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Lamas CC, Coelho LE, Grinsztejn BJ, Veloso VG. Community-acquired lower respiratory tract infections in HIV-infected patients on antiretroviral therapy: predictors in a contemporary cohort study. Infection 2017; 45:801-809. [PMID: 28660356 PMCID: PMC5873951 DOI: 10.1007/s15010-017-1041-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 06/21/2017] [Indexed: 01/17/2023]
Abstract
Community-acquired pneumonia represents the most frequent bacterial infection in patients with HIV/AIDS. PURPOSE We aimed to assess variables associated with lower respiratory tract infection (LRTI) among HIV-infected adults using ART. METHODS A cohort study of HIV-infected patients aged ≥18 years, enrolled from 2000 to 2015, on ART for at least 60 days, with primary outcome as the 1st episode of LRTI during follow-up. The independent variables included were sex at birth, age, race/skin color, educational level, tobacco smoking, alcohol use, cocaine use, diabetes mellitus, CD4 count, HIV viral load, influenza and pneumococcal vaccination. Extended Cox proportional hazards models accounting for time-updated variables were fitted to assess LRTI predictors. RESULTS 2669 patients were included; median follow-up was 3.9 years per patient. LRTI was diagnosed in 384 patients; incidence rate was 30.7/1000 PY. In the unadjusted Cox extended models, non-white race [crude hazard ratio (cHR) 1.28, p = 0.020], cocaine use (cHR 2.01, p < 0.001), tobacco smoking (cHR 1.34, p value 0.007), and HIV viral load ≥400 copies/mL (cHR 3.40, p < 0.001) increased the risk of LRTI. Lower risk of LRTI was seen with higher educational level (cHR 0.61, p < 0.001), rise in CD4 counts (cHR 0.81, p < 0.001, per 100 cells/mm3 increase), influenza (cHR 0.60, p = 0.002) and pneumococcal vaccination (cHR 0.57, p < 0.001). In the adjusted model, aHR for CD4 count was 0.86, for cocaine use 1.47 and for viral load ≥400 copies 2.20. CONCLUSIONS LRTI has a high incidence in HIV-infected adults using ART. Higher CD4 counts and undetectable viral loads were protective, as were pneumococcal and influenza vaccines.
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Affiliation(s)
- Cristiane C Lamas
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Avenida Brasil 4365-Manguinhos, Rio de Janeiro, RJ, CEP 21.040-900, Brazil.
- Universidade do Grande Rio, Rio de Janeiro, Brazil.
| | - Lara E Coelho
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Avenida Brasil 4365-Manguinhos, Rio de Janeiro, RJ, CEP 21.040-900, Brazil
| | - Beatriz J Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Avenida Brasil 4365-Manguinhos, Rio de Janeiro, RJ, CEP 21.040-900, Brazil
| | - Valdilea G Veloso
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Avenida Brasil 4365-Manguinhos, Rio de Janeiro, RJ, CEP 21.040-900, Brazil
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Abstract
The association between alcohol abuse and pneumonia has been recognized for more than two centuries and represents an enormous health burden worldwide. The first published notation of alcohol as a clinical risk factor for the development of pneumonia is now over 200 years old, and since then there have been over a 1,000 references in the medical literature confirming these observations. Even in this modern era of medicine pneumonia remains a common infection that afflicts over 450 million persons worldwide annually and causes 7 % of all deaths. When one considers that alcohol is the most commonly abused substance in the world, the enormous excessive burden that alcohol contributes to the morbidity and mortality of pneumonia represents a major public health consideration. In this chapter we review the foundational literature that has chronicled the evolution of our understanding of the association between pneumonia and alcohol abuse over the past century. In addition, we discuss some of the specific pathogens that are particularly associated with serious lung infections in individuals with alcohol use disorders. Finally, we consider some of the specific guidelines for the treatment and prevention of pneumonia in the setting of alcohol abuse.
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Affiliation(s)
- David M. Guidot
- Division of Pulmonary, Allergy and Critical Care Medicine, Emory University School of Medicine and the Atlanta VA Medical Center, Atlanta, Georgia USA
| | - Ashish J. Mehta
- Division of Pulmonary, Allergy and Critical Care Medicine, Emory University School of Medicine and the Atlanta VA Medical Center, Decatur, Georgia USA
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Effect of socioeconomic status on mortality after bacteremia in working-age patients. A Danish population-based cohort study. PLoS One 2013; 8:e70082. [PMID: 23936145 PMCID: PMC3723741 DOI: 10.1371/journal.pone.0070082] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 06/16/2013] [Indexed: 11/19/2022] Open
Abstract
Objectives To examine the effect of socioeconomic status (SES) on mortality in patients with bacteremia and the underlying factors that may mediate differences in mortality. Methods We conducted a population-based cohort study in two Danish regions. All patients 30 to 65 years of age with first time bacteremia from 2000 through 2008 were identified in a population-based microbiological bacteremia database (n = 8,653). Individual-level data on patients’ SES (educational level and personal income) and comorbid conditions were obtained from public and medical registries. We used Cox regression to examine mortality within 30 days after bacteremia with and without cumulative adjustment for potential mediators. Results Bacteremia patients of low SES were more likely to live alone and be unmarried than patients of high SES. They also had more pre-existing comorbidity, more substance abuse, more Staphylococcus aureus and nosocomial infections, and more admissions to small nonteaching hospitals. Overall, 1,374 patients (15.9%) died within 30 days of follow-up. Patients of low SES had consistently higher mortality after bacteremia than those of high SES crude hazard ratio for low vs. high education, 1.38 [95% confidence interval (CI), 1.18–1.61]; crude hazard ratio for low-income vs. high-income tertile, 1.58 [CI, 1.39–1.80]. Adjustment for differences in social support, pre-existing comorbidity, substance abuse, place of acquisition of the infection, and microbial agent substantially attenuated the effect of SES on mortality (adjusted hazard ratio for low vs. high education, 1.15 [95% CI, 0.98–1.36]; adjusted hazard ratio for low-income vs. high-income tertile, 1.29 [CI, 1.12–1.49]). Further adjustment for characteristics of the admitting hospital had minimal effect on observed mortality differences. Conclusions Low SES was strongly associated with increased 30-day mortality after bacteremia. Less social support, more pre-existing comorbidity, more substance abuse, and differences in place of acquisition and agent of infection appeared to mediate much of the observed disparities in mortality.
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Izquierdo C, Oviedo M, Ruiz L, Sintes X, Vera I, Nebot M, Bayas JM, Carratalà J, Varona W, Sousa D, Celorrio JM, Salleras L, Domínguez A. Influence of socioeconomic status on community-acquired pneumonia outcomes in elderly patients requiring hospitalization: a multicenter observational study. BMC Public Health 2010; 10:421. [PMID: 20633254 PMCID: PMC2916903 DOI: 10.1186/1471-2458-10-421] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Accepted: 07/15/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The associations between socioeconomic status and community-acquired pneumonia outcomes in adults have been studied although studies did not always document a relationship.The aim of this multicenter observational study was to determine the association between socioeconomic status and community-acquired pneumonia outcomes in the elderly, in the context of a public health system providing universal free care to the whole population. METHODS A total of 651 patients aged > or =65 years hospitalized due to community-acquired pneumonia through the emergency departments of five Spanish public hospitals were recruited and followed up between May 2005 and January 2007. The primary outcomes studied were: length of stay, intensive care unit admission, overall mortality and readmission. Socioeconomic status was measured using both individual and community data: occupation [categorized in six social groups (I, II, III, IVa, IVb and V)], educational level (< or = primary level or > or = secondary level) and disposable family income of the municipality or district of residence [>12,500 euro (high municipality family income) and < or =12,500 euro (low municipality family income)]. The six social groups were further categorized as upper/middle social class (groups I-IVb) and lower class (group V).Bivariate and multivariate analyses were performed. OR and their 95% confidence intervals were calculated. All statistical tests were two tailed and statistical significance was established as p < 0.05. RESULTS 17.7% of patients lived in a municipality or district with a high municipality family income and 63.6% were upper/middle social class (I-IVb). Only 15.7% of patients had a secondary education. The adjusted analysis showed no association between pneumonia outcomes and social class, educational level or municipality family income. However, length of stay increased significantly in patients in whom the factors, living alone and being a smoker or ex-smoker coincided (p < 0.001). CONCLUSIONS We measured socioeconomic status using both individual and community data and found no association between social class, educational level or municipality family income and the variables of pneumonia outcomes. The lack of differences between social classes supports the provision of universal, equitable health care by the public health system.
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Affiliation(s)
- Conchita Izquierdo
- Department of Health, Generalitat of Catalonia, Roc Boronat 81-95, 08005 Barcelona, Spain.
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Huang JQ, Hooper PM, Marrie TJ. Factors associated with length of stay in hospital for suspected community-acquired pneumonia. Can Respir J 2007; 13:317-24. [PMID: 16983447 PMCID: PMC2683319 DOI: 10.1155/2006/325087] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To determine factors associated with the length of stay (LOS) for patients with suspected community-acquired pneumonia (CAP) who required hospitalization for treatment. STUDY DESIGN The authors studied a population-based prospective cohort of 2,757 adults with suspected CAP who were admitted over a two-year period. Logistic regression, multiple linear regression, and classification and regression trees were used to determine the factors associated with LOS. SETTING The study was conducted in two community and tertiary care hospitals, two community and secondary care hospitals, and two community hospitals in the Capital Health Region of Edmonton, Alberta. RESULTS Symptoms such as sweats, shaking chills and wheezing were associated with an LOS of seven days or shorter, whereas weight loss, functional impairment, heart, renal or neoplastic diseases and time to first dose of antibiotic were predictive of an LOS greater than seven days. Regression tree analysis indicated that rapid achievement of physiological stability was associated with a shorter LOS. The use of an indwelling urinary catheter was found to be an important determinant of LOS. CONCLUSIONS The present study found several new associations with increased LOS in patients with CAP, including functional status, time to receipt of first dose of antibiotic therapy, use of certain antibiotics, presence of a urinary catheter and the importance of time to physiological stability. An intervention targeting avoidance of urinary catheters may be associated with a shorter LOS.
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Affiliation(s)
- Jane Q Huang
- Department of Medicine, University of Alberta, Edmonton, Alberta
- Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, Alberta
| | - Peter M Hooper
- Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, Alberta
| | - Thomas J Marrie
- Department of Medicine, University of Alberta, Edmonton, Alberta
- Correspondence: Dr Thomas J Marrie, Faculty of Medicine and Dentistry, 2J2.01 Walter C Mackenzie Health Sciences Centre, 8440 – 112 Street, Edmonton, Alberta T6G 2R7. Telephone 780-492-9728, fax 780-492-7303, e-mail
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Crighton EJ, Elliott SJ, Moineddin R, Kanaroglou P, Upshur R. A spatial analysis of the determinants of pneumonia and influenza hospitalizations in Ontario (1992-2001). Soc Sci Med 2007; 64:1636-50. [PMID: 17250939 DOI: 10.1016/j.socscimed.2006.12.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2006] [Indexed: 11/25/2022]
Abstract
Previous research on the determinants of pneumonia and influenza has focused primarily on the role of individual level biological and behavioural risk factors resulting in partial explanations and largely curative approaches to reducing the disease burden. This study examines the geographic patterns of pneumonia and influenza hospitalizations and the role that broad ecologic-level factors may have in determining them. We conducted a county level, retrospective, ecologic study of pneumonia and influenza hospitalizations in the province of Ontario, Canada, between 1992 and 2001 (N=241,803), controlling for spatial dependence in the data. Non-spatial and spatial regression models were estimated using a range of environmental, social, economic, behavioural, and health care predictors. Results revealed low education to be positively associated with hospitalization rates over all age groups and both genders. The Aboriginal population variable was also positively associated in most models except for the 65+-year age group. Behavioural factors (daily smoking and heavy drinking), environmental factors (passive smoking, poor housing, temperature), and health care factors (influenza vaccination) were all significantly associated in different age and gender-specific models. The use of spatial error regression models allowed for unbiased estimation of regression parameters and their significance levels. These findings demonstrate the importance of broad age and gender-specific population-level factors in determining pneumonia and influenza hospitalizations, and illustrate the need for place and population-specific policies that take these factors into consideration.
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Affiliation(s)
- Eric J Crighton
- Department of Geography, University of Ottawa, 60 University Avenue, Simard Hall Room 06, Ottawa, Ont., Canada K1N 6N5.
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McGregor MJ, Reid RJ, Schulzer M, Fitzgerald JM, Levy AR, Cox MB. Socioeconomic status and hospital utilization among younger adult pneumonia admissions at a Canadian hospital. BMC Health Serv Res 2006; 6:152. [PMID: 17125520 PMCID: PMC1697815 DOI: 10.1186/1472-6963-6-152] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2006] [Accepted: 11/25/2006] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although the general association between socioeconomic status (SES) and hospitalization has been well established, few studies have considered the relationship between SES and hospital length of stay (LOS), and/or hospital re-admission. The primary objective of this study therefore, was to examine the relationship of SES to LOS and early re-admission among adult patients hospitalized with community-acquired pneumonia in a setting with universal health insurance. METHODS Four hundred and thirty-four (434) individuals were included in this retrospective, longitudinal cohort analysis of adult patients less than 65 years old admitted to a large teaching hospital in Vancouver, British Columbia. Hospital chart review data were linked to population-based health plan administrative data. Chart review was used to gather data on demographics, illness severity, co-morbidity, functional status and other measures of case mix. Two different types of administrative data were used to determine hospital LOS and the occurrence of all-cause re-admission to any hospital within 30 days of discharge. SES was measured by individual-level financial hardship (receipt of income assistance or provincial disability pension) and neighbourhood-level income quintiles. RESULTS Those with individual-level financial hardship had an estimated 15% (95% CI -0.4%, +32%, p = 0.057) longer adjusted LOS and greater risk of early re-admission (adjusted OR 2.65, 95% CI 1.38, 5.09). Neighbourhood-level income quintiles, showed no association with LOS or early re-admission. CONCLUSION Among hospitalized pneumonia patients less than 65 years, financial hardship derived from individual-level data, was associated with an over two-fold greater risk of early re-admission and a marginally significant longer hospital LOS. However, the same association was not apparent when an ecological measure of SES derived from neighbourhood income quintiles was examined. The ecological SES variable, while useful in many circumstances, may lack the sensitivity to detect the full range of SES effects in clinical studies.
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Affiliation(s)
- Margaret J McGregor
- Centre for Clinical Epidemiology and Evaluation, Family Practice Research Office, 828 West 10Avenue, Vancouver, BC, Canada
- Department of Family Practice, Department of Medicine, University of British Columbia, 5950 University Boulevard, Vancouver, BC, Canada
| | - Robert J Reid
- Department of Health Care and Epidemiology, Faculty of Medicine, University of British Columbia, 5804 Fairview Avenue, Vancouver, BC, Canada
- Group Health Cooperative, 1730 Minor Avenue, Suite 1600, Seattle, WA, USA
| | - Michael Schulzer
- Centre for Clinical Epidemiology and Evaluation, Family Practice Research Office, 828 West 10Avenue, Vancouver, BC, Canada
| | - J Mark Fitzgerald
- Centre for Clinical Epidemiology and Evaluation, Family Practice Research Office, 828 West 10Avenue, Vancouver, BC, Canada
| | - Adrian R Levy
- Department of Health Care and Epidemiology, Faculty of Medicine, University of British Columbia, 5804 Fairview Avenue, Vancouver, BC, Canada
- Centre for Health Evaluation & Outcome Sciences (CHÉOS), St. Paul's Hospital, 620-1081 Burrard Street, Vancouver, BC, Canada
| | - Michelle B Cox
- Centre for Clinical Epidemiology and Evaluation, Family Practice Research Office, 828 West 10Avenue, Vancouver, BC, Canada
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El Solh A, Pineda L, Bouquin P, Mankowski C. Determinants of short and long term functional recovery after hospitalization for community-acquired pneumonia in the elderly: role of inflammatory markers. BMC Geriatr 2006; 6:12. [PMID: 16899118 PMCID: PMC1557854 DOI: 10.1186/1471-2318-6-12] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2006] [Accepted: 08/09/2006] [Indexed: 01/08/2023] Open
Abstract
Background Hospitalization for older patients with community-acquired pneumonia (CAP) is associated with functional decline. Little is know about the relationship between inflammatory markers and determinants of functional status in this population. The aim of the study is to investigate the association between tumor necrosis factor (TNF)-α, C-reactive protein (CRP) and Activities of Daily Living, and to identify risk factors associated with one year mortality or hospital readmission. Methods 301 consecutive patients hospitalized for CAP (mean age 73.9 ± 5.3 years) in a University affiliated hospital over 18 month period were included. All patients were evaluated on admission to identify baseline demographic, microbiological, cognitive and functional characteristics. Serum levels for TNF-α and CRP were collected at the same time. Reassessment of functional status at discharge, and monthly thereafter till 3 months post discharge was obtained and compared with preadmission level to document loss or recovery of functionality. Outcome was assessed by the composite endpoint of hospital readmission or death from any cause up to one year post hospital discharge. Results 36% of patients developed functional decline at discharge and 11% had persistent functional impairment at 3 months. Serum TNF-α (odds ratio [OR] 1.12, 95% CI 1.08–1.15; p < 0.001) and the Charlson Index (OR = 1.39, 95% CI 1.14 to 1.71; p = 0.001) but not age, CRP, or cognitive status were independently associated with loss of functionality at the time of hospital discharge. Lack of recovery in functional status at 3 months was associated with impaired cognitive ability and preadmission comorbidities. In Cox regression analysis, persistent functional impairment at 3 months, impaired cognitive function, and the Charlson Index were highly predictive of one year hospital readmission or death. Conclusion Serum TNF-α levels can be useful in determining patients at risk for functional impairment following hospitalization from CAP. Old patients with impaired cognitive function and preexisting comorbidities who exhibit delay in functional recovery at 3 months post discharge may be at high risk for hospital readmission and death. With the scarcity of resources, a future risk stratification system based on these findings might be proven helpful to target older patients who are likely to benefit from interventional strategies.
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Affiliation(s)
- Ali El Solh
- Western New York Respiratory Research Center, 462 Grider Street, Buffalo, NY 14215, USA
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Lilibeth Pineda
- Western New York Respiratory Research Center, 462 Grider Street, Buffalo, NY 14215, USA
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Pam Bouquin
- Western New York Respiratory Research Center, 462 Grider Street, Buffalo, NY 14215, USA
| | - Corey Mankowski
- Western New York Respiratory Research Center, 462 Grider Street, Buffalo, NY 14215, USA
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Mourad O, Redelmeier DA. Clinical teaching and clinical outcomes: teaching capability and its association with patient outcomes. MEDICAL EDUCATION 2006; 40:637-44. [PMID: 16836536 DOI: 10.1111/j.1365-2929.2006.02508.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND There is little research on the impact of medical education on patient outcome. We studied whether teaching capability is associated with altered short-term patient outcomes. METHODS We performed a multicentre retrospective cross-sectional study involving 40 clinician teachers who had attended on the general internal medicine services in hospitals affiliated with the University of Toronto along with the clinical outcomes of consecutive patients treated for community-acquired pneumonia, congestive heart failure, chronic obstructive pulmonary disease and gastrointestinal bleeding (n = 4377) between 1999 and 2001. Doctors were characterised by teaching effectiveness scores (n = 677) as high-rated or low-rated according to house staff ratings. RESULTS There was no correlation between the teaching effectiveness scores and the mean length of stay for those patients treated for community-acquired pneumonia (high-rated = 10.3 versus low-rated = 8.1 days, P = 0.058), congestive heart failure (high-rated = 10.1 versus low-rated = 9.9 days, P = 0.978), chronic obstructive pulmonary disease (high-rated = 9.4 versus low-rated = 9.9 days, P = 0.419) and gastrointestinal bleeding (high-rated = 6.3 versus low-rated = 6.8 days, P = 0.741). In addition, we observed no significant correlation between teaching effectiveness scores and 7-day, 28-day and 1-year readmission rates for all pre-specified diagnoses. CONCLUSION There is no large correlation between teaching effectiveness scores and short-term patient outcomes, suggesting that doctor teaching capabilities, as perceived by house staff, does not generally impact clinical care.
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Affiliation(s)
- Ophyr Mourad
- St Michael's Hospital, Toronto, Ontario, Canada.
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Labarere J, Stone RA, Scott Obrosky D, Yealy DM, Meehan TP, Auble TE, Fine JM, Graff LG, Fine MJ. Factors associated with the hospitalization of low-risk patients with community-acquired pneumonia in a cluster-randomized trial. J Gen Intern Med 2006; 21:745-52. [PMID: 16808776 PMCID: PMC1924717 DOI: 10.1111/j.1525-1497.2006.00510.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2005] [Revised: 01/24/2006] [Accepted: 03/10/2006] [Indexed: 11/28/2022]
Abstract
BACKGROUND Many low-risk patients with pneumonia are hospitalized despite recommendations to treat such patients in the outpatient setting. OBJECTIVE To identify the factors associated with the hospitalization of low-risk patients with pneumonia. METHODS We analyzed data collected by retrospective chart review for 1,889 low-risk patients (Pneumonia Severity Index [PSI] risk classes I to III without evidence of arterial oxygen desaturation) enrolled in a cluster-randomized trial conducted in 32 emergency departments. RESULTS Overall, 845 (44.7%) of all low-risk patients were treated as inpatients. Factors independently associated with an increased odds of hospitalization included PSI risk classes II and III, the presence of medical or psychosocial contraindications to outpatient treatment, comorbid conditions that were not contained in the PSI (cognitive impairment, history of coronary artery disease, diabetes mellitus, or pulmonary disease), multilobar radiographic infiltrates, and home therapy with oxygen, corticosteroids, or antibiotics before presentation. While 32.8% of low-risk inpatients had a contraindication to outpatient treatment and 47.1% had one or more preexisting treatments, comorbid conditions, or radiographic abnormalities not contained in the PSI, 20.1% had no identifiable risk factors for hospitalization other than PSI risk class II or III. CONCLUSIONS Hospital admission appears justified for one-third of low-risk inpatients based upon the presence of one or more contraindications to outpatient treatment. At least one-fifth of low-risk inpatients did not have a contraindication to outpatient treatment or an identifiable risk factor for hospitalization, suggesting that treatment of a larger proportion of such low-risk patients in the outpatient setting could be achieved without adversely affecting patient outcomes.
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Affiliation(s)
- Jose Labarere
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA.
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Vrbova L, Mamdani M, Moineddin R, Jaakimainen L, Upshur REG. Does socioeconomic status affect mortality subsequent to hospital admission for community acquired pneumonia among older persons? J Negat Results Biomed 2005; 4:4. [PMID: 15819975 PMCID: PMC1090611 DOI: 10.1186/1477-5751-4-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2004] [Accepted: 04/08/2005] [Indexed: 11/10/2022] Open
Abstract
Background Low socioeconomic status has been associated with increased morbidity and mortality for various health conditions. The purpose of this study was twofold: to examine the mortality experience of older persons admitted to hospital with community acquired pneumonia and to test the hypothesis of whether an association exists between socioeconomic status and mortality subsequent to hospital admission for community-acquired pneumonia. Methods A population based retrospective cohort study was conducted including all older persons patients admitted to Ontario hospitals with community acquired pneumonia between April 1995 and March 2001. The main outcome measures were 30 day and 1 year mortality subsequent to hospital admission for community-acquired pneumonia. Results Socioeconomic status for each patient was imputed from median neighbourhood income. Multivariate analyses were undertaken to adjust for age, sex, co-morbid illness, hospital and physician characteristics. The study sample consisted of 60,457 people. Increasing age, male gender and high co-morbidity increased the risk for mortality at 30 days and one year. Female gender and having a family physician as attending physician reduced mortality risk. The adjusted odds of death after 30-days for the quintiles compared to the lowest income quintile (quintile 1) were 1.02 (95% CI: 0.95–1.09) for quintile 2, 1.04 (95% CI: 0.97–1.12) for quintile 3, 1.01 (95% CI: 0.94–1.08) for quintile 4 and 1.03 (95% CI: 0.96–1.12) for the highest income quintile (quintile 5). For 1 year mortality, compared to the lowest income quintile the adjusted odds ratios were 1.01 (95% CI: 0.96–1.06) for quintile 2, 0.99 (95% CI: 0.94–1.04) for quintile 3, 0.99 (95% CI: 0.93–1.05) for quintile 4 and 1.03 (95% CI: 0.97–1.10) for the highest income quintile. Conclusion Socioeconomic status is not associated with mortality in the older persons from community-acquired pneumonia in Ontario, Canada.
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Affiliation(s)
- Linda Vrbova
- Department of Public Health Sciences, University of Toronto, McMurrich Building, 12 Queen's Park Crescent W, Toronto, ON, M5S 1A8, Canada
| | - Muhammad Mamdani
- Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Health Policy Management and Evaluation, University of Toronto, McMurrich Building, 2Floor, 12 Queen's Park Crescent West, Toronto, ON, Ma5S 1A8, Canada
- Faculty of Pharmacy, University of Toronto, 19 Russell Street, Toronto, ON, M5S 2S2, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, University of Toronto, 256 McCaul Street, 2Floor, Toronto, ON, M5T 2W5, Canada
| | - Liisa Jaakimainen
- Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Department of Family and Community Medicine, University of Toronto, 256 McCaul Street, 2Floor, Toronto, ON, M5T 2W5, Canada
| | - Ross EG Upshur
- Department of Public Health Sciences, University of Toronto, McMurrich Building, 12 Queen's Park Crescent W, Toronto, ON, M5S 1A8, Canada
- Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Department of Family and Community Medicine, University of Toronto, 256 McCaul Street, 2Floor, Toronto, ON, M5T 2W5, Canada
- Primary Care Research Unit, Department of Family and Community Medicine, Sunnybrook and Women's College Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
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Loeb MB. Use of a Broader Determinants of Health Model for Community-Acquired Pneumonia in Seniors. Clin Infect Dis 2004; 38:1293-7. [PMID: 15127343 DOI: 10.1086/383469] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2003] [Indexed: 11/03/2022] Open
Abstract
Community-acquired pneumonia in older adults represents an important clinical and public health challenge. This article discusses the role that factors such as socioeconomic status, air pollution, crowding, exposure to tobacco smoke, and nutrition play in predisposing elderly persons to such respiratory infections. It is proposed that a model that addresses these factors is needed for a comprehensive understanding of these infections. Although the causal pathways may be unclear, there are data to suggest a relationship between low socioeconomic status and risk of acquiring respiratory infection. The need for more research in this area is emphasized.
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Affiliation(s)
- Mark B Loeb
- Department of Pathology, McMaster University, Hamilton, Ontario, Canada.
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Niederman MS. What Is the Prognosis for Using the Pneumonia Severity Index To Make Site-of-Care Decisions In Community-Acquired Pneumonia? Chest 2003; 124:2051-3. [PMID: 14665475 DOI: 10.1378/chest.124.6.2051] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Liu K, Dong H, Sauerborn R. Cost analysis of pneumonia treatment in the Philippines. Int J Health Plann Manage 2003; 18:221-31. [PMID: 12968799 DOI: 10.1002/hpm.711] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The objectives of this study were to describe the cost distribution of pneumonia treatment in tertiary hospitals in the National Capital Region (NCR) and to identify variations in costs in order to provide basic information to the Philippine Health Insurance Corporation (PHIC) for quality assurance and policy development. This study focuses on 3861 reimbursement claims, which come from 22 government and 38 private tertiary hospitals. Wide variations of cost existed among the hospitals and among the inpatients. Medicine was the leading expenditure in total costs (38%), second was examinations (27%), third was beds (22%) and the last was doctors fees (13%). The same ranking ocurred for reimbursement by PHIC. The private hospitals were more expensive than the government hospitals, but also more efficient in the length of hospitalization. The member patients spent more and were reimbursed more for clinical practice than the dependent patients. However, there was no difference in the length of hospitalization between member and dependent patients. There was no difference in the length of hospitalization and expenditure between Government Service Insurance System (GSIS) in 1997 and Social Security System (SSS) patients. Clinical guidelines should be effectively implemented and PHIC should contribute more to reduce existing variations, improve cost-effectiveness and the quality of clinical practices.
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Affiliation(s)
- Kehui Liu
- Health and Prevention Center of Shaanxi Province Xian, Shaanxi 710054, P.R. China.
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Abstract
Community-acquired pneumonia (CAP) poses a substantial threat to the health of older adults. The incidence of this infection and mortality associated with it increase with age. Despite the considerable effect of CAP on older adults, little is known about the effect of socioeconomic and environmental factors on CAP in older people. This paper argues that broader determinants, including socioeconomic status (SES), nutrition, and factors in the physical environment such as exposure to tobacco smoke and air pollution need to be evaluated as potential risk factors for CAP in older adults. Data suggesting a relationship between low SES and risk of acquiring CAP exist; possible causal pathways include increased exposure through crowding or increased susceptibility to infection. Inadequate nutrition, exposure to tobacco smoke, air pollution, and not receiving immunization may predispose older people to lower respiratory tract infection. This study reviews current evidence for these potential risk factors and suggests priorities for research. A thorough understanding of these factors and their underlying biological mechanisms is needed to develop successful health-promotion strategies such as better immunization strategies and educational programs about nutrition. Determining the effect of air pollution on CAP in older adults is important in terms of reducing personal risk to older individuals and for healthcare agencies charged with formulating policy to protect the health of older adults.
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Affiliation(s)
- Mark B Loeb
- Department of Pathology and Molecular Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
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