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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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