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Biomedical subjects

M J Fine

Publications and source records attributed to M J Fine.

At least 37 records · Page 2Linked to original sources
PubMed1998

Patients hospitalized after initial outpatient treatment for community-acquired pneumonia.

STUDY OBJECTIVE: To determine the incidence, causes, and outcomes of patients hospitalized within 30 days of initiating outpatient treatment for community-acquired pneumonia (CAP). DESIGN: Patients were enrolled in the Pneumonia Patient Outcomes Research Team's multicenter, prospective cohort study of CAP. All hospitalizations within 30 days of study enrollment of patients initially treated as outpatients for CAP were recorded. Two physicians used a set of predetermined definitions to independently categorize the reasons for these subsequent hospitalizations. Thirty-day mortality rate and measures of resolution of pneumonia were assessed. The setting included three university teaching hospitals, a community teaching hospital, and a staff model medical practice within a health maintenance organization. RESULTS: Of the 944 enrollees with CAP initially treated in the outpatient setting, 71 (7.5%) were subsequently hospitalized within 30 days. The reason for subsequent hospitalization was CAP related in 40 patients and comorbidity related in 26 patients; 5 refused an initial offer of hospitalization. Ninety percent of pneumonia-related hospitalizations occurred within 10 days of initial presentation. Patients who were subsequently hospitalized required a median of 14 days to return to usual activities compared with 6 days for those who were not hospitalized (P<.0001). Patients with a subsequent hospitalization had a higher 30-day mortality rate, 4.2% compared with .3% (P<.01). CONCLUSION: A small proportion of patients with CAP initially treated in the outpatient setting are subsequently hospitalized. Such patients face a higher risk of delayed recovery or death. However, the vast majority of outpatients, whether subsequently hospitalized or not, had a successful resolution of their illness. Subsequent hospitalization by 10 days after initial outpatient treatment seems a reasonable screening tool for potentially unsatisfactory quality of care for patients with CAP.

Adult↗
PubMed1998

Assessing prognosis and selecting an initial site of care for adults with community-acquired pneumonia.

Over the last 20 years, more than 15 medical practice guidelines and clinical prediction rules have emerged to assist physicians in assessing the prognosis of adult patients with community-acquired pneumonia (CAP) and selecting an appropriately matched initial site of care. Most of these guidelines and rules suffer from major methodological flaws. One, the Pneumonia Patient Outcomes Research Team (PORT) clinical prediction rule, has satisfied rigorous methodological standards for the derivation and validation of high-quality prediction rules. This rule was incorporated into the Infectious Disease Society of America medical practice guideline for the management of adults with CAP. Strengths of the rule include its derivation and validation in over 50,000 inpatients and outpatients; stratification of all immunocompetent adult patients into one of five risk strata for short-term mortality and other unambiguous adverse medical outcomes; initial site of care recommendations for all patients, particularly those at low risk; and reliance on predictor variables readily available to clinicians at the time of initial patient presentation. A recent small-scale intervention trial demonstrates that the pneumonia PORT rule can reduce admissions for adult patients with CAP without compromising patient outcomes.

Adult↗
PubMed1998

Relationship of provider characteristics to outcomes, process, and costs of care for community-acquired pneumonia.

OBJECTIVES: The authors describe the relation of provider characteristics to processes, costs, and outcomes of medical care for elderly patients hospitalized for community-acquired pneumonia. METHODS: Using Medicare claims data, Medicare beneficiaries discharged from Pennsylvania hospitals during 1990 with community-acquired pneumonia were identified. Claims data were used to ascertain mortality, readmissions, use of procedures and physician consultations, and the costs of care. The relationship of these measures to provider characteristics was analyzed using regression techniques to adjust for patient characteristics, including comorbidity and microbial etiology. RESULTS: Among 22,294 pneumonia episodes studied, 30-day mortality was 17.0%. After adjusting for patient characteristics, 30-day mortality and readmission rates were unrelated to hospital teaching status or urban location or to physician specialty. Use of procedures and physician consultations was more common and costs were 11% higher among patients discharged from teaching hospitals compared with nonteaching hospitals. Similarly, costs were 15% higher at urban hospitals compared with rural hospitals. General internists and medical subspecialists used more procedures and had higher costs than family practitioners. CONCLUSIONS: Processes and costs of care for community-acquired pneumonia varied by provider characteristics, but neither mortality nor readmission rates did. These differences cannot be explained by clinical variables in the database. Further studies should determine whether less costly patterns of care for pneumonia, and perhaps other conditions, could replace more costly ones without compromising patient outcomes.

Aged↗
PubMed1997

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

CONTEXT: Pneumonia is a frequent cause of hospitalization and death among elderly patients, but the relationships between processes of care for pneumonia and outcomes are uncertain, making quality improvement a challenge. OBJECTIVES: To assess quality of care for Medicare patients hospitalized with pneumonia and to determine whether process of care performance is associated with lower 30-day mortality. DESIGN: Multicenter retrospective cohort study with medical record review. SETTING: A total of 3555 acute care hospitals throughout the United States. PATIENTS: A total of 14069 patients at least 65 years old hospitalized with pneumonia. MAIN OUTCOME MEASURES: Four processes of care: time from hospital arrival to initial antibiotic administration; blood culture collection before initial hospital antibiotics; blood culture collection within 24 hours of hospital arrival; and oxygenation assessment within 24 hours of hospital arrival. Associations between processes of care and 30-day mortality were determined with logistic regression analysis. RESULTS: National estimates of process-of-care performance were antibiotic administration within 8 hours of hospital arrival, 75.5% (95% confidence interval [CI], 73.1-77.9); blood cultures before antibiotics, 57.3% (95% CI, 54.5-60.1); initial blood culture collection, 68.7% (95% CI, 66.2-71.2); and initial oxygenation assessment, 89.3% (95% CI, 87.5-90.9). Lower 30-day mortality was associated with antibiotic administration within 8 hours of hospital arrival (odds ratio [OR], 0.85; 95% CI, 0.75-0.96) and blood culture collection within 24 hours of arrival (OR, 0.90; 95% CI, 0.81-1.00). State and territory performance estimates varied from 49.0% to 89.7% for antibiotics given within 8 hours and from 45.6% to 82.6% for blood cultures drawn within 24 hours. CONCLUSIONS: Administering antibiotics within 8 hours of hospital arrival and collecting blood cultures within 24 hours were associated with improved survival. The fact that states varied widely in the performance of these measures suggests that opportunities exist to improve hospital care of elderly patients with pneumonia.

Aged↗
PubMed1997

Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination.

Community-acquired pneumonia is an important cause of acute respiratory symptoms (eg, cough) in the ambulatory care setting. Distinguishing pneumonia from other causes of respiratory illnesses, such as acute bronchitis and upper respiratory tract infections, has important therapeutic and prognostic implications. The reference standard for diagnosing pneumonia is chest radiography, but it is likely that many physicians rely on the patient's history and their physical examination to diagnose or exclude this disease. A review of published studies of patients suspected of having pneumonia reveals that there are no individual clinical findings, or combinations of findings, that can rule in the diagnosis of pneumonia for a patient suspected of having this illness. However, some studies have shown that the absence of any vital sign abnormalities or any abnormalities on chest auscultation substantially reduces the likelihood of pneumonia to a point where further diagnostic evaluation may be unnecessary. This article reviews the literature on the appropriate use of the history and physical examination in diagnosing community-acquired pneumonia.

Community-Acquired Infections↗
PubMed1997

Influence of age on symptoms at presentation in patients with community-acquired pneumonia.

BACKGROUND: Advanced age has become a well-recognized risk factor for death in patients with pneumonia. It may also be associated with reduced symptom reporting, raising the possibility that diagnosis and treatment may be delayed in older patients. OBJECTIVE: To evaluate the association between age and the presenting symptoms in patients with community-acquired pneumonia. METHODS: This study was conducted at inpatient and outpatient facilities at 3 university hospitals, 1 community hospital, and 1 staff-model health maintenance organization. Patients included adults (age > or = 18 years) with clinical and radiographic evidence of pneumonia, who were able to complete a baseline interview. The presence of 5 respiratory symptoms and 13 nonrespiratory symptoms were recorded during a baseline patient interview. A summary symptom score was computed as the total number of symptoms at presentation. RESULTS: The 1812 eligible study patients were categorized into 4 age groups: 18 through 44 years (43%), 45 through 64 years (25%), 65 through 74 years (17%), and 75 years or older (15%). For 17 of the 18 symptoms, there were significant decreases in reported prevalence with increasing age (P < .01). In a linear regression analysis, controlling for patient demographics, comorbidity, and severity of illness at presentation, older age remained associated with lower symptom scores (P < .001). CONCLUSIONS: Respiratory and nonrespiratory symptoms are less commonly reported by older patients with pneumonia, even after controlling for the increased comorbidity and illness severity in these older patients. Recognition of this phenomenon by clinicians and patients is essential given the increased mortality in elderly patients with pneumonia.

Adult↗
PubMed1997

Medical outcomes and antimicrobial costs with the use of the American Thoracic Society guidelines for outpatients with community-acquired pneumonia.

CONTEXT: The American Thoracic Society (ATS) published guidelines based on expert opinion and published data--but not clinically derived or validated--for treating adult outpatients with community-acquired pneumonia. OBJECTIVE: To compare medical outcomes and antimicrobial costs for patients whose antimicrobial therapy was consistent or inconsistent with ATS guidelines. DESIGN: Multicenter, prospective cohort study. SETTING: Emergency departments, medical clinics, and practitioner offices affiliated with 3 university hospitals, 1 community teaching hospital, and 1 health maintenance organization. PARTICIPANTS: A total of 864 immunocompetent, adult outpatients with community-acquired pneumonia: 546 aged 60 years or younger with no comorbidity and 318 older than 60 years or with 1 comorbidity or more. MAIN OUTCOME MEASURES: Patients' antimicrobial therapy was classified as being consistent or inconsistent with the ATS guidelines. Mortality, subsequent hospitalization, medical complications, symptom resolution, return to work and usual activities, health-related quality of life, and antimicrobial costs were compared among those treated consistently or inconsistently with the guidelines. RESULTS: Outpatients aged 60 years or younger with no comorbidity who were prescribed therapy consistent with ATS guidelines (ie, erythromycin with some exceptions) had 3-fold lower antimicrobial costs ($5.43 vs $18.51; P<.001) and no significant differences in medical outcomes. Outpatients older than 60 years or with 1 comorbidity or more who were prescribed therapy consistent with ATS guidelines (ie, second-generation cephalosporin, sulfamethoxazole-trimethoprim, or beta-lactam and beta-lactamase inhibitor with or without a macrolide) had 10-fold higher antimicrobial costs ($73.50 vs $7.50; P<.001); despite trends toward higher mortality and subsequent hospitalization, no significant differences in medical outcomes were observed. CONCLUSION: Our findings support the use of erythromycin as recommended by the ATS guidelines for outpatients aged 60 years or younger with no comorbidity. Although the antimicrobial therapy recommended in outpatients older than 60 years or with 1 comorbidity or more is more costly, this observational study provides no evidence of improved medical outcomes in the small subgroup who received ATS guideline-recommended therapy.

Adult↗
PubMed1997

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

BACKGROUND: There is considerable variability in rates of hospitalization of patients with community-acquired pneumonia, in part because of physicians' uncertainty in assessing the severity of illness at presentation. METHODS: From our analysis of data on 14,199 adult inpatients with community-acquired pneumonia, we derived a prediction rule that stratifies patients into five classes with respect to the risk of death within 30 days. The rule was validated with 1991 data on 38,039 inpatients and with data on 2287 inpatients and outpatients in the Pneumonia Patient Outcomes Research Team (PORT) cohort study. The prediction rule assigns points based on age and the presence of coexisting disease, abnormal physical findings (such as a respiratory rate of > or = 30 or a temperature of > or = 40 degrees C), and abnormal laboratory findings (such as a pH <7.35, a blood urea nitrogen concentration > or = 30 mg per deciliter [11 mmol per liter] or a sodium concentration <130 mmol per liter) at presentation. RESULTS: There were no significant differences in mortality in each of the five risk classes among the three cohorts. Mortality ranged from 0.1 to 0.4 percent for class I patients (P=0.22), from 0.6 to 0.7 percent for class II (P=0.67), and from 0.9 to 2.8 percent for class III (P=0.12). Among the 1575 patients in the three lowest risk classes in the Pneumonia PORT cohort, there were only seven deaths, of which only four were pneumonia-related. The risk class was significantly associated with the risk of subsequent hospitalization among those treated as outpatients and with the use of intensive care and the number of days in the hospital among inpatients. CONCLUSIONS: The prediction rule we describe accurately identifies the patients with community-acquired pneumonia who are at low risk for death and other adverse outcomes. This prediction rule may help physicians make more rational decisions about hospitalization for patients with pneumonia.

Adult↗
PubMed1997

The hospital admission decision for patients with community-acquired pneumonia. Results from the pneumonia Patient Outcomes Research Team cohort study.

BACKGROUND: The hospital admission decision directly influences the magnitude of resource use in patients with community-acquired pneumonia, yet little information exists on how medical practitioners make this decision. OBJECTIVES: To determine which factors medical practitioners consider in making the hospital admission decision and which health care services they believe would allow ambulatory treatment of low-risk hospitalized patients with community-acquired pneumonia. METHODS: Medical practitioners responsible for the hospital admission decision for low-risk patients with community-acquired pneumonia were asked to describe patient characteristics at initial examination that influenced the hospitalization decision, and to identify the health care services that would have allowed initial outpatient treatment of hospitalized patients. RESULTS: A total of 292 medical practitioners completed questionnaires for 472 (76%) of the 624 low-risk patients eligible for this study. Although all patients had a predicted probability of death of less than 4%, practitioners estimated that 5% of outpatients and 41% of inpatients had an expected 30-day risk of death of more than 5%. Univariate analyses identified 3 practitioner-rated factors that were nearly universally associated with hospitalization: hypoxemia (odds ratio, 173.3; 95% confidence interval, 23.8-1265.0), inability to maintain oral intake (odds ratio, 53.3; 95% confidence interval, 12.8-222.5), and lack of patient home care support (odds ratio, 54.4; 95% confidence interval, 7.3-402.6). In patients without these 3 factors, logistic regression analysis demonstrated that practitioner-estimated risk of death of more than 5% had a strong independent association with hospitalization (odds ratio, 18.4; 95% confidence interval, 6.1-55.7). Practitioners identified home intravenous antibiotic therapy and home nursing observation as services that would have allowed outpatient treatment of more than half (68% and 59%, respectively) of the patients initially hospitalized for treatment. CONCLUSIONS: Practitioners' survey responses suggest that the availability of outpatient intravenous antimicrobial therapy and home nursing care would allow outpatient care for a large proportion of low-risk patients who are hospitalized for community-acquired pneumonia. These data also suggest that methods to improve practitioners' identification of low-risk patients with community-acquired pneumonia could decrease the hospitalization of such patients. Future studies are required to help physicians identify which low-risk patients could safely be treated in the outpatient setting on the basis of clinical information readily available at presentation.

Adult↗
PubMed1997

The hospital discharge decision for patients with community-acquired pneumonia. Results from the Pneumonia Patient Outcomes Research Team cohort study.

BACKGROUND: The hospital discharge decision directly influences the length of stay in patients with community-acquired pneumonia, yet no information exists on how physicians make this decision. OBJECTIVES: To identify the factors physicians considered the factors responsible for extending length of hospital stay in clinically stable patients, and the outpatient medical services that would allow earlier hospital discharge for patients with community-acquired pneumonia. METHODS: Physicians responsible for the hospital discharge decision of patients with community-acquired pneumonia were asked to identify the factors responsible for extending stay in patients hospitalized beyond stability, and the medical services that could have allowed earlier hospital discharge to occur. RESULTS: For the 418 eligible patients with community-acquired pneumonia identified during the study, 332 questionnaires (79%) were completed by 168 physicians. Physicians believed 71 patients (22%) were discharged from the hospital 1 day or more (median, 2.5 days) after reaching clinical stability. The most common factors rated as being "very important" in delaying discharge were diagnostic evaluation or treatment of comorbid illness (56%), completion of a "standard course" of antimicrobials (15%), and delays with arrangements for long-term care (14%). Among the 302 patients with available information on both length of hospital stay and stability at discharge, median length of stay was 7.0 days for the 29 low-risk patients hospitalized beyond reaching clinical stability and 5.0 days for the remaining 128 low-risk patients (P < .005); median length of stay was 12.5 days for the 42 medium- and high-risk patients hospitalized beyond reaching clinical stability and 8.0 days in the remaining 113 medium- and high-risk patients (P < .001). Frequently cited medical services that "probably" or "definitely" would have allowed earlier discharge to occur included availability of home intravenous antimicrobial infusion (26%) and home visits by nurses (20%). CONCLUSIONS: Physicians believed that diagnostic evaluation or treatment of comorbid illness, completion of a standard course of antimicrobial therapy, and delays with arrangements for long-term care delayed hospital discharge in clinically stable patients. Addressing the efficiency of these aspects of inpatient medical care, as well as providing home treatment programs, could decrease the length of hospital stay in patients with community-acquired pneumonia.

Adult↗
PubMed1997

An evaluation of machine-learning methods for predicting pneumonia mortality.

This paper describes the application of eight statistical and machine-learning methods to derive computer models for predicting mortality of hospital patients with pneumonia from their findings at initial presentation. The eight models were each constructed based on 9847 patient cases and they were each evaluated on 4352 additional cases. The primary evaluation metric was the error in predicted survival as a function of the fraction of patients predicted to survive. This metric is useful in assessing a model's potential to assist a clinician in deciding whether to treat a given patient in the hospital or at home. We examined the error rates of the models when predicting that a given fraction of patients will survive. We examined survival fractions between 0.1 and 0.6. Over this range, each model's predictive error rate was within 1% of the error rate of every other model. When predicting that approximately 30% of the patients will survive, all the models have an error rate of less than 1.5%. The models are distinguished more by the number of variables and parameters that they contain than by their error rates; these differences suggest which models may be the most amenable to future implementation as paper-based guidelines.

Artificial Intelligence↗
PubMed1997

Measuring symptomatic and functional recovery in patients with community-acquired pneumonia.

OBJECTIVE: To determine the rates of resolution of symptoms and return to premorbid health status and assess the association of these outcomes with health care utilization in patients with community-acquired pneumonia. DESIGN: A prospective, multicenter cohort study. SETTING: Inpatient and outpatient facilities at three university hospitals, one community hospital, and one staff-model health maintenance organization. PATIENTS: Five hundred seventy-six adults (aged > or = 18 years) with clinical and radiographic evidence of pneumonia, judged by a validated pneumonia severity index to be at low risk of dying. MEASUREMENTS AND MAIN RESULTS: The presence and severity of five symptoms (cough, fatigue, dyspnea, sputum, and chest pain) were recorded through questionnaires administered at four time points: 0, 7, 30, and 90 days from the time of radiographic diagnosis of pneumonia. A summary symptom score was tabulated as the sum of the five individual severity scores. Patients also provided responses to the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) and reported the number of and reason for outpatient physician visits. Symptoms and health status 30 days before pneumonia onset (prepneumonia) were obtained at the initial interview. All symptoms, except pleuritic chest pain, were still commonly reported at 30 days, and the prevalence of each symptom at 90 days was still nearly twice prepneumonia levels. Physical health measures derived from the SF-36 Form declined significantly at presentation but continued to improve over all three follow-up time periods. Patients with elevated symptom scores at day 7 or day 30 were significantly more likely to report pneumonia-related ambulatory care visits at the subsequent day 30 or day 90 interviews, respectively. CONCLUSIONS: Disease-specific symptom resolution and recovery of the premorbid physical health status requires more than 30 days for many patients with pneumonia. Delayed resolution of symptoms is associated with increased utilization of outpatient physician visits.

Adult↗
PubMed1997

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

The use of administrative data to study pneumonia is limited because International Classification of Diseases, 9th revision, Clinical Modification (ICD9-CM) diagnosis codes do not specify whether pneumonia is community-acquired (CAP), a key clinical distinction. We classified 212 patients discharged with a diagnosis code for pneumonia as to whether or not they had CAP, using three administrative data-based systems (Diagnosis Related Groups (DRGs) alone, principal diagnosis alone, and a complex algorithm). We examined agreement with classification by clinician chart review. We also compared the length of stay (LOS) and mortality among the CAP populations identified with different methods. Agreement between the clinical review and the three administrative data methods ranged from 86 to 80%. Classification by DRG performed least well. Populations defined by claims data had similar mortality but shorter mean LOS (9.70, 9.40, and 7.91 days for the algorithm, principal diagnosis and DRG methods, respectively) than the clinically defined population (10.85 days). We conclude that studies of CAP using populations identified by claims may underestimate LOS.

Adult↗
PubMed1996

Do pulmonary radiographic findings at presentation predict mortality in patients with community-acquired pneumonia?

BACKGROUND: Previous studies have reported conflicting results on whether pulmonary radiographic findings predict mortality for patients with community-acquired pneumonia (CAP). OBJECTIVE: To determine whether pulmonary radiographic findings at presentation are independently associated with 30-day mortality in patients with suspected CAP. METHODS: This study was conducted as part of the Pneumonia Patient Outcomes Research Team multicenter, prospective cohort study of ambulatory and hospitalized patients with clinical and radiographic evidence of CAP. For each patient with CAP, a structured data form was completed by a panel of radiologists to evaluate the radiographic pattern of infiltrate, number of lobes involved, presence of pleural effusion, and 8 other radiographic characteristics. Cox proportional hazards models were used to evaluate the independent association between radiographic findings and 30-day mortality, while controlling for patient demographic, clinical, and laboratory characteristics with a known association with this outcome. RESULTS: Of 2287 patients enrolled in the Pneumonia Patient Outcomes Research Team cohort study, 1906 patients (83.3%) had a pulmonary radiographic infiltrate confirmed by the radiology panel. Overall, 30-day mortality in this cohort was 4.9%. Univariate regression analyses demonstrated the following radiographic characteristics to be significantly associated with 30-day mortality: (1) bilateral pleural effusions (risk ratio [RR], 7.0; 95% confidence interval [CI], 3.9-12.6); (2) a pleural effusion of moderate or greater size (RR, 3.4; 95% CI, 1.4-8.4); (3) 2 or more lobes involved with infiltrate (RR, 2.5; 95% CI, 1.6-3.8); (4) bilateral infiltrate (RR, 2.8; 95% CI, 1.9-4.2); (5) bronchopneumonia (RR, 1.6; 95% CI, 1.0-2.7); and (6) air bronchograms (RR, 0.5; 95% CI, 0.2-0.9). Multivariate analysis of radiographic features and other clinical characteristics showed the presence of bilateral pleural effusions (RR, 2.8; 95% CI, 1.4-5.8) was independently associated with mortality. CONCLUSIONS: In patients with CAP, the presence of bilateral pleural effusions is an independent predictor of short-term mortality. This finding, which is available at presentation, can help guide physicians' assessment of prognosis in CAP.

Adolescent↗
PubMed1996

Preferences for home vs hospital care among low-risk patients with community-acquired pneumonia.

OBJECTIVE: To measure preferences for initial outpatient vs hospital care among low-risk patients who were being actively treated for community-acquired pneumonia (CAP). METHODS: Study patients included 159 patients with CAP, 57 (36%) initially hospitalized, who were identified as being at low risk for early mortality using a validated prediction model. Subjects were enrolled from university and community health care facilities located in Boston, Mass, Halifax, Nova Scotia, and Pittsburgh, Pa, participating in the Pneumonia Patient Outcome Research Team prospective cohort study of CAP. Three utility assessment techniques (category scaling, standard gamble, and willingness to pay) were used to measure the strength of patient preferences for the site of care for low-risk CAP. At the time of initial therapy or during the early recuperative period, patient preferences were assessed across a spectrum of potential clinical outcomes using 7 standardized pneumonia clinical vignettes. RESULTS: Responses to the 7 pneumonia scenarios indicated that most patients consistently preferred outpatient-based therapy. This pattern was observed regardless of whether patients had actually been treated initially at home or in a hospital. Patients (74%) who stated that they generally preferred home care for low-risk CAP were willing to pay a mean of 24% of 1 month's household income to be assured of this preference. Preference for home care, as measured by the category scaling and the willingness to pay, persisted after adjustment for sociodemographic and baseline health status covariates. Sixty nine percent of interviewed patients said that their physician alone determined whether they would be treated in the hospital or at home. Only 11% recalled being asked if they had a preference for either site of care. CONCLUSIONS: Most patients, even those treated initially in a hospital, who were at low risk for mortality from CAP prefer outpatient treatment. However, most physicians appear not to involve patients in the site-of-care decision. More explicit discussion of patient preferences for the location of care would likely yield more highly valued care by patients as well as less costly treatment for CAP.

Adult↗
PubMed1996

Prognosis and outcomes of patients with community-acquired pneumonia. A meta-analysis.

OBJECTIVE: To systematically review the medical literature on the prognosis and outcomes of patients with community-acquired pneumonia (CAP). DATA SOURCES: A MEDLINE literature search of English-language articles involving human subjects and manual reviews of article bibliographies were used to identify studies of prognosis in CAP. STUDY SELECTION: Review of 4573 citations revealed 122 articles (127 unique study cohorts) that reported medical outcomes in adults with CAP. DATA EXTRACTION: Qualitative assessments of studies' patient populations, designs, and patient outcomes were performed. Summary univariate odds ratios (ORs) and rate differences (RDs) and their associated 95% confidence intervals (CIs) were computed to estimate a summary effect size for the association of prognostic factors and mortality. DATA SYNTHESIS: The overall mortality for the 33,148 patients in all 127 study cohorts was 13.7%, ranging from 5.1% for the 2097 hospitalized and ambulatory patients (in six study cohorts) to 36.5% for the 788 intensive care unit patients (in 13 cohorts). Mortality varied by pneumonia etiology, ranging from less than 2% to greater than 30%. Eleven prognostic factors were significantly associated with mortality using both summary ORs and RDs: male sex (OR = 1.3; 95% CI, 1.2 to 1.4), pleuritic chest pain (OR = 0.5; 95% CI, 0.3 to 0.8), hypothermia (OR = 5.0; 95% CI, 2.4 to 10.4), systolic hypotension (OR = 4.8; 95% CI, 2.8 to 8.3), tachypnea (OR = 2.9; 95% CI, 1.7 to 4.9), diabetes mellitus (OR = 1.3; 95% CI, 1.1 to 1.5), neoplastic disease (OR = 2.8; 95% CI, 2.4 to 3.1), neurologic disease (OR = 4.6; 95% CI, 2.3 to 8.9), bacteremia (OR = 2.8; 95% CI, 2.3 to 3.6), leukopenia (OR = 2.5, 95% CI, 1.6 to 3.7), and multilobar radiographic pulmonary infiltrate (OR = 3.1; 95% CI, 1.9 to 5.1). Assessments of other clinically relevant medical outcomes such as morbid complications (41 cohorts), symptoms resolution (seven cohorts), return to work or usual activities (five cohorts), or functional status (one cohort) were infrequently performed. CONCLUSIONS: Mortality for patients hospitalized with CAP was high and was associated with characteristics of the study cohort, pneumonia etiology, and a variety of prognostic factors. Generalization of these findings to all patients with CAP should be made with caution because of insufficient published information on medical outcomes other than mortality in ambulatory patients.

Adult↗
PubMed1996

Hospitalized pneumonia. Outcomes, treatment patterns, and costs in urban and rural areas.

OBJECTIVES: To describe discharge rates, geographic and patient characteristics, treatment patterns, costs, and outcomes of patients hospitalized with community-acquired pneumonia (CAP) in Pennsylvania hospitals and compare these patients from rural and urban counties. DESIGN: A retrospective database study. PATIENTS: Adult patients (age > or = 18) with an ICD-9-CM diagnosis of pneumonia discharged from 193 Pennsylvania hospitals (n = 36,222) in 1991 from the MediQual Systems Pennsylvania database. MEASUREMENTS: Patient characteristics included a pneumonia-specific severity index, microbiologic etiology, and a number of comorbid conditions. Treatment indicators included the specialty of the admitting physician, length of stay, admittance to an intensive care unit, and mechanical ventilation. Cost indicators included charges and estimated costs. Outcomes measured were inpatient mortality and discharge disposition. Counties in Pennsylvania were classified into seven urban or rural groups, and patients were classified by the county of residence. RESULTS: The discharge rate for CAP was 4.0 per 1,000 and did not vary systematically across urban or rural counties. Most patients were treated in local hospitals. The average distance between residence and hospital was 5.4 miles and varied with urban or rural classification (range 2.5-9.3 miles). Among CAP patients, 37.8% were at low risk of mortality, with no systematic differences across rural or urban patients with respect to pneumonia severity. Rural patients were more likely to be treated by a family physician and somewhat less likely to be admitted to an intensive care unit or to be mechanically ventilated. Costs of treating rural patients were lower. In-hospital mortality rates, with controls for admission severity, were comparable or better for rural patients than for urban patients. CONCLUSIONS: Patients with CAP are treated in hospitals located in counties similar to ones in which they reside. The cost of treatment was lower for rural patients than for urban patients, but outcomes were not different.

Adult↗