Influence of socioeconomic status on features and outcome of community-acquired pneumonia

Community-acquired lower respiratory tract infections in HIV-infected patients on antiretroviral therapy: predictors in a contemporary cohort study

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.

The Epidemiology of Alcohol Abuse and Pneumonia

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.

Effect of socioeconomic status on mortality after bacteremia in working-age patients. A Danish population-based cohort study

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.

Influence of socioeconomic status on community-acquired pneumonia outcomes in elderly patients requiring hospitalization: a multicenter observational study

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.

Factors associated with length of stay in hospital for suspected community-acquired pneumonia

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.

A spatial analysis of the determinants of pneumonia and influenza hospitalizations in Ontario (1992-2001)

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.

Socioeconomic status and hospital utilization among younger adult pneumonia admissions at a Canadian hospital

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.

Determinants of short and long term functional recovery after hospitalization for community-acquired pneumonia in the elderly: role of inflammatory markers

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.

Clinical teaching and clinical outcomes: teaching capability and its association with patient outcomes

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.

Factors associated with the hospitalization of low-risk patients with community-acquired pneumonia in a cluster-randomized trial

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.

Does socioeconomic status affect mortality subsequent to hospital admission for community acquired pneumonia among older persons?

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.

Use of a Broader Determinants of Health Model for Community-Acquired Pneumonia in Seniors

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.

Cost analysis of pneumonia treatment in the Philippines

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.

Community-acquired pneumonia in older people: the need for a broader perspective

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.