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1 Supplementary Online Content Lee JS, Nsa W, Hausmann LRM, et al. Quality of care for elderly patients hospitalized for pneumonia in the United States, 2006 to JAMA Intern Med. Published online September 8, doi: /jamainternmed etable 1. ICD-9-CM codes used to identify cases of pneumonia etable 2. Definitions and eligibility criteria for recommended CMS processes of care for patients hospitalized for pneumonia, January 1, 2006, to December 31, 2010 etable 3. Characteristics of elderly ( age 65) FFS Medicare patients hospitalized for pneumonia stratified by receipt of processes of care, January 1, 2006 to December 31, 2010 etable 4. Multivariable associations between processes of care and medical outcomes for elderly ( age 65) FFS Medicare patients hospitalized for pneumonia, January 1, 2006, to December 31, 2010 efigure. Flow diagram of patient identification and selection This supplementary material has been provided by the authors to give readers additional information about their work American Medical Association. All rights reserved.

2 etable 1. ICD-9-CM codes used to identify cases of pneumonia a ICD-9-CM Code Shortened description Pneumonia 481 PNEUMOCOCCAL PNEUMONIA K. PNEUMONIAE PNEUMONIA PSEUDOMONAL PNEUMONIA H.INFLUENZAE PNEUMONIA STREPTOCOCCAL PNEUMN NOS PNEUMONIA STRPTOCOCCUS A PNEUMONIA STRPTOCOCCUS B PNEUMONIA OTH STREP STAPHYLOCOCCAL PNEU NOS METH SUS PNEUM D/T STAPH METH RES PNEU D/T STAPH STAPH PNEUMONIA NEC PNEUMONIA E COLI PNEUMO OTH GRM-NEG BACT LEGIONNAIRES' DISEASE PNEUMONIA OTH SPCF BACT BACTERIAL PNEUMONIA NOS PNEU MYCPLSM PNEUMONIAE PNEUMONIA D/T CHLAMYDIA PNEUMON OTH SPEC ORGNSM 485 BRONCHOPNEUMONIA ORG NOS 486 PNEUMONIA, ORGANISM NOS Septicemia STREPTOCOCCAL SEPTICEMIA STAPHYLCOCC SEPTICEM NOS METH SUSC STAPH AUR SEPT MRSA SEPTICEMIA STAPHYLCOCC SEPTICEM NEC PNEUMOCOCCAL SEPTICEMIA ANAEROBIC SEPTICEMIA GRAM-NEG SEPTICEMIA NOS H. INFLUENAE SEPTICEMIA 2

3 E COLI SEPTICEMIA PSEUDOMONAS SEPTICEMIA SERRATIA SEPTICEMIA GRAM-NEG SEPTICEMIA NEC SEPTICEMIA NEC SEPTICEMIA NOS 3

4 etable 1. ICD-9-CM codes used to identify cases of pneumonia a (continued) ICD-9-CM Code Shortened description Respiratory failure ACUTE RESPIRATRY FAILURE ACUTE & CHRONC RESP FAIL a ICD-9-CM codes used to identify cases of pneumonia are based on the Specifications Manual for National Hospital Inpatient Quality Measures, Version 3.1. In our study, all cases had an ICD-9-CM principal diagnosis code for pneumonia or a principal diagnosis code for septicemia or respiratory failure accompanied by another diagnosis code for pneumonia 4

5 etable 2. Definitions and eligibility criteria for recommended CMS processes of care for patients hospitalized for pneumonia, January 1, 2006 to December 31, 2010 a Processes of care Definitions of processes of care Exclusion criteria for processes of care Antibiotic initiation 6 hours First dose of antibiotics within 6 hours after hospital arrival Patients less than 18 years of age Patients who have a length of stay greater than 120 days Patients with cystic fibrosis Patients who had no chest x-ray or CT scan that indicated abnormal findings within 24 hours prior to hospital arrival or anytime during this hospitalization Major changes in exclusion criteria from January 1, 2006, to December 31, 2010 Added July 2006 Patients with Comfort Measures Only documented on day of or day after arrival Patients enrolled in clinical trials Patients as a transfer from the emergency department of another hospital Patients as a transfer from an acute care facility where they were an inpatient or outpatient Patients as a transfer from an ambulatory surgery center Added October 2007 Patients who had no diagnosis of pneumonia either as the ED final diagnosis/impression or direct admission diagnosis/impression Patients with Diagnostic Uncertainty as defined in the Data Dictionary Added April 2008 Patients discharged/transferred to another hospital for inpatient care on Added April 2007 day of or day after arrival Patients who left against medical advice or discontinued care on day of Added April 2007 or day after arrival Patients who died on day of or day after arrival Added April 2007 Patients discharged/transferred to another federal health care facility on Added April 2007 day of or day after arrival Patients who do not receive any antibiotics within 24 hours after arrival Revised April 2008 or who antibiotics the day of arrival (prior to arrival to the hospital) or the day prior to arrival (Revised from patients who have 5

6 antibiotics within 24 hours prior to hospital arrival) Patients as a transfer from one distinct unit of the hospital to another distinct unit of the same hospital Added October 2007 and removed October

7 etable 2. Definitions and eligibility criteria for recommended CMS processes of care for patients hospitalized for pneumonia, January 1, 2006 to December 31, 2010 a (continued) Processes of care Definitions of processes of care Exclusion criteria for processes of care Appropriate antibiotic selection Initial antibiotic regimen during the first 24 hours consistent with guidelines Process measure antibiotic consensus recommendations were revised to include the use of anti-pseudomonal antibiotics for ICU patients even in the absence of documented pseudomonal risk in October Patients less than 18 years of age Patients who have a length of stay greater than 120 days Patients with cystic fibrosis Patients who had no chest x-ray or CT scan that indicated abnormal findings within 24 hours prior to hospital arrival or anytime during this hospitalization Major changes in exclusion criteria from January 1, 2006, to December 31, 2010 Added July 2006 Patients with Comfort Measures Only documented on day of or day after arrival Patients enrolled in clinical trials Patients as a transfer from the emergency department of another hospital Patients as a transfer from an acute care facility where they were an inpatient or outpatient Patients as a transfer from an ambulatory surgery center Added October 2007 Patients who have no diagnosis of pneumonia either as the ED final diagnosis/impression or direct admission diagnosis/impression Patients with Healthcare Associated PN as defined in the Data Dictionary Patients who are Compromised as defined in the Data Dictionary Patients transferred/admitted to the ICU within 24 hours after arrival to this hospital, with a beta-lactam allergy Pneumonia patients with Another Source of Infection who did not receive an antibiotic regimen recommended for pneumonia, but did receive antibiotics within the first 24 hours of hospitalization Patients who have duration of stay less than or equal to one day (Revised from patients who died, were discharged, were transferred to another hospital, or left against medical advice on day of or day after arrival) Added April 2010 Added October 2006 Added April 2007 and revised April

8 Patients as a transfer from one distinct unit of the hospital to another distinct unit of the same hospital Patients with an Identified Pathogen as defined in the Data Dictionary Patients who only antibiotics prior to hospital arrival Patients who do not receive any antibiotics within 24 hours after arrival Added October 2007 and removed October 2010 Added April 2008 and removed April 2010 Added April 2008 and removed October 2009 Added October 2008 and removed October

9 etable 2. Definitions and eligibility criteria for recommended CMS processes of care for patients hospitalized for pneumonia, January 1, 2006 to December 31, 2010 a (continued) Processes of care Definitions of processes of care Exclusion criteria for processes of care Performance of blood cultures within 24 hours for ICU patients Blood cultures performed within 24 hours prior to or 24 hours after hospital arrival for patients transferred or admitted to the ICU within 24 hours of hospital arrival Patients less than 18 years of age Patients who have a length of stay greater than 120 days Patients with cystic fibrosis Patients who had no chest x-ray or CT scan that indicated abnormal findings within 24 hours prior to hospital arrival or anytime during this hospitalization Major changes in exclusion criteria from January 1, 2006, to December 31, 2010 Added July 2006 Patients with Comfort Measures Only documented on day of or day after arrival Patients enrolled in clinical trials Patients as a transfer from the emergency department of another hospital Patients as a transfer from an acute care facility where they were an inpatient or outpatient Patients as a transfer from an ambulatory surgery center Added October 2007 Patients who had no diagnosis of pneumonia either as the ED final diagnosis/impression or direct admission diagnosis/impression Patients not transferred or admitted to the ICU within 24 hours of hospital arrival Patients who have duration of stay less than or equal to one day (Revised from patients who died, were discharged, were transferred to another hospital, or left against medical advice on day of or day after arrival) Patients as a transfer from one distinct unit of the hospital to another distinct unit of the same hospital Added April 2007 and revised April 2010 Added October 2007 and removed October

10 etable 2. Definitions and eligibility criteria for recommended CMS processes of care for patients hospitalized for pneumonia, January 1, 2006 to December 31, 2010 a (continued) Processes of care Definitions of processes of care Exclusion criteria for processes of care Performance of blood cultures before antibiotic therapy in the ED Initial emergency room blood culture collected prior to first hospital dose of antibiotics Patients less than 18 years of age Patients who have a length of stay greater than 120 days Patients with cystic fibrosis Patients who had no chest x-ray or CT scan that indicated abnormal findings within 24 hours prior to hospital arrival or anytime during this hospitalization Patients with Comfort Measures Only documented day of or day after arrival Patients enrolled in clinical trials Patients who have a final diagnosis/impression of pneumonia upon direct admit Patients who had no diagnosis of pneumonia either as the ED final diagnosis/impression or direct admission diagnosis/impression Patients who only antibiotics prior to hospital arrival Patients who do not receive any antibiotics within 24 hours after arrival Major changes in exclusion criteria from January 1, 2006, to December 31, 2010 Added July 2006 Added April 2008 Added April 2008 Added October 2008 Patients who do not receive a blood culture Added October 2008 Patients who do not have a blood culture collected in Added October 2008 the ED prior to admission order Patients who have a blood culture collected within 24 Added April 2008 hours prior to hospital arrival Patients discharged/transferred to another hospital for Added April 2007 inpatient care on day of or day after arrival Patients discharged/transferred to a federal health Added April 2007 care facility on the day of or the day after arrival Patients who left against medical advice or Added April 2007 discontinued care on day of or day after arrival 10

11 Patients who died on day of or day after arrival Added April 2007 Patients as a transfer from the emergency Removed October 2010 department of another hospital 11

12 etable 2. Definitions and eligibility criteria for recommended CMS processes of care for patients hospitalized for pneumonia, January 1, 2006 to December 31, 2010 a (continued) Processes of care Definitions of processes of care Exclusion criteria for processes of care Major changes in exclusion criteria from January 1, 2006, Smoking cessation counseling Smoking cessation advice or counseling during hospital stay for patients who smoked cigarettes anytime during the year prior to hospital arrival Patients less than 18 years of age Patients who have a length of stay greater than 120 days Patients with cystic fibrosis Patients who had no chest x-ray or CT scan that indicated abnormal findings within 24 hours prior to hospital arrival or anytime during this hospitalization Patients with Comfort Measures Only documented Patients enrolled in clinical trials Patients discharged/transferred to another hospital for inpatient care Patients who left against medical advice or discontinued care Patients who died Patients discharged/transferred to a federal health care facility Patients discharged/transferred to hospice to December 31, 2010 Added July 2006 Pneumococcal vaccination Patients, age 65 years and older, who were screened for vaccine status and had been vaccinated prior to admission, were vaccinated prior to discharge if indicated, had contraindications to receive the vaccine, or refused vaccination. Patients less than 65 years of age Patients who have a length of stay greater than 120 days Patients with cystic fibrosis Patients who had no chest x-ray or CT scan that indicated abnormal findings within 24 hours prior to hospital arrival or anytime during this hospitalization Patients with Comfort Measures Only documented Added July

13 Patients enrolled in clinical trials Patients discharged/transferred to another hospital for inpatient care Patients who left against medical advice or discontinued care Patients who died Patients discharged/transferred to a federal health care facility Patients discharged/transferred to hospice Patients as a transfer from an acute care facility Patients as a transfer from an emergency department of another hospital Patients who have no diagnosis of pneumonia either as the ED final diagnosis/impression or direct admission diagnosis/impression Removed July 2006 Removed July 2006 Removed October

14 etable 2. Definitions and eligibility criteria for recommended CMS processes of care for patients hospitalized for pneumonia, January 1, 2006 to December 31, 2010 a (continued) Processes of care Definitions of processes of care Exclusion criteria for processes of care Influenza vaccination Patients, age 50 years and older, who were hospitalized between October and March and were screened for vaccine status and had been vaccinated prior to admission, were vaccinated prior to discharge if indicated, had contraindications to receive the vaccine, or refused vaccination. Patients discharged in March were added to the measure population in October 2007 (in addition to patients discharged in October through February, as previously defined). Patients less than 50 years of age Patients who have a length of stay greater than 120 days Patients with cystic fibrosis Patients who had no chest x-ray or CT scan that indicated abnormal findings within 24 hours prior to hospital arrival or anytime during this hospitalization Patients with Comfort Measures Only documented Patients enrolled in clinical trials Patients with a secondary diagnosis of (influenza with pneumonia) Patients discharged/transferred to another hospital for inpatient care Patients who left against medical advice or discontinued care Patients who died Patients discharged/transferred to a federal health care facility Patients discharged/transferred to hospice Major changes in exclusion criteria from January 1, 2006, to December 31, 2010 Added July 2006 Patients as a transfer from an acute care facility Removed April 2006 Patients who have no diagnosis of pneumonia either as the ED final Removed July 2006 diagnosis/impression or direct admission diagnosis/impression Abbreviations: ED, emergency department; ICU, intensive care unit. a Process measure definitions and exclusion criteria are based on the Specifications Manual for National Hospital Inpatient Quality Measures, Version

15 etable 3. Characteristics of elderly ( age 65) FFS Medicare patients hospitalized for pneumonia stratified by receipt of processes of care, January 1, 2006 to December 31, 2010 Patient characteristics Processes of care Antibiotic initiation 6 hours Appropriate antibiotic selection All patients Appropriate antibiotic selection Non-ICU patients Process Process not P- Value Process Process not P- Value Process Process not P- Value n=1,102,5 n=67,467 n=630,059 n=77,288 n=585,960 n=53, Age in years, mean 79.9 (8.2) 79.6 (8.2) < (8.1) 79.2 (8.1) < (8.1) 79.8 (8.1).90 (SD) Women, % < <.001 Race and ethnicity, % <.001 <.001 <.001 White, non-hispanic Black, non-hispanic Hispanic Other b Below poverty, median 9.5 (6.1- < ( (6.0- < ( (6.0- <.001 (IQR), % c 8.7 ( ) 15.1) 13.1) 14.8) 13.1) 15.0) With at least some college, median (IQR), 27.7 ( ) < ( ) 27.5 ( ) < ( ) 27.3 ( ) <.001 % c 28.5 ( ) Admission characteristics, % Admission via ED < < <.001 Admitted to ICU within < < hours Healthcare associated pneumonia d Comorbid conditions, % e Hypertension < <.001 Chronic pulmonary disease Fluid and electrolyte disorder < < < < < <

16 Congestive heart < <.001 failure Diabetes < <.001 Anemia Renal failure < <.001 Neurologic disorder Hypothyroidism < Psychiatric illness < < <.001 Neoplastic disease < < <.001 Liver disease < Comorbid conditions per patient, mean (SD) 3.6 (1.8) 3.6 (1.8) (1.7) 3.4 (1.7) < (1.7) 3.2 (1.7) <

17 8.7 (5.7- etable 3. Characteristics of elderly ( age 65) FFS Medicare patients hospitalized for pneumonia stratified by receipt of processes of care, January 1, 2006 to December 31, 2010 (continued) Patient Processes of care characteristics Appropriate antibiotic selection ICU patients Performance of blood cultures within 24 hours for ICU patients Performance of blood cultures before antibiotic therapy in ED Process Process P- Process Process not P-Value Process Process P-Value not Value not n=44,099 n=24,090 n=190,522 n=13,307 n=997,999 n=65,285 Age in years, mean 77.9 (7.8) 77.9 (7.9) (7.9) 78.3 (7.9) (8.2) 79.8 (8.2) <.001 (SD) Women, % < <.001 Race and ethnicity, <.001 <.001 <.001 % White, non- Hispanic Black, non Hispanic Hispanic Other b Below poverty, 9.3 (6.1- < ( (6.4- < ( (5.9- <.001 median (IQR), % c 13.4) 14.3) 13.7) 15.1) 13.0) 14.0) With at least some ( ( (20.0- < ( (20.7- <.001 college, median (IQR), % c ( ) 38.2) 39.1) 36.7) 39.6) 38.9) Admission characteristics, % Admission via ED < < Admitted to ICU <.001 within 24 hours Healthcare < <.001 associated pneumonia d Comorbid conditions, % e Hypertension < <

18 Chronic pulmonary < <.001 disease Fluid and < < <.001 electrolyte disorder Congestive heart < < <.001 failure Diabetes Anemia < <.001 Renal failure < <.001 Neurologic disorder < <.001 Hypothyroidism <.001 Psychiatric illness <.001 Neoplastic disease < < <.001 Liver disease Comorbid conditions per patient, mean (SD) 3.6 (1.8) 3.6 (1.8) (1.7) 3.4 (1.7) < (1.7) 3.2 (1.7) <

19 etable 3. Characteristics of elderly ( age 65) FFS Medicare patients hospitalized for pneumonia stratified by receipt of processes of care, January 1, 2006 to December 31, 2010 (continued) Patient Processes of care characteristics Smoking cessation counseling Pneumococcal vaccination Influenza vaccination Process Process not P-Value Process Process not P-Value Process Process not P- Value n=200,87 n=15,136 n=1,455,861 n=214,472 n=726,920 n=120,088 0 Age in years, mean 74.1 (6.6) 75.4 (7.0) < (8.1) 79.8 (8.4) < (8.1) 79.6 (8.4).13 (SD) Women, % < < Race and ethnicity, <.001 <.001 <.001 % White, non Hispanic Black, non Hispanic Hispanic Other b Below poverty, 9.6 ( (6.6- < ( (6.1- < ( (6.1- <.001 median (IQR), % c 14.5) 15.3) 13.3) 15.0) 13.3) 15.0) With at least some ( ( (20.5- < ( (20.4- <.001 college, median (IQR), % c ( ) 35.5) 39.0) 38.7) 39.0) 38.4) Admission characteristics, % Admission via ED < < <.001 Admitted to ICU < < <.001 within 24 hours Healthcare < < <.001 associated pneumonia d Comorbid conditions, % e Hypertension < < <

20 Chronic pulmonary < < <.001 disease Fluid and < <.001 electrolyte disorder Congestive heart < <.001 failure Diabetes < <.001 Anemia < <.001 Renal failure < < <.001 Neurologic disorder < < <.001 Hypothyroidism < <.001 Psychiatric illness < <.001 Neoplastic disease < < <.001 Liver disease Comorbid conditions per patient, mean (SD) 3.7 (1.7) 3.6 (1.7) < (1.8) 3.5 (1.7) < (1.8) 3.6 (1.8) <

21 etable 3. Characteristics of elderly ( age 65) FFS Medicare patients hospitalized for pneumonia stratified by receipt of processes of care, January 1, 2006 to December 31, 2010 (continued) Patient characteristics Processes of care All-or-none measure All patients All-or-none measure Non-ICU patients All-or-none measure ICU patients Process Process not P-Value Process Process not P-Value Process Process not P- Value n=200,870 n=15,136 n=1,455,861 n=214,472 n=726,920 n=120,088 Age in years, mean 79.7 (8.2) 79.6 (8.3) < (8.2) 79.9 (8.3) (7.9) 77.9 (7.9) <.001 (SD) Women, % < Race and ethnicity, % <.001 <.001 <.001 White, non-hispanic Black, non-hispanic Hispanic Other b Below poverty, median 8.6 ( ( ) < ( (6.0- < ( (6.1- <.001 (IQR), % c 13.2) 13.2) 14.6) 13.5) 14.4) With at least some college, median (IQR), 28.7 ( ) 28.0 ( ) < ( ) 28.0 ( ) < ( ) 28.0 ( ) <.001 % c Admission characteristics, % Admission via ED < < <.001 Admitted to ICU within < hours Healthcare associated < < <.001 pneumonia d Comorbid conditions, % e Hypertension < < <.001 Chronic pulmonary < < <.001 disease Fluid and electrolyte < <.001 disorder Congestive heart failure < < <

22 Diabetes < < Anemia < < <.001 Renal failure < < <.001 Neurologic disorder < < <.001 Hypothyroidism < < <.001 Psychiatric illness < < <.001 Neoplastic disease < < <.001 Liver disease Comorbid conditions per patient, mean (SD) 3.7 (1.8) 3.5 (1.7) < (1.8) 3.5 (1.7) < (1.8) 4.0 (1.8) <.001 Abbreviations: ED, emergency department; FFS, fee-for-service; ICU, intensive care unit; IQR, interquartile range; SD, standard deviation. a The n represents the total number of cases of pneumonia in hospitalized elderly ( age 65) FFS Medicare patients who or did not receive a process of care from 2006 to Comparisons of patient characteristics by process of care over time were calculated using the Cochran-Armitage chi-square test for trend for categorical variables and linear regression analyses for continuous variables. b Other race and ethnicity consisted of patients whose race was reported as Asian, Pacific Islander, Native American, or Alaskan Native, and patients with unreported race or ethnicity. c Poverty status represents the proportion of people in a patient s neighborhood of residence living below poverty level and educational attainment represents the proportion with at least some college experience. Both characteristics were calculated based on ZIP Codes of residence using data from the US Census Bureau. d Healthcare associated pneumonia was defined by the presence of at least one of the following criteria: acute care hospitalization within 90 days; residence in a nursing home or extended care facility within 90 days; chronic dialysis within 30 days; or wound, tracheostomy, or ventilator care within 30 days of admission. e Selected comorbid conditions in the Elixhauser Comorbidity Index that were assessed using ICD-9-CM codes. 22

23 etable 4. Multivariable associations between processes of care and medical outcomes for elderly ( age 65) FFS Medicare patients hospitalized for pneumonia, January 1, 2006 to December 31, 2010 Medical outcomes and Year 2006 Year 2007 Year 2008 Year 2009 Year 2010 All Years processes of care by patient AOR (95% CI) a AOR (95% CI) a AOR (95% CI) a AOR (95% CI) a AOR (95% CI) a AOR (95% CI) a group Antibiotic therapy Initiation 6 hours 30-day mortality 0.97 ( ) 0.94 ( ) 0.94 ( ) 0.96 ( ) 0.96 ( ) 0.95 ( ) 30-day 0.88 ( ) 0.89 ( ) 0.94 ( ) 0.91 ( ) 0.91 ( ) 0.90 ( ) readmission Appropriate selection ICU patients b 30-day mortality 0.78 ( ) 0.87 ( ) 0.92 ( ) 0.87 ( ) 0.84 ( ) 0.85 ( ) 30-day 0.90 ( ) 0.89 ( ) 0.91 ( ) 0.98 ( ) 0.88 ( ) 0.91 ( ) readmission Non-ICU patients b 30-day mortality 0.73 ( ) 0.76 ( ) 0.79 ( ) 0.74 ( ) 0.76 ( ) 0.75 ( ) 30-day 0.85 ( ) 0.84 ( ) 0.83 ( ) 0.82 ( ) 0.84 ( ) 0.84 ( ) readmission All patients 30-day mortality 0.74 ( ) 0.80 ( ) 0.85 ( ) 0.81 ( ) 0.80 ( ) 0.79 ( ) 30-day 0.86 ( ) 0.85 ( ) 0.85 ( ) 0.87 ( ) 0.85 ( ) 0.85 ( ) readmission Performance of blood cultures Within 24 hours for ICU patients 30-day mortality 1.01 ( ) 0.87 ( ) 0.97 ( ) 0.83 ( ) 0.95 ( ) 0.94 ( ) 30-day 1.00 ( ) 0.98 ( ) 0.91 ( ) 0.90 ( ) 0.93 ( ) 0.96 ( ) readmission Before antibiotic therapy in ED 30-day mortality 0.90 ( ) 0.88 ( ) 0.96 ( ) 0.91 ( ) 0.91 ( ) 0.92 ( ) 30-day 0.95 ( ) 0.98 ( ) 1.00 ( ) 0.92 ( ) 0.98 ( ) 0.97 ( ) readmission Prevention measures Smoking cessation 23

24 counseling 30-day mortality 0.69 ( ) 0.77 ( ) 0.78 ( ) 0.68 ( ) 0.72 ( ) 0.74 ( ) 30-day 0.86 ( ) 0.87 ( ) 0.92 ( ) 0.87 ( ) 0.91 ( ) 0.88 ( ) readmission Pneumococcal vaccination 30-day mortality 0.78 ( ) 0.81 ( ) 0.77 ( ) 0.80 ( ) 0.80 ( ) 0.80 ( ) 30-day 0.97 ( ) 0.99 ( ) 1.01 ( ) 1.04 ( ) 1.08 ( ) 1.00 ( ) readmission Influenza vaccination 24

25 etable 4. Multivariable associations between processes of care and medical outcomes for elderly ( age 65) FFS Medicare patients hospitalized for pneumonia, January 1, 2006 to December 31, 2010 (continued) Medical Year 2006 Year 2007 Year 2008 Year 2009 Year 2010 All Years outcomes and processes of care by patient group AOR (95% CI) a AOR (95% CI) a AOR (95% CI) a AOR (95% CI) a AOR (95% CI) a AOR (95% CI) a ( ) 0.77 ( ) 0.79 ( ) 0.77 ( ) 0.76 ( ) 0.78 ( ) day mortality 30- day readmission 0.95 ( ) 0.99 ( ) 0.96 ( ) 0.97 ( ) 0.95 ( ) 0.97 ( ) Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; ED, emergency department; FFS, fee-for-service; ICU, intensive care unit. a Adjusted odds ratios (AORs) were calculated using multivariable logistic regression, adjusting for patient and hospital characteristics. These AORs represent the adjusted odds of mortality or hospital readmission within 30 days for all eligible cases in the study sample eligible for a given process of care, comparing those who versus did not receive a given process measure. b Definitions: ICU patients are individuals who were admitted or transferred to the ICU within 24 hours of hospital admission. Non-ICU patients are all other individuals not meeting these criteria. 25

26 efigure. Flow diagram of patient identification and selection. Identification of Potential Study Cases We identified 5,412,117 cases of pneumonia in adults (=18 years of age) admitted to US hospitals and submitted to the IQR Clinical Data Warehouse (01/01/06 12/31/10) Excluded Cases 3,593,138 cases sequentially excluded: 1,061,950 ineligible for all 7 pneumonia processes of care 1,505,004 age < 65 years 1,026,184 not linkable to CMS databases to assess 30 day medical outcomes Final Study Cohort 1,818,979 cases of pneumonia in hospitalized, elderly, fee for service, Medicare recipients We identified 5,412,117 cases of pneumonia in adults ( 18 years of age) that were admitted to non-federal US acute care hospitals and submitted to the IQR Clinical Data Warehouse (1/1/06-12/31/10). From this sample, we sequentially excluded 1,061,950 cases who were ineligible for all 7 recommended pneumonia processes of care and 1,505,004 cases who were less than 65 years of age. From this potentially eligible sample, we further excluded 1,026,184 cases whose hospital insurance claims were missing or unverifiable and could not be linked with CMS databases to obtain information on 30-day mortality and/or readmission. The final study cohort consisted of 1,818,979 cases of pneumonia in hospitalized, elderly, fee-for-service, Medicare recipients, representing 64% of the eligible pool of 2,845,163 cases of pneumonia in elderly patients. 26