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Requests for reprints should be addressed to Harry A. Conte, MD, Section of Infectious Diseases, Yale University School of Medicine, LCI 800, 333 Cedar Street, New Haven, Connecticut 06520
Affiliations
Department of Internal Medicine, Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut USAConnecticut Peer Review Organization, Middletown (JDS), Connecticut, USA
Department of Internal Medicine, Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut USAConnecticut Peer Review Organization, Middletown (JDS), Connecticut, USA
Department of Internal Medicine, Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut USAConnecticut Peer Review Organization, Middletown (JDS), Connecticut, USA
Department of Internal Medicine, Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut USAConnecticut Peer Review Organization, Middletown (JDS), Connecticut, USA
Department of Internal Medicine, Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut USAConnecticut Peer Review Organization, Middletown (JDS), Connecticut, USA
Department of Internal Medicine, Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut USAConnecticut Peer Review Organization, Middletown (JDS), Connecticut, USA
PURPOSE: We sought to identify admission characteristics predicting mortality in elderly patients hospitalized with community-acquired pneumonia and to develop a prognostic staging system and discriminant rule.
PATIENTS AND METHODS: We retrospectively analyzed data from 2,356 patients aged ≥65 years admitted with community-acquired pneumonia. Multivariable analyses of a derivation cohort (n = 1,000) identified characteristics associated with hospital mortality. A staging system and discriminant rule based on these characteristics were tested in a validation cohort (n = 1,356). Our discriminant rule was compared with a rule formulated from a heterogeneous adult population with community-acquired pneumonia.
RESULTS: Hospital mortality rates were 9% (derivation cohort) and 12% (validation cohort). We identified five independent predictors of mortality: age ≥85 years [odds ratio 1.8 (95% confidence interval 1.1–3.1)], comorbid disease [odds ratio 4.1 (2.1–8.1)], impaired motor response [odds ratio 2.3 (1.4–3.7)], vital sign abnormality [odds ratio 3.4 (2.1–5.4)], and creatinine level ≥1.5 mg/dL [odds ratio 2.5 (1.5–4.2)]. These variables stratified patients into four distinct stages with increasing mortality in the derivation cohort (Stage 1, 2%; Stage 2, 7%; Stage 3, 22%; Stage 4, 45%; P = 0.001) as well as in the validation cohort (Stage 1, 4%; Stage 2, 11%; Stage 3, 23%; Stage 4, 41%; P = 0.001). The discriminant rule developed from the derivation cohort had greater overall accuracy (77.1%) in the validation cohort than a rule formulated from a heterogeneous adult population (68.0%, P = 0.001).
CONCLUSION: Elderly patients with community-acquired pneumonia have characteristics at admission that can predict mortality. Our staging system and discriminant rule improve prognostic stratification of these patients.
Approximately 4 million patients develop community-acquired pneumonia each year in the United States, with an annual cost approaching 24 billion dollars. Close to one-fifth of patients require hospitalization and, of these, 10% to 24% die (
). There is an increased incidence and mortality of community-acquired pneumonia in patients older than 50 years of age, and pneumonia is the fourth leading cause of death in the elderly in the United States (
Many studies have identified factors associated with mortality from community-acquired pneumonia in adults, and a few have developed prognostic staging systems based on such factors (
British Thoracic Society and Public Health Laboratory Service Community-acquired pneumonia in adults in British hospitals in 1982–1983 a survey of aetiology, mortality, prognostic factors and outcome.
British Thoracic Society and Public Health Laboratory Service Community-acquired pneumonia in adults in British hospitals in 1982–1983 a survey of aetiology, mortality, prognostic factors and outcome.
) retrospectively validated a discriminant rule for hospital mortality developed in a prospective study of 453 adults with community-acquired pneumonia. Fine et al (
) prospectively developed a pneumonia-specific prognostic index for adults that successfully identified patients with a low risk of mortality. Although these indexes are useful for determining prognosis in the general adult population, they might be less useful when applied to subsets of patients, such as the elderly. Indeed, elderly patients with community-acquired pneumonia have a different spectrum of causative agents, a more subtle clinical presentation, and a different response to therapy than do younger patients (
We analyzed data from a large cohort of elderly patients hospitalized with community-acquired pneumonia to identify clinical characteristics at presentation that were predictive of hospital mortality. These characteristics were used to develop a prognostic staging system for identifying patients at low, intermediate, and high risk for hospital mortality. Furthermore, we derived and validated a simple discriminant rule for predicting hospital mortality and compared its accuracy with that of a discriminant rule formulated from a heterogeneous adult population with community-acquired pneumonia.
Patients and methods
Description of database
Data were analyzed from a regional and national pilot test of the Pneumonia Module of the Medicare Quality Indicator System. The pilot test is a retrospective compilation of medical records of patients with community-acquired pneumonia discharged from acute care hospitals in the United States and Puerto Rico between January 1, 1993, and January 31, 1994. The regional sample was defined by randomly identifying patients from four states (Massachusetts, Maryland, New Hampshire, West Virginia) from Medicare’s National Claims History File who had a principal discharge diagnosis of pneumonia [International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes 480.0–480.9, 481, 482.0–482.9, 483.0–483.8, 485, 486, 487.0, 507.0] or a principal discharge diagnosis of respiratory failure (ICD-9-CM code 518.81) and a secondary diagnosis of pneumonia. The national random sample was generated by selecting a number of similarly defined cases from each state or territory. The records of these patients were forwarded to one of two clinical data abstraction centers, where trained medical abstractors collected data using an electronic data collection instrument, including several historical and clinical characteristics of the patients. The accuracy of the abstractors was monitored by both a clinical supervisor and an internal quality control process.
For this study, a diagnosis of pneumonia required that a patient have a chest radiograph performed within the first 48 hours of admission that was consistent with pneumonia (new air bronchogram, air space disease, consolidation, infiltrate, inflammation, opacity, pneumonia, or pneumonitis), and whose admitting clinician documented pneumonia as the initial working diagnosis. In addition, patients were excluded from further analysis if they met any of the following criteria: age <65 years, serologic evidence of infection with human immunodeficiency virus, history of organ transplant, receiving chemotherapy within previous 2 months, transfer from another acute care hospital, readmission within 10 days from a prior acute care hospitalization, or discharge or death on date of admission. Comprehensive historical and clinical parameters recorded within 24 hours of admission were available on the remaining patients.
Identification of predictor variables
For the derivation of our staging system and discriminant rule, patients from the four-state random sample (n = 1,000) were used as the derivation cohort; patients from the national sample (n = 1,356) were used as the validation cohort. Bivariate analyses were performed to identify variables that were associated with hospital mortality. Candidate predictor variables included demographic variables (age, sex, race, pre-arrival setting), functional variables (urinary continence, physical mobility), vital signs (temperature, systolic and diastolic blood pressure, respiratory rate, heart rate), measures of consciousness (eye opening, verbal response, motor response), and laboratory values (hematocrit, white blood cell count, and serum sodium, blood urea nitrogen, creatinine, and glucose levels). An impaired motor response was defined as failure to exhibit a motor response to verbal stimuli (localization of painful stimuli alone, flexion withdrawal, decorticate/decerebrate posturing, or no response). In addition, we considered patients to have a comorbid condition if there was documentation of acute or chronic leukemia, Hodgkin’s or non-Hodgkin’s lymphoma, multiple myeloma, any cancer with local or distant metastases, hepatic failure, cirrhosis, chemotherapy or radiotherapy within the last year (but not 2 months before admission), or a collagen vascular disease.
A multivariable logistic regression analysis was performed using significant variables identified in the bivariate analyses. Those variables found to have significant independent association with hospital mortality in the multivariable analyses were used to construct both a prognostic staging system and a discriminant rule for hospital mortality. To avoid overfitting of logistic regression models (
), variables were organized into groups delineated by category as well as anticipated clinical interrelatedness. Thus, demographic variables (including comorbid conditions) were tested together. Next, functional variables and measures of consciousness were tested, followed by vital signs. Finally, the laboratory values were tested. The independent variables identified by these grouped analyses were then entered into a logistic regression model.
Derivation and validation of the prognostic staging system
Using these variables, a clinically useful prognostic staging system was formulated for hospital mortality. We assigned each predictor variable an integer value, or “risk score,” based on the relative magnitude of its multivariate association with hospital mortality. The mortality gradients that were achieved by partitioning the derivation cohort (four-state sample) based on total risk score were examined. A four-staged ranking of total risk scores was developed. This system was then applied to the validation cohort (national sample), and the risk gradients of hospital mortality in the four stages of the validation cohort were compared to the risk gradients occurring in the same stages in the derivation cohort.
Derivation and validation of the discriminant rule
To define further the utility of the predictor variables, we used them to construct a discriminant rule for hospital mortality. The discriminant rule was established by examining the sensitivity, specificity, positive and negative predictive values, and overall accuracy of each potential rule employing an incrementally increasing sum of risk scores in the derivation cohort. We chose the rule achieving the best combination of sensitivity and specificity for clinical decision making in the derivation cohort (four-state sample). Our discriminant rule was applied to the validation cohort (national sample), and its sensitivity, specificity, positive and negative predictive values, and overall accuracy were examined. Finally, we compared our discriminant rule to a previous discriminant rule developed from a heterogeneous adult population by the British Thoracic Society, and validated by Farr et al (
British Thoracic Society and Public Health Laboratory Service Community-acquired pneumonia in adults in British hospitals in 1982–1983 a survey of aetiology, mortality, prognostic factors and outcome.
) in an independent sample of adults. This system classified patients into a high-risk or low-risk category for hospital mortality, with high-risk patients having any two of the following characteristics on admission: blood urea nitrogen level >7 mmol/L (19.6 mg/dL), respiratory rate ≥30 breaths per minute, and diastolic blood pressure ≤60 mm Hg, while low-risk patients had one or none of these characteristics. We applied this discriminant rule to the validation cohort and compared its sensitivity, specificity, positive and negative predictive values, and overall accuracy with the discriminant rule derived from the derivation cohort of exclusively elderly patients.
Statistical analysis
In bivariate analyses, differences in proportions were tested with the chi-square or Fisher’s exact tests, and differences in means of dimensional variables with the Student’s t test. Missing values for dimensional or binary variables were coded as unknown, and “dummy” variables were created for “unknown” categories. In the multivariable analyses, candidate predictor variables were first selected within each domain, then entered into a final model using stepwise logistic regression analysis. A significance level of less than 0.10 was required for inclusion in the models and a significance level of greater than 0.05 was required for exclusion. All analyses were performed using PC-SAS 6.12 (
The pilot test of the Pneumonia Module of the Medicare Quality Indicator System provided 2,528 patients, with 1,073 patients in the four-state sample and 1,455 patients in the national sample. Exclusion of patients aged less than 65 years (n = 172) yielded 2,356 patients for subsequent analysis, of whom 1,000 were in the four-state sample (derivation cohort) and 1,356 in the national sample (validation cohort). There were small but statistically significant differences between the two patient groups (Table 1). Patients in the national sample were more likely to be men and to have arrived from a skilled nursing facility than those in the four-state sample. These patients also were more likely to exhibit urinary incontinence on admission and had higher mean serum blood urea nitrogen and creatinine levels. The patients in the four-state sample were more likely to be white and to exhibit spontaneous eye opening, an oriented verbal response, and motor response to verbal commands on admission. The patients in both groups had similar clinical complications, discharge dispositions, and mean lengths of stay (Table 2). The mortality rates were 9% in the four-state sample and 12% in the national sample.
Table 1Characteristics of the Derivation and Validation Sets of Patients 65 Years of Age and Older Hospitalized with Community-acquired Pneumonia
Table 2Clinical Complications and Outcomes in the Derivation and Validation Sets of Patients 65 Years of Age and Older Hospitalized with Community-acquired Pneumonia
Clinical complications (except incontinence and impaired mobility) and hospital mortality are expressed as percent of all patients developing such outcomes and complications. Length of stay and discharge disposition refer to patients surviving hospital stay.
Outcome
Four-State Sample, Derivation Set (n = 1,000)
National Sample, Validation Set (n = 1,356)
Clinical complications (%)
Decubitus ulcer
9
12
Deep venous thrombosis
0.4
0.8
Cerebrovascular accident
0.9
1.4
Myocardial infarction
1
4
Intensive care unit transfer
2
3
Incontinence
31
36
Impaired mobility
51
55
Mean length of stay (days)
8.3
8.8
Discharge disposition (%)
Home
66
61
Noninstitutional setting
1.8
1.7
Skilled nursing facility
28
33
Acute care hospital
3
3
Chronic hospital
1.1
1.2
Unknown
0.2
0.1
Hospital mortality
9
12
∗ Clinical complications (except incontinence and impaired mobility) and hospital mortality are expressed as percent of all patients developing such outcomes and complications. Length of stay and discharge disposition refer to patients surviving hospital stay.
Bivariate and multivariable predictors of mortality in the derivation set
When divided into age groups, patients aged 85 years or older had a greater risk of hospital mortality compared with patients aged 65 to 84 years (Table 3). Arrival from a skilled nursing facility was associated with twofold greater mortality than arrival from home or a noninstitutional setting. The presence of a comorbid condition was significantly associated with hospital mortality. Variables reflecting abnormal functional status (urinary incontinence, impaired physical mobility) and measures of consciousness (eye opening, verbal response, motor response) also had significant association with hospital mortality. Abnormal vital signs (temperature <36.1°C, systolic blood pressure <90 mm Hg, respiratory rate >30 breaths per minute, heart rate >110 beats per minute), and lab values reflecting dehydration (blood urea nitrogen ≥20 mg/dL, serum sodium <130 or >145 mmol/L, serum creatinine ≥1.5 mg/dL) or sepsis (white blood cells <4,000 or >20,000 cells per μL, glucose <60 or >200 mg/dL) were significantly associated with hospital mortality. Diastolic blood pressure was not significantly associated with mortality, nor was the mean value for hematocrit (data not shown).
Table 3Bivariate Analysis of the Derivation Set (n = 1,000) of Patients 65 Years of Age and Older Hospitalized with Community-acquired Pneumonia
In multivariable models, abnormal temperature (<36.1°C), heart rate (>110 beats per minute), or systolic blood pressure (<90 mm Hg) were combined as a composite variable (abnormal vital sign). In the final multivariable model, presence of a comorbid condition, and abnormal vital sign were the strongest predictors of hospital mortality (Table 4).
Table 4Independent Predictors of Hospital Mortality in the Derivation Set of Patients 65 Years of Age and Older Hospitalized with Community-acquired Pneumonia
Abnormal vital sign defined as presence of any one or more of the following: temperature <36.1°C, systolic blood pressure <90 mm Hg, and heart rate >110 beats/min.
3.4 (2.1–5.4)
0.0001
Serum creatinine level ≥1.5 mg/dL
2.5 (1.5–4.2)
0.0003
∗ See Methods.
† Abnormal vital sign defined as presence of any one or more of the following: temperature <36.1°C, systolic blood pressure <90 mm Hg, and heart rate >110 beats/min.
Derivation and validation of the prognostic staging system
Risk scores for each of the predictor variables were assigned as follows: age ≥85 years, impaired motor response, and serum creatinine level ≥1.5 mg/dL were each assigned a risk score of 1; presence of a comorbid condition and an abnormal vital sign were each assigned a value of 2. The low-risk subset (Stage 1) was composed of patients having a risk score of 0. Two intermediate stages were composed of patients with risk scores of 1 to 2 (Stage 2) and 3 to 4 (Stage 3). A high-risk Stage (Stage 4) included patients with risk scores of 5 or greater. The incremental progression in mortality from Stage 1 to Stage 4 in the derivation cohort (Figure 1) was statistically significant (4% for Stage 1, 11% for Stage 2, 23% for Stage 3, 41% for Stage 4, P = 0.001). The incremental progression in mortality achieved in the validation cohort (4% for Stage 2, 11% for Stage 3, 23% for Stage 3, 41% for Stage 4) was similar and remained statistically significant (Figure 1, P = 0.001).
Figure 1Prognostic staging system in the derivation set (left) and validation set (right) of patients 65 years of age and older hospitalized with community-acquired pneumonia. X-axis indicates risk Stage for hospital mortality. Y-axis indicates hospital mortality (percent).
Derivation and validation of the discriminant rule
Table 5shows the sensitivity, specificity, positive and negative predictive values, and overall accuracy obtained when potential discriminant rules employing increasing total risk scores were applied to the derivation cohort. Based on these values, we chose the discriminant rule that predicted hospital mortality when the patient total risk score was greater than or equal to 3. The overall accuracy of our chosen discriminant rule was 81.9% in the derivation cohort and 77.1% in the validation cohort (Table 5).
Table 5Test Characteristics of Rules with Different Prediction Scores for Hospital Mortality in the Derivation and Validation Sets of Patients 65 Years of Age and Older Hospitalized with Community-acquired Pneumonia
Rules formulated by considering as positive patients having the total risk scores for predictor variables as follows: age 85 years or greater, impaired motor response, and creatinine ≥1.5 mg/dL each given risk score of 1; presence of comorbid disease and abnormal vital sign each given risk score of 2.
Sensitivity (%)
Specificity (%)
Positive Predictive Value (%)
Negative Predictive Value (%)
Overall Accuracy (%)
Derivation Set (N = 1,000)
≥0
100
0
8.6
—
8.6
≥1
91.9
37.3
12.1
98.0
42.0
≥2
80.2
58.1
15.3
96.9
60.0
≥3
52.3
84.8
24.4
95.0
81.9
≥4
26.7
94.2
30.3
93.2
88.3
≥5
10.5
98.8
45.0
92.1
91.1
≥6
2.3
99.7
40.0
91.5
91.2
Validation Set (N = 1,356)
≥0
100
0
11.7
—
11.6
≥1
89.2
35.1
15.4
96.1
41.4
≥2
68.4
56.8
17.3
93.1
58.0
≥3
46.2
81.4
24.7
92.0
77.1
≥4
20.9
92.9
28.0
89.9
84.0
≥5
8.2
98.4
40.6
89.0
87.8
≥6
3.8
99.7
66.7
88.7
88.4
∗ Rules formulated by considering as positive patients having the total risk scores for predictor variables as follows: age 85 years or greater, impaired motor response, and creatinine ≥1.5 mg/dL each given risk score of 1; presence of comorbid disease and abnormal vital sign each given risk score of 2.
British Thoracic Society and Public Health Laboratory Service Community-acquired pneumonia in adults in British hospitals in 1982–1983 a survey of aetiology, mortality, prognostic factors and outcome.
) was applied to our validation cohort, it had a sensitivity of 50.3%; a specificity of 70.3%; a positive predictive value of 18.4%; and a negative predictive value of 91.4%; these values are similar to those for our discriminant rule. Our rule, however, had a superior overall accuracy, defined as the percentage of all patients that were classified correctly as to hospital mortality (77.1% vs 68.0%, P = 0.001). In addition, our discriminant rule, when positive, was associated with a threefold greater risk of hospital mortality, compared with a twofold greater risk associated with the previous rule.
Discussion
We derived a prognostic staging system and a discriminant rule for elderly patients with community-acquired pneumonia that utilized well defined variables at presentation. Both the staging system and the discriminant rule were successfully validated in a large independent cohort of elderly patients. We identified five demographic and clinical variables that were independently associated with hospital mortality: age 85 years or older, presence of a comorbid condition, lack of motor response to verbal commands, an abnormal vital sign, and serum creatinine level of 1.5 mg/dL or greater. A discriminant rule formulated from these variables performed well in both the derivation and validation cohorts of elderly patients with community-acquired pneumonia and had better accuracy than a discriminant rule developed from a heterogeneous group of adults with community-acquired pneumonia.
Our study had several advantages over previous work. First, we explicitly defined the potential predictors and the outcome, and neither the data abstraction personnel nor those responsible for identifying patients were aware of our analyses, minimizing the potential for bias (
). Second, to avoid spurious associations, we selected a limited number of variables for analysis based on clinical experience and the previous literature. Third, the large size of the derivation sample led to a sufficient number of patients who had the outcome of hospital mortality (n = 87), which reduced the risk of model overfitting (
). Finally, we had two independent samples of elderly patients with community-acquired pneumonia, allowing for validation of our discriminant rule and prognostic staging system (
Other studies examining prognostic factors of pneumonia in the elderly have also identified several of our predictor variables. These studies, however, were limited by imprecise variable definitions, lack of multivariable analysis or prognostic staging, or failure to validate a staging system in an independent cohort. For example, Venkatesan et al (
) prospectively followed 73 patients aged greater than 65 years with pneumonia and identified four predictors of mortality by univariate analysis: apyrexia, systolic hypotension, increasing hypoxemia, and new urinary incontinence. Janssens et al (
) prospectively followed a similar group of 99 patients aged 79 to 91 years and identified apyrexia, admission from a nursing home, and elevated blood urea nitrogen level as predictors of mortality. Hedlund et al (
Short and long term prognosis for middle aged and elderly patients hospitalized with community acquired pneumonia impact of nutritional and inflammatory factors.
) prospectively followed 97 patients aged 50 to 85 years with pneumonia and evaluated several predictors of mortality, including APACHE II score, body mass index, and triceps skin fold measurement. In all of these studies, multivariable analyses were not performed, and no prognostic staging systems were derived or validated. Starczewski et al(
) prospectively followed 100 patients aged greater than 70 years and identified four multivariable predictors of mortality: acute confusion, respiratory rate >26 breaths per minute, history of dementia, and bronchial breathing. Houston et al (
) retrospectively evaluated 413 patients aged 65 years or greater with community-acquired pneumonia or bronchitis and found that atypical symptoms, neurologic illness, current diagnosis of cancer, and recent or current use of antibiotics were predictors of 30-day mortality. These authors, however, did not derive or validate a prognostic index based on these predictors. Finally, Zweig et al (
) retrospectively reviewed the course of 133 elderly patients with pneumonia and identified five predictors of mortality by multivariable analysis: impaired consciousness, tachypnea, subnormal temperature, elevated white blood cell count, and cyanosis. However, this study was limited because the prognostic index was validated in a small sample from the same group from which it was derived, and two of the predictor variables (level of consciousness and cyanosis) lacked clearly stated definitions.
Our study identified some unique predictors of hospital mortality in elderly patients with community-acquired pneumonia. First, we found that within the subgroup of patients aged 65 years or older, those aged 85 years or greater had a higher likelihood of hospital mortality. While advanced age (>65 years) is a risk factor for mortality in community-acquired pneumonia among the general population, the importance of extreme advanced age (ie, ≥85 years) has not been demonstrated previously. Since several studies have identified an altered level of consciousness on presentation as an important predictor of mortality in elderly patients with community-acquired pneumonia (
Short and long term prognosis for middle aged and elderly patients hospitalized with community acquired pneumonia impact of nutritional and inflammatory factors.
), we evaluated several well defined measures of consciousness. Of these, we identified an impaired motor response, defined as failure to exhibit a motor response to verbal stimuli, as an independent risk factor.
Our independent predictor variables and discriminant rule compared well with those derived by the British Thoracic Society (BTS) and confirmed by Farr et al (
British Thoracic Society and Public Health Laboratory Service Community-acquired pneumonia in adults in British hospitals in 1982–1983 a survey of aetiology, mortality, prognostic factors and outcome.
). Our discriminant rule had comparable sensitivity, specificity, positive and negative predictive values, as well as superior overall accuracy.
Our prognostic staging system may be useful to investigators for comparing the mortality rates of elderly patients with community-acquired pneumonia among hospitals and for stratifying elderly patients according to mortality risk in the evaluation of new therapeutic agents. The discriminant rule is simple and easy to apply, can quickly stratify elderly patients into high- and low-risk groups, and can identify elderly patients who have a threefold increased risk of hospital mortality from community-acquired pneumonia.
There were several limitations to our study. First, it was limited to elderly patients hospitalized with community-acquired pneumonia, and our prognostic staging system and discriminant rule may not apply to elderly patients treated as outpatients. Second, the retrospective design of our study limited the choice of potential predictor variables, such as arterial oxygen saturation, arterial blood gas results (
), which might be associated with hospital mortality. Variables related to process and quality of care during hospitalization might also be associated with mortality in elderly patients with community-acquired pneumonia. Recently, Meehan et al (
) evaluated provider-amenable risk factors for 30-day mortality and found that initial administration of antibiotics after 8 hours and failure to obtain blood cultures within 24 hours of admission were associated with poor outcomes. Finally, hospital mortality is not the only outcome of interest. Other outcomes, such as need for intensive-care-unit transfer, change in mobility status, development of incontinence, 30-day mortality (
), and discharge disposition other than to home, are also relevant.
Community-acquired pneumonia is a common and severe disease in elderly patients. Our prognostic staging system and discriminant rule for hospital mortality, derived and validated in a cohort of elderly patients with community-acquired pneumonia, clarifies the risk factors for hospital mortality in these patients.
☆The analyses on which this publication is based were performed under Contract Number 500-96-P549, entitled “Utilization and Quality Control Peer Review Organization for the State of Connecticut” sponsored by the Health Care Financing Administration, Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US government.
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