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Causes of Death for Patients With Community-Acquired Pneumonia
Results From the Pneumonia Patient Outcomes Research Team Cohort Study
Eric M. Mortensen, MD, MSc;
Christopher M. Coley, MD;
Daniel E. Singer, MD;
Thomas J. Marrie, MD;
D. Scott Obrosky, MSc;
Wishwa N. Kapoor, MD, MPH;
Michael J. Fine, MD, MSc
Arch Intern Med. 2002;162:1059-1064.
Background To our knowledge, no previous study has systematically examined pneumonia-related
and pneumonia-unrelated mortality. This study was performed to identify the
cause(s) of death and to compare the timing and risk factors associated with
pneumonia-related and pneumonia-unrelated mortality.
Methods For all deaths within 90 days of presentation, a synopsis of all events
preceding death was independently reviewed by 2 members of a 5-member review
panel (C.M.C., D.E.S., T.J.M., W.N.K., and M.J.F.). The underlying and immediate
causes of death and whether pneumonia had a major, a minor, or no apparent
role in the death were determined using consensus. Death was defined as pneumonia
related if pneumonia was the underlying or immediate cause of death or played
a major role in the cause of death. Competing-risk Cox proportional hazards
regression models were used to identify baseline characteristics associated
with mortality.
Results Patients (944 outpatients and 1343 inpatients) with clinical and radiographic
evidence of pneumonia were enrolled, and 208 (9%) died by 90 days. The most
frequent immediate causes of death were respiratory failure (38%), cardiac
conditions (13%), and infectious conditions (11%); the most frequent underlying
causes of death were neurological conditions (29%), malignancies (24%), and
cardiac conditions (14%). Mortality was pneumonia related in 110 (53%) of
the 208 deaths. Pneumonia-related deaths were 7.7 times more likely to occur
within 30 days of presentation compared with pneumonia-unrelated deaths. Factors
independently associated with pneumonia-related mortality were hypothermia,
altered mental status, elevated serum urea nitrogen level, chronic liver disease,
leukopenia, and hypoxemia. Factors independently associated with pneumonia-unrelated
mortality were dementia, immunosuppression, active cancer, systolic hypotension,
male sex, and multilobar pulmonary infiltrates. Increasing age and evidence
of aspiration were independent predictors of both types of mortality.
Conclusions For patients with community-acquired pneumonia, only half of all deaths
are attributable to their acute illness. Differences in the timing of death
and risk factors for mortality suggest that future studies of community-acquired
pneumonia should differentiate all-cause and pneumonia-related mortality.
From the Division of General Internal Medicine, Department of Medicine,
and the Center for Research on Health Care, University of Pittsburgh (Drs
Mortensen, Kapoor, and Fine and Mr Obrosky), and the Center for the Study
of Health Disparities, VA Pittsburgh Healthcare System (Dr Fine), Pittsburgh,
Pa; the General Medicine Unit, Department of Medicine, Massachusetts General
Hospital and Harvard Medical School, Boston (Drs Coley and Singer); and the
Division of Infectious Disease, Department of Medicine, University of Alberta,
Edmonton (Dr Marrie).
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