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 2010. JAMA Intern Med. Published online September 8, 2014. doi:10.1001/jamainternmed.2014.4501. 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. 2014 American Medical Association. All rights reserved.
etable 1. ICD-9-CM codes used to identify cases of pneumonia a ICD-9-CM Code Shortened description Pneumonia 481 PNEUMOCOCCAL PNEUMONIA 482.0 K. PNEUMONIAE PNEUMONIA 482.1 PSEUDOMONAL PNEUMONIA 482.2 H.INFLUENZAE PNEUMONIA 482.30 STREPTOCOCCAL PNEUMN NOS 482.31 PNEUMONIA STRPTOCOCCUS A 482.32 PNEUMONIA STRPTOCOCCUS B 482.39 PNEUMONIA OTH STREP 482.40 STAPHYLOCOCCAL PNEU NOS 482.41 METH SUS PNEUM D/T STAPH 482.42 METH RES PNEU D/T STAPH 482.49 STAPH PNEUMONIA NEC 482.82 PNEUMONIA E COLI 482.83 PNEUMO OTH GRM-NEG BACT 482.84 LEGIONNAIRES' DISEASE 482.89 PNEUMONIA OTH SPCF BACT 482.9 BACTERIAL PNEUMONIA NOS 483.0 PNEU MYCPLSM PNEUMONIAE 483.1 PNEUMONIA D/T CHLAMYDIA 483.8 PNEUMON OTH SPEC ORGNSM 485 BRONCHOPNEUMONIA ORG NOS 486 PNEUMONIA, ORGANISM NOS Septicemia 038.0 STREPTOCOCCAL SEPTICEMIA 038.10 STAPHYLCOCC SEPTICEM NOS 038.11 METH SUSC STAPH AUR SEPT 038.12 MRSA SEPTICEMIA 038.19 STAPHYLCOCC SEPTICEM NEC 038.2 PNEUMOCOCCAL SEPTICEMIA 038.3 ANAEROBIC SEPTICEMIA 038.40 GRAM-NEG SEPTICEMIA NOS 038.41 H. INFLUENAE SEPTICEMIA 2
038.42 E COLI SEPTICEMIA 038.43 PSEUDOMONAS SEPTICEMIA 038.44 SERRATIA SEPTICEMIA 038.49 GRAM-NEG SEPTICEMIA NEC 038.8 SEPTICEMIA NEC 038.9 SEPTICEMIA NOS 3
etable 1. ICD-9-CM codes used to identify cases of pneumonia a (continued) ICD-9-CM Code Shortened description Respiratory failure 518.81 ACUTE RESPIRATRY FAILURE 518.84 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
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
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 2010 6
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 2010. 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 2010 7
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 2009 8
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 2010 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 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
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
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 2006 12
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 2006 13
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 487.0 (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 3.1. 14
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=53,198 55 Age in years, mean 79.9 (8.2) 79.6 (8.2) <.001 79.7 (8.1) 79.2 (8.1) <.001 79.8 (8.1) 79.8 (8.1).90 (SD) Women, % 52.9 56.4 <.001 53.3 53.0.11 53.7 55.4 <.001 Race and ethnicity, % <.001 <.001 <.001 White, non-hispanic 84.1 78.4 85.1 83.7 85.2 84.2 Black, non-hispanic 7.2 9.8 5.8 6.2 5.8 5.6 Hispanic 4.4 7.3 4.5 5.5 4.5 5.6 Other b 4.3 4.4 4.5 4.7 4.4 4.5 Below poverty, median 9.5 (6.1- <.001 8.5 (5.7-9.3 (6.0- <.001 8.5 (5.7-9.4 (6.0- <.001 (IQR), % c 8.7 (5.8-13.3) 15.1) 13.1) 14.8) 13.1) 15.0) With at least some college, median (IQR), 27.7 (20.2-38.3) <.001 28.6 (20.8-39.4) 27.5 (20.2-38.0) <.001 28.7 (20.8-39.4) 27.3 (20.1-37.8) <.001 % c 28.5 (20.9-39.0) Admission characteristics, % Admission via ED 80.0 71.5 <.001 83.6 75.2 <.001 83.0 68.8 <.001 Admitted to ICU within 14.3 10.8 <.001 7.0 31.2 <.001 - - - 24 hours Healthcare associated 35.4 35.3.52 - - - - - - pneumonia d Comorbid conditions, % e Hypertension 63.0 63.1.71 65.3 60.6 <.001 65.7 61.5 <.001 Chronic pulmonary disease Fluid and electrolyte disorder 53.2 51.1 <.001 52.3 56.5 <.001 51.6 54.1 <.001 38.2 37.2 <.001 36.1 37.5 <.001 35.1 33.0 <.001 15
Congestive heart 32.8 32.7.55 28.2 34.5 <.001 26.9 28.9 <.001 failure Diabetes 29.3 30.2 <.001 28.2 28.1.53 28.0 27.1 <.001 Anemia 27.5 27.5.88 23.8 24.0.22 23.6 23.4.27 Renal failure 17.9 18.2.06 14.6 15.1 <.001 14.2 13.4 <.001 Neurologic disorder 15.9 15.5.006 12.2 12.1.61 12.3 12.4.39 Hypothyroidism 16.0 15.8.19 16.0 15.0 <.001 16.3 16.0.11 Psychiatric illness 14.0 13.4 <.001 12.0 10.9 <.001 12.1 11.5 <.001 Neoplastic disease 8.0 9.5 <.001 3.9 5.2 <.001 3.9 5.3 <.001 Liver disease 1.0 1.3 <.001 0.9 1.0.007 0.9 0.9.75 Comorbid conditions per patient, mean (SD) 3.6 (1.8) 3.6 (1.8).07 3.3 (1.7) 3.4 (1.7) <.001 3.3 (1.7) 3.2 (1.7) <.001 16
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).64 78.3 (7.9) 78.3 (7.9).59 80.1 (8.2) 79.8 (8.2) <.001 (SD) Women, % 48.4 47.8.16 49.1 51.0 <.001 52.9 53.9 <.001 Race and ethnicity, <.001 <.001 <.001 % White, non- Hispanic 83.5 82.6 81.0 82.4 83.7 80.6 Black, non- 6.0 7.3 8.9 7.6 7.3 8.6 Hispanic Hispanic 5.2 5.2 5.3 5.3 4.6 6.1 Other b 5.2 4.9 4.8 4.7 4.4 4.7 Below poverty, 9.3 (6.1- <.001 8.9 (5.8-9.8 (6.4- <.001 8.5 (5.6-9.0 (5.9- <.001 median (IQR), % c 13.4) 14.3) 13.7) 15.1) 13.0) 14.0) With at least some 28.2 27.8 (20.4-.007 28.8 (20.9-27.2 (20.0- <.001 29.0 (21.1-28.4 (20.7- <.001 college, median (IQR), % c (20.5-38.7) 38.2) 39.1) 36.7) 39.6) 38.9) Admission characteristics, % Admission via ED 92.0 89.2 <.001 81.7 75.5 <.001 - - - Admitted to ICU - - - - - - 15.8 17.2 <.001 within 24 hours Healthcare - - - 49.2 44.8 <.001 39.7 35.9 <.001 associated pneumonia d Comorbid conditions, % e Hypertension 60.1 58.5 <.001 56.9 56.5.35 63.1 61.7 <.001 17
Chronic pulmonary 61.9 61.7.52 58.3 62.7 <.001 52.3 54.0 <.001 disease Fluid and 49.8 47.6 <.001 51.8 43.9 <.001 40.1 39.1 <.001 electrolyte disorder Congestive heart 45.5 46.9 <.001 45.6 48.1 <.001 33.2 34.3 <.001 failure Diabetes 30.3 30.2.71 31.3 30.0.002 29.6 29.3.17 Anemia 25.9 25.2.053 29.7 26.8 <.001 28.6 26.8 <.001 Renal failure 19.3 18.6.03 22.6 19.6 <.001 18.7 17.4 <.001 Neurologic disorder 11.3 11.6.23 16.3 13.2 <.001 17.2 15.8 <.001 Hypothyroidism 13.1 12.9.58 13.5 13.2.23 16.1 14.9 <.001 Psychiatric illness 10.3 9.8.03 12.2 11.5.02 14.4 13.3 <.001 Neoplastic disease 4.2 5.0 <.001 9.1 8.2 <.001 8.1 7.4 <.001 Liver disease 1.2 1.3.70 1.4 1.2.04 1.1 1.0.47 Comorbid conditions per patient, mean (SD) 3.6 (1.8) 3.6 (1.8).07 3.3 (1.7) 3.4 (1.7) <.001 3.3 (1.7) 3.2 (1.7) <.001 18
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) <.001 79.5 (8.1) 79.8 (8.4) <.001 79.6 (8.1) 79.6 (8.4).13 (SD) Women, % 50.9 49.4 <.001 54.4 53.9 <.001 54.8 54.6.12 Race and ethnicity, <.001 <.001 <.001 % White, non- 85.7 83.0 84.7 76.5 84.9 77.6 Hispanic Black, non- 7.9 8.4 7.0 10.8 6.8 10.6 Hispanic Hispanic 3.0 3.5 4.2 6.7 4.2 6.2 Other b 3.3 5.1 4.2 5.9 4.1 5.6 Below poverty, 9.6 (6.3-10.0 (6.6- <.001 8.6 (5.7-9.5 (6.1- <.001 8.7 (5.7-9.5 (6.1- <.001 median (IQR), % c 14.5) 15.3) 13.3) 15.0) 13.3) 15.0) With at least some 26.5 26.3 (19.6-.03 28.6 (20.9-28.0 (20.5- <.001 28.5 (20.9-27.8 (20.4- <.001 college, median (IQR), % c (19.7-36.0) 35.5) 39.0) 38.7) 39.0) 38.4) Admission characteristics, % Admission via ED 78.7 74.9 <.001 75.4 76.9 <.001 73.9 74.4 <.001 Admitted to ICU 14.2 16.4 <.001 10.4 13.8 <.001 10.3 13.9 <.001 within 24 hours Healthcare 27.8 37.8 <.001 35.9 37.6 <.001 34.7 38.4 <.001 associated pneumonia d Comorbid conditions, % e Hypertension 58.9 53.9 <.001 64.2 59.6 <.001 64.7 59.8 <.001 19
Chronic pulmonary 80.5 76.2 <.001 54.5 47.5 <.001 54.3 50.4 <.001 disease Fluid and 37.7 37.1.13 38.0 40.6 <.001 38.2 40.8 <.001 electrolyte disorder Congestive heart 28.4 29.6.001 33.1 32.6 <.001 33.0 33.9 <.001 failure Diabetes 26.2 25.5.04 30.4 28.8 <.001 30.4 29.6 <.001 Anemia 24.3 25.1.03 28.4 26.4 <.001 28.3 26.8 <.001 Renal failure 13.9 11.9 <.001 18.9 16.5 <.001 18.9 17.1 <.001 Neurologic disorder 10.0 12.4 <.001 15.6 18.6 <.001 15.5 18.6 <.001 Hypothyroidism 11.0 10.5.06 16.6 14.1 <.001 16.7 14.5 <.001 Psychiatric illness 16.6 16.3.38 14.4 13.4 <.001 14.3 13.8 <.001 Neoplastic disease 9.8 10.8 <.001 7.7 6.8 <.001 7.3 7.6 <.001 Liver disease 1.5 1.5.95 1.1 1.0.009 1.1 1.1.95 Comorbid conditions per patient, mean (SD) 3.7 (1.7) 3.6 (1.7) <.001 3.7 (1.8) 3.5 (1.7) <.001 3.7 (1.8) 3.6 (1.8) <.001 20
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) <.001 79.9 (8.2) 79.9 (8.3).15 78.2 (7.9) 77.9 (7.9) <.001 (SD) Women, % 54.0 54.1.18 54.6 55.0 <.001 49.4 49.5.62 Race and ethnicity, % <.001 <.001 <.001 White, non-hispanic 84.7 79.9 85.1 80.0 82.0 79.1 Black, non-hispanic 7.0 9.2 6.8 9.0 8.6 9.9 Hispanic 4.1 5.7 4.0 5.8 4.9 5.7 Other b 4.1 5.2 4.1 5.2 4.5 5.3 Below poverty, median 8.6 (5.7-9.3 (6.0-14.5) <.001 8.6 (5.7-9.3 (6.0- <.001 8.8 (5.8-9.3 (6.1- <.001 (IQR), % c 13.2) 13.2) 14.6) 13.5) 14.4) With at least some college, median (IQR), 28.7 (20.9-39.2) 28.0 (20.5-38.6) <.001 28.7 (21.0-39.2) 28.0 (20.5-38.6) <.001 28.7 (20.9-39.1) 28.0 (20.4-38.4) <.001 % c Admission characteristics, % Admission via ED 75.2 77.0 <.001 74.9 75.8 <.001 77.2 82.8 <.001 Admitted to ICU within 11.5 17.2 <.001 - - - - - - 24 hours Healthcare associated 39.6 32.5 <.001 37.3 31.4 <.001 55.0 37.0 <.001 pneumonia d Comorbid conditions, % e Hypertension 63.6 60.6 <.001 64.4 61.4 <.001 57.9 56.4 <.001 Chronic pulmonary 53.7 51.8 <.001 53.1 50.2 <.001 58.3 59.7 <.001 disease Fluid and electrolyte 39.6 39.5.22 37.9 37.3 <.001 52.5 49.8 <.001 disorder Congestive heart failure 33.9 33.6 <.001 32.4 30.8 <.001 46.0 47.0 <.001 21
Diabetes 30.1 29.1 <.001 29.8 28.6 <.001 31.9 31.4.007 Anemia 28.7 26.6 <.001 28.4 26.3 <.001 30.5 27.8 <.001 Renal failure 19.5 16.9 <.001 19.0 16.1 <.001 23.7 20.8 <.001 Neurologic disorder 16.2 16.5 <.001 16.1 16.8 <.001 16.7 15.0 <.001 Hypothyroidism 16.4 14.7 <.001 16.8 15.1 <.001 13.9 12.6 <.001 Psychiatric illness 14.3 13.3 <.001 14.5 13.7 <.001 12.6 11.3 <.001 Neoplastic disease 8.5 7.5 <.001 8.4 7.5 <.001 9.7 7.2 <.001 Liver disease 1.1 1.1.02 1.1 1.0.01 1.5 1.3.006 Comorbid conditions per patient, mean (SD) 3.7 (1.8) 3.5 (1.7) <.001 3.7 (1.8) 3.5 (1.7) <.001 4.2 (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 2010. 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
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 (0.93-1.02) 0.94 (0.89-1.00) 0.94 (0.88-0.99) 0.96 (0.89-1.02) 0.96 (0.89-1.04) 0.95 (0.93-0.98) 30-day 0.88 (0.85-0.92) 0.89 (0.85-0.93) 0.94 (0.90-0.98) 0.91 (0.87-0.97) 0.91 (0.86-0.96) 0.90 (0.89-0.92) readmission Appropriate selection ICU patients b 30-day mortality 0.78 (0.71-0.85) 0.87 (0.79-0.97) 0.92 (0.84-1.01) 0.87 (0.79-0.96) 0.84 (0.76-0.94) 0.85 (0.81-0.88) 30-day 0.90 (0.82-0.98) 0.89 (0.80-0.98) 0.91 (0.83-0.99) 0.98 (0.88-1.08) 0.88 (0.78-0.99) 0.91 (0.87-0.95) readmission Non-ICU patients b 30-day mortality 0.73 (0.68-0.78) 0.76 (0.70-0.83) 0.79 (0.73-0.86) 0.74 (0.67-0.82) 0.76 (0.68-0.84) 0.75 (0.72-0.78) 30-day 0.85 (0.81-0.88) 0.84 (0.80-0.89) 0.83 (0.78-0.87) 0.82 (0.77-0.88) 0.84 (0.78-0.90) 0.84 (0.82-0.86) readmission All patients 30-day mortality 0.74 (0.71-0.78) 0.80 (0.75-0.86) 0.85 (0.80-0.90) 0.81 (0.75-0.86) 0.80 (0.74-0.87) 0.79 (0.77-0.82) 30-day 0.86 (0.82-0.89) 0.85 (0.81-0.89) 0.85 (0.81-0.89) 0.87 (0.82-0.92) 0.85 (0.80-0.91) 0.85 (0.84-0.87) readmission Performance of blood cultures Within 24 hours for ICU patients 30-day mortality 1.01 (0.93-1.09) 0.87 (0.79-0.96) 0.97 (0.88-1.07) 0.83 (0.74-0.93) 0.95 (0.83-1.08) 0.94 (0.90-0.98) 30-day 1.00 (0.91-1.09) 0.98 (0.89-1.09) 0.91 (0.82-1.02) 0.90 (0.78-1.03) 0.93 (0.80-1.07) 0.96 (0.91-1.01) readmission Before antibiotic therapy in ED 30-day mortality 0.90 (0.86-0.95) 0.88 (0.84-0.93) 0.96 (0.91-1.02) 0.91 (0.85-0.98) 0.91 (0.84-0.98) 0.92 (0.89-0.94) 30-day 0.95 (0.91-0.99) 0.98 (0.94-1.02) 1.00 (0.95-1.05) 0.92 (0.87-0.98) 0.98 (0.92-1.05) 0.97 (0.95-0.99) readmission Prevention measures Smoking cessation 23
counseling 30-day mortality 0.69 (0.60-0.79) 0.77 (0.65-0.91) 0.78 (0.65-0.95) 0.68 (0.54-0.87) 0.72 (0.52-0.98) 0.74 (0.68-0.80) 30-day 0.86 (0.80-0.92) 0.87 (0.79-0.95) 0.92 (0.83-1.03) 0.87 (0.76-1.00) 0.91 (0.77-1.06) 0.88 (0.84-0.92) readmission Pneumococcal vaccination 30-day mortality 0.78 (0.75-0.81) 0.81 (0.77-0.84) 0.77 (0.73-0.81) 0.80 (0.75-0.86) 0.80 (0.74-0.87) 0.80 (0.78-0.82) 30-day 0.97 (0.95-1.00) 0.99 (0.97-1.02) 1.01 (0.98-1.04) 1.04 (1.00-1.08) 1.08 (1.04-1.13) 1.00 (0.99-1.02) readmission Influenza vaccination 24
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 30-0.79 (0.74-0.83) 0.77 (0.72-0.82) 0.79 (0.74-0.84) 0.77 (0.71-0.84) 0.76 (0.70-0.84) 0.78 (0.76-0.80) day mortality 30- day readmission 0.95 (0.92-0.98) 0.99 (0.95-1.03) 0.96 (0.93-1.00) 0.97 (0.92-1.02) 0.95 (0.90-1.00) 0.97 (0.95-0.98) 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
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