated using subjects demographics
• comorbidities
• presenting symptoms
• lab results

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Methods

• Calculated the score
• Two groups
• lt130
• gt130

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Methods

• Exclusion criteria
• History of acquired immunodeficiency syndrome or
  positive titer of antibodies to HIV
• History of previous hospitalization within 7 days
  prior to admission
• Transfer from another acute care hospital
• Patients with principal diagnosis of chest pain

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Results

• 125 patients admitted with primary ICD-09 codes
  for CAP chart reviewed
• 19 excluded
• 106 admissions, 98 patients

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Results

• 19 excluded
• 9 patients transfers from other facilities
• 3 immunocompromised (2 HIV/1neutropenic)
• 1 found to have CXR findings gt2 days after
  admission
• 6 miscoded (3 chest pain, 1 syncope, 1 coder
  mislabeled as patient was not actually admitted,
  1 miscoded by resident on discharge diagnosis)

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Results

• 106 admissions, 98 total patients
• 81 patients with prediction rule gt130
• 17 patients with prediction rule lt130

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Results

• 81 patients with prediction rule lt130
• Mean survival 620 days
• 95 confidence interval (547.08, 693.83)
• 55 censored, 26 died
• 17 patients with prediction rule gt130
• Mean survival 418 days
• 95 confidence interval (245.75, 591.43)
• 6 censored, 11 died

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Results

• p value for difference between the mean days of
  survival was 0.0196
• Mean mortality was 37.7
• Mortality for patients with prediction rule
• lt 130 was 32.1
• gt130 was 64.7

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Conclusion

• Patients with a prediction number gt130 had a
  statically significantly higher mortality than
  those with score lt130
• Long term mortality in patients with score gt130
  was 60
• PSI prediction rule can be used to predict long
  term mortality

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References

• Fine MJ et al. A prediction rule to identify low
  risk patients with community acquired pneumonia.
  NEJM 3364243-50.
• Fine MJ et al. Prognosis and outcomes of patients
  with community acquired pneumonia. JAMA
  2752134-41
• Brancati Fl et al. Is pneumonia really the old
  mans friend? Two year prognosis after
  community-acquired pneumonia. Lancet
  199334230-3.
• Kaplan V et al. Pneumonia Still the old mans
  friend. Arch In Med Feb 2003 163317-23.

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References

• Garibaldi RA. Epidemiology of community acquired
  respiratory tract infection in adults incidence,
  etiology, and impact. Am J Med 19857832-7
• Iezzoni LI et al. A clinical assessment of
  MedisGroups. JAMA. 19882603159-63.
• Adams PF et al. Current estimates from NHI survey
  1994, National Health Statistics. Vital Health
  Statistics. 1995 10.
• Lave JR et al. The cost of treating patients with
  community-acquired pneumonia. Sem Respir Crit
  Care Med 199920189.

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References

• Koivula I et al. Prognosis after
  community-acquired pneumonia in the elderly a
  population-based 12-year follow-up study. Arch
  Intern Med 1999 Jul 26159(14)1550-5.
• Hedlund JU et al. Factors of importance for the
  long term prognosis after hospital treated
  pneumonia. Department of Infectious Diseases,
  Karolinska Institute, Stockholm, Sweden.
• Fine MJ et al. Hospitalization decision in
  patients with community acquired pneumonia a
  prospective cohort. Am J Med Dec 1990 89713-21.

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