Chest
Volume 142, Issue 2, August 2012, Pages 476-481
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Original Research
Chest Infections
Predictors of In-Hospital vs Postdischarge Mortality in Pneumonia

https://doi.org/10.1378/chest.11-2393Get rights and content

Background

Many patients who die within 30 days of admission to the hospital for pneumonia die after discharge. Recently, 30-day mortality for patients with pneumonia became a publicly reported performance measure, meaning that hospitals are, in part, being measured based on how the patient fares after discharge from the hospital. This study was undertaken to determine which factors predict in-hospital vs postdischarge mortality in patients with pneumonia.

Methods

This was a retrospective analysis of a database of 21,223 patients on Medicare aged 65 years and older admitted to the hospital between 2000 and 2001. Multivariate logistic regression analyses were performed to determine the association between 26 patient characteristics and the timing of death (in-hospital vs postdischarge) among those patients who died within 30 days of hospital admission.

Results

Among the 21,223 patients, 2,561 (12.1%) died within 30 days of admission: 1,343 (52.4%) during the hospital stay, and 1,218 (47.6%) after discharge. Multivariate logistic regression demonstrated that seven factors were significantly associated with death prior to discharge: systolic BP < 90 mm Hg, respiration rate > 30/min, bacteremia, arterial pH < 7.35, BUN level > 11 mmol/L, arterial Po2 < 60 mm Hg or arterial oxygen saturation < 90%, and need for mechanical ventilation. Some underlying comorbidities were associated with a nonstatistically significant trend toward death after discharge.

Conclusions

Of elderly patients dying within 30 days of admission to the hospital, approximately one-half die after discharge from the hospital. Comorbidities, in general, were equally associated with death in the hospital and death after discharge.

Section snippets

Sample Selection

Data analyzed in this study were part of the Medicare National Pneumonia Project, a component of CMS's Quality Improvement Program. As such, Human Subjects Committee approval is not required. Eligible patients were fee-for-service Medicare beneficiaries aged ≥ 65 years who had been discharged from the hospital during calendar years 2000 and 2001 with a principal diagnosis of pneumonia (International Classification of Disease, Ninth Edition, Clinical Modification codes 480.0-483.99, 485-486.99,

Results

There were 37,123 patients included in the initial sample. The most common reasons for exclusion were the lack of a working diagnosis of pneumonia at the time of admission (4,114), age younger than 65 years (3,478), lack of a confirmatory chest radiograph (3,241), prior hospital discharge within 14 days (1,548), and admission for comfort measures only (1,505). After all exclusions were applied, 21,223 cases were included in the analysis. Of the 2,561 patients (12.1%) who died within 30 days of

Discussion

Although risk factors for mortality in patients with pneumonia have been investigated extensively, there have been few studies comparing patient-specific factors for mortality before and after discharge from the hospital. In this analysis of patients on Medicare admitted to the hospital with pneumonia, we found that factors associated with the acute severity of pneumonia were predictive of in-hospital death but that the timing of death was unrelated to baseline patient demographic factors and

Acknowledgments

Author contributions: Dr Metersky is responsible for the integrity of the manuscript and is the guarantor.

Dr Metersky: contributed to study design, data analysis, and drafting the manuscript.

Dr Waterer: contributed to study design and drafting the manuscript.

Dr Nsa: contributed to study design, data analysis, critical review, and revision of the manuscript.

Dr Bratzler: contributed to obtaining funding, data analysis, critical review, and revision of the manuscript.

Financial/nonfinancial

References (15)

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Funding/Support: The analyses upon which this publication is based were performed under funding by the Centers for Medicare & Medicaid Services, an agency of the US Department of Health and Human Services [Contract Number HHSM-500-2008-OK9THC].

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