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Pneumonia in Long-term Care
A Prospective Case-Control Study of Risk Factors and Impact on Survival
Emanuel N. Vergis, MD;
Carole Brennen, RN, MSN;
Marilyn Wagener, MPH;
Robert R. Muder, MD
Arch Intern Med. 2001;161:2378-2381.
Background Pneumonia is a major cause of morbidity and mortality in long-term care
facilities. Prior studies of pneumonia have failed to identify risk factors
potentially amenable to intervention. Our objectives were to (1) identify
modifiable risk factors for the occurrence of pneumonia and (2) determine
the long-term impact of pneumonia on survival.
Methods We performed a case-control study among residents of a Veterans Affairs
long-term care facility. Case patients included all patients developing pneumonia
from 2 days to 1 year after admission. Control subjects were matched for admission
date, level of nursing care, and dependence in activities of daily living.
Patients were followed up for 2 years or until death or discharge from the
facility.
Results We identified 104 case-control pairs. Risk factors significantly associated
with pneumonia included witnessed aspiration (odds ratio, 13.9; 95% confidence
interval, 1.7-111.0; P = .01), sedative medication
(odds ratio, 2.6; 95% confidence interval, 1.2-5.4; P
= .01), and comorbidity score (odds ratio, 1.2; 95% confidence interval, 1.0-1.4; P = .05). Mortality due to pneumonia was 23% at 14 days.
Patients with pneumonia had a significantly higher mortality than did controls
at 1 year (75% vs 40%; P<.001); survival curves
converged at 2 years. In a Cox proportional hazards regression model, an episode
of pneumonia was independently associated with mortality during follow-up
(odds ratio, 2.6; 95% confidence interval, 1.7-3.9; P<.001).
Conclusions Among long-term care patients closely matched for age, level of dependency,
and duration of institutionalization, an episode of pneumonia is associated
with significant excess mortality that persists for up to 2 years. Two identified
risk factors, large-volume aspiration and receipt of sedating medication,
are potentially amenable to intervention.
From the VA Pittsburgh Healthcare System (Drs Vergis and Muder and
Mss Brennen and Wagener) and the Division of Infectious Diseases, Department
of Medicine, University of Pittsburgh Medical Center (Drs Vergis and Muder
and Ms Wagener), Pittsburgh, Pa.
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