Processes and outcomes of care for patients with community-acquired pneumonia: results from the Pneumonia Patient Outcomes Research Team (PORT) cohort study.

BACKGROUND: Although understanding the processes of care and medical outcomes for patients with community-acquired pneumonia is instrumental to improving the quality and cost-effectiveness of care for this illness, limited information is available on how physicians manage patients with this illness or on medical outcomes other than short-term mortality. OBJECTIVES: To describe the processes of care and to assess a broad range of medical outcomes for ambulatory and hospitalized patients with community-acquired pneumonia. METHODS: This prospective, observational study was conducted at 4 hospitals and 1 health maintenance organization in Pittsburgh, Pa, Boston, Mass, and Halifax, Nova Scotia. Data were collected via patient interviews and reviews of medical records for 944 outpatients and 1343 inpatients with clinical and radiographic evidence of community-acquired pneumonia. Processes of care and medical outcomes were assessed 30 days after presentation. RESULTS: Only 29.7% of outpatients had 1 or more microbiologic tests performed, and only 5.7% had an assigned microbiologic cause. Although 95.7% of inpatients had 1 or more microbiologic tests performed, a cause was established in only 29.6%. Six outpatients (0.6%) died, and 3 of these deaths were pneumonia related. Of surviving outpatients, 8.0% had 1 or more medical complications. At 30 days, 88.9% (nonemployed) to 95.6% (employed) of the surviving outpatients had returned to usual activities, yet 76.0% of outpatients had 1 or more persisting pneumonia-related symptoms. Overall, 107 inpatients (8.0%) died, and 81 of these deaths were pneumonia related. Most surviving inpatients (69.0%) had 1 or more medical complications. At 30 days, 57.3% (non-employed) to 82.0% (employed) of surviving inpatients had returned to usual activities, and 86.1% had 1 or more persisting pneumonia-related symptoms. CONCLUSIONS: In this study, conducted primarily at hospital sites with affiliated medical education training programs, virtually all outpatients and most inpatients had pneumonia of unknown cause. Although outpatients had an excellent prognosis, pneumonia-related symptoms often persisted at 30 days. Inpatients had substantial mortality, morbidity, and pneumonia-related symptoms at 30 days.

Influence of age on symptoms at presentation in patients with community-acquired pneumonia.

BACKGROUND: Advanced age has become a well-recognized risk factor for death in patients with pneumonia. It may also be associated with reduced symptom reporting, raising the possibility that diagnosis and treatment may be delayed in older patients. OBJECTIVE: To evaluate the association between age and the presenting symptoms in patients with community-acquired pneumonia. METHODS: This study was conducted at inpatient and outpatient facilities at 3 university hospitals, 1 community hospital, and 1 staff-model health maintenance organization. Patients included adults (age > or = 18 years) with clinical and radiographic evidence of pneumonia, who were able to complete a baseline interview. The presence of 5 respiratory symptoms and 13 nonrespiratory symptoms were recorded during a baseline patient interview. A summary symptom score was computed as the total number of symptoms at presentation. RESULTS: The 1812 eligible study patients were categorized into 4 age groups: 18 through 44 years (43%), 45 through 64 years (25%), 65 through 74 years (17%), and 75 years or older (15%). For 17 of the 18 symptoms, there were significant decreases in reported prevalence with increasing age (P < .01). In a linear regression analysis, controlling for patient demographics, comorbidity, and severity of illness at presentation, older age remained associated with lower symptom scores (P < .001). CONCLUSIONS: Respiratory and nonrespiratory symptoms are less commonly reported by older patients with pneumonia, even after controlling for the increased comorbidity and illness severity in these older patients. Recognition of this phenomenon by clinicians and patients is essential given the increased mortality in elderly patients with pneumonia.

The hospital admission decision for patients with community-acquired pneumonia. Results from the pneumonia Patient Outcomes Research Team cohort study.

BACKGROUND: The hospital admission decision directly influences the magnitude of resource use in patients with community-acquired pneumonia, yet little information exists on how medical practitioners make this decision. OBJECTIVES: To determine which factors medical practitioners consider in making the hospital admission decision and which health care services they believe would allow ambulatory treatment of low-risk hospitalized patients with community-acquired pneumonia. METHODS: Medical practitioners responsible for the hospital admission decision for low-risk patients with community-acquired pneumonia were asked to describe patient characteristics at initial examination that influenced the hospitalization decision, and to identify the health care services that would have allowed initial outpatient treatment of hospitalized patients. RESULTS: A total of 292 medical practitioners completed questionnaires for 472 (76%) of the 624 low-risk patients eligible for this study. Although all patients had a predicted probability of death of less than 4%, practitioners estimated that 5% of outpatients and 41% of inpatients had an expected 30-day risk of death of more than 5%. Univariate analyses identified 3 practitioner-rated factors that were nearly universally associated with hospitalization: hypoxemia (odds ratio, 173.3; 95% confidence interval, 23.8-1265.0), inability to maintain oral intake (odds ratio, 53.3; 95% confidence interval, 12.8-222.5), and lack of patient home care support (odds ratio, 54.4; 95% confidence interval, 7.3-402.6). In patients without these 3 factors, logistic regression analysis demonstrated that practitioner-estimated risk of death of more than 5% had a strong independent association with hospitalization (odds ratio, 18.4; 95% confidence interval, 6.1-55.7). Practitioners identified home intravenous antibiotic therapy and home nursing observation as services that would have allowed outpatient treatment of more than half (68% and 59%, respectively) of the patients initially hospitalized for treatment. CONCLUSIONS: Practitioners' survey responses suggest that the availability of outpatient intravenous antimicrobial therapy and home nursing care would allow outpatient care for a large proportion of low-risk patients who are hospitalized for community-acquired pneumonia. These data also suggest that methods to improve practitioners' identification of low-risk patients with community-acquired pneumonia could decrease the hospitalization of such patients. Future studies are required to help physicians identify which low-risk patients could safely be treated in the outpatient setting on the basis of clinical information readily available at presentation.

The hospital discharge decision for patients with community-acquired pneumonia. Results from the Pneumonia Patient Outcomes Research Team cohort study.

BACKGROUND: The hospital discharge decision directly influences the length of stay in patients with community-acquired pneumonia, yet no information exists on how physicians make this decision. OBJECTIVES: To identify the factors physicians considered the factors responsible for extending length of hospital stay in clinically stable patients, and the outpatient medical services that would allow earlier hospital discharge for patients with community-acquired pneumonia. METHODS: Physicians responsible for the hospital discharge decision of patients with community-acquired pneumonia were asked to identify the factors responsible for extending stay in patients hospitalized beyond stability, and the medical services that could have allowed earlier hospital discharge to occur. RESULTS: For the 418 eligible patients with community-acquired pneumonia identified during the study, 332 questionnaires (79%) were completed by 168 physicians. Physicians believed 71 patients (22%) were discharged from the hospital 1 day or more (median, 2.5 days) after reaching clinical stability. The most common factors rated as being "very important" in delaying discharge were diagnostic evaluation or treatment of comorbid illness (56%), completion of a "standard course" of antimicrobials (15%), and delays with arrangements for long-term care (14%). Among the 302 patients with available information on both length of hospital stay and stability at discharge, median length of stay was 7.0 days for the 29 low-risk patients hospitalized beyond reaching clinical stability and 5.0 days for the remaining 128 low-risk patients (P < .005); median length of stay was 12.5 days for the 42 medium- and high-risk patients hospitalized beyond reaching clinical stability and 8.0 days in the remaining 113 medium- and high-risk patients (P < .001). Frequently cited medical services that "probably" or "definitely" would have allowed earlier discharge to occur included availability of home intravenous antimicrobial infusion (26%) and home visits by nurses (20%). CONCLUSIONS: Physicians believed that diagnostic evaluation or treatment of comorbid illness, completion of a standard course of antimicrobial therapy, and delays with arrangements for long-term care delayed hospital discharge in clinically stable patients. Addressing the efficiency of these aspects of inpatient medical care, as well as providing home treatment programs, could decrease the length of hospital stay in patients with community-acquired pneumonia.

Community-acquired pneumonia: can it be defined with claims data?

The use of administrative data to study pneumonia is limited because International Classification of Diseases, 9th revision, Clinical Modification (ICD9-CM) diagnosis codes do not specify whether pneumonia is community-acquired (CAP), a key clinical distinction. We classified 212 patients discharged with a diagnosis code for pneumonia as to whether or not they had CAP, using three administrative data-based systems (Diagnosis Related Groups (DRGs) alone, principal diagnosis alone, and a complex algorithm). We examined agreement with classification by clinician chart review. We also compared the length of stay (LOS) and mortality among the CAP populations identified with different methods. Agreement between the clinical review and the three administrative data methods ranged from 86 to 80%. Classification by DRG performed least well. Populations defined by claims data had similar mortality but shorter mean LOS (9.70, 9.40, and 7.91 days for the algorithm, principal diagnosis and DRG methods, respectively) than the clinically defined population (10.85 days). We conclude that studies of CAP using populations identified by claims may underestimate LOS.

Postdoctoral research training of full-time faculty in academic departments of medicine.

This report shows the results of a survey of 5604 faculty in departments of medicine, 4200 of whom had postdoctoral research training. As a follow-up to a previous study of research activity in the same population, this retrospective survey focused on location of training, source of funding, structure of the training program, impact of the training experience on career development, and respondents' recommendations for changes in training programs. A predominant finding is that most postdoctoral training occurred in medical schools, and the primary source of funding was the National Institutes of Health. For faculty members with the MD degree, being an active researcher and principal investigator for a peer-reviewed research grant were associated with length of training. The average length of time between the end of postdoctoral research training and obtaining the first peer-reviewed research grant was 24 months, regardless of length of training, source of training support, training site, or type of academic degree (MD, MD-PhD, or PhD). The results of this survey suggest a tentative formula to be a successful researcher in academic medicine: 2 or more years of postdoctoral research training, including formal course work in the fundamental sciences pertinent to biomedical research; 2 to 3 years of full research support from the academic institution until the first extramural grant is obtained; and commitment of at least 33% of time to research activities. The results also suggest directions for change and improvement in future research training programs.

Validity of hypothalamic-pituitary testing in hyperprolactinemia: prolactin responses to insulin hypoglycemia and arginine.

The release of prolactin (PRL) following insulin tolerance testing (ITT) and arginine infusion was studied in four groups of women: normal volunteers, amenorrheic women with normal PRL levels, and hyperprolactinemic women with and without roentgenographic evidence of pituitary adenoma. Women with normal serum PRL concentrations were found to have an increase in peripheral PRL and both testing modalities. Hyperprolactinemic women, whether or not there was evidence of a pituitary adenoma, did not appear to have a PRL response to either of these tests. Based on the percent change of PRL over basal values, there was a significant difference between the euprolactinemic and hyperprolactinemic groups (p less than 0.01 for insulin and p less than 0.05 for arginine). Our data indicate that in women with hyperprolactinemia neither ITT- nor arginine-induced PRL release can be utilized to discriminate between the presence and absence of an adenoma. This poor PRL response to ITT and arginine in the hyperprolactinemic patients could be the result of hypothalamic dysfunction.

Prolactin-secreting pituitary adenomas: serum and tissue prolactin levels with ultrastructural correlation.

Adenomatous tissue was obtained from 10 women with evidence of prolactin-secreting pituitary adenoma at the time of transsphenoidal removal of the tumor. Tissue levels of prolactin (hPRL) were estimated after extraction and were compared to preoperative peripheral serum levels of hPRL. No correlation was found between the tissue and serum concentrations of hPRL, although high levels of hPRL were found in the tissue extracts. Electron microscopy confirmed active secretion of the individual cells, and the ultrastructural findings were compatible with prolactin-secreting adenomas. Associated with the active secretion was extensive exocytosis of the secretory granules away from the capillary wall. These findings suggest that, although active secretion of hPRL is occurring, large amounts of secreted hPRL are not available for immediate uptake into the capillary plexus; thus a slow absorption of hPRL could be taking place from the adenomatous tissue. These data could explain the failure of provocative tests of hPRL stimulation and inhibition to unequivocally characterize an adenoma in an individual with elevated serum levels of hPRL.