Six underlying health conditions strongly influence mortality based on pneumonia severity in an ageing population of Japan: a prospective cohort study

Abstract

Background: Mortality prediction of pneumonia by severity scores in patients with multiple underlying health conditions has not fully been investigated. This prospective cohort study is to identify mortality-associated underlying health conditions and to analyse their influence on severity-based pneumonia mortality prediction.

Methods: Adult patients with community-acquired pneumonia or healthcare-associated pneumonia (HCAP) who visited four community hospitals between September 2011 and January 2013 were enrolled. Candidate underlying health conditions, including demographic and clinical characteristics, were incorporated into the logistic regression models, along with CURB (confusion, elevated urea nitrogen, tachypnoea, and hypotension) score as a measure of disease severity. The areas under the receiver operating characteristic curves (AUROC) of the predictive index based on significant underlying health conditions was compared to that of CURB65 (CURB and age ≥ 65) score or Pneumonia severity index (PSI). Mortality association between disease severity and the number of underlying health conditions was analysed.

Results: In total 1772 patients were eligible for analysis, of which 140 (7.9%) died within 30 days. Six underlying health conditions were independently associated: home care (adjusted odds ratio, 5.84; 95% confidence interval, CI, 2.28-14.99), recent hospitalization (2.21; 1.36-3.60), age ≥ 85 years (2.15; 1.08-4.28), low body mass index (1.99, 1.25-3.16), neoplastic disease (1.82; 1.17-2.85), and male gender (1.78; 1.16-2.75). The predictive index based on these conditions alone had a significantly or marginally higher AUROC than that based on CURB65 score (0.78 vs 0.66, p = 0.02) or PSI (0.78 vs 0.71, p = 0.05), respectively. Compared to this index, the AUROC of the total score consisting of six underlying health conditions and CURB score (range 0-10) did not improve mortality predictions (p = 0.3). In patients with one or less underlying health conditions, the mortality was discretely associated with severe pneumonia (CURB65 ≥ 3) (risk ratio: 7.24, 95%CI: 3.08-25.13), whereas in patients with 2 or more underlying health conditions, the mortality association with severe pneumonia was not detected (risk ratio: 1.53, 95% CI: 0.94-2.50).

Conclusions: Mortality prediction based on pneumonia severity scores is highly influenced by the accumulating number of underlying health conditions in an ageing society. The validation using a different cohort is necessary to generalise the conclusion.

Keywords: Adult pneumonia; Ageing population; Mortality prediction; Underlying health conditions.

Fig. 1

Enrolment and investigation flow. Enrolment and investigation flow after patients with no chest X ray (CXR) taken and no infiltrate on CXR were excluded, 1772 patients were eligible for the analysis, and 140 patients (7.9%) died within 30 days

Fig. 2

Mortality predictive index based on six underlying health factors had a higher AUROC curve compared with CURB65 and PSI. The AUROC curve of six underlying health factors was significantly higher than that of CURB65 (p = 0.02) and was marginally higher than that of PSI (p = 0.05). CURB65 age ≥ 65 years, Confusion, blood Urea nitrogen ≥7 mmol/L, Respiratory rate > 30 per minute, and Blood pressure < 90 mmHg in systole or ≤ 60 mmHg in diastole, PSI Pneumonia Severity Index, AUROC area under the receiver operating characteristic, CI confidence interval. Six underlying health conditions: age ≥ 85 years, hospitalization ≥2 days in the preceding 90 days, home care (wound care or infusion therapy at home), male gender, neoplastic disease, body mass index < 18.5

Fig. 3

Mortality of mild and severe pneumonia according to the number of six underlying health conditions. The difference of morality between mild and severe pneumonia was not significant in patients with multiple underlying health conditions whereas mortality of severe pneumonia was significantly higher in patients with single or no underlying condition. CURB65 age ≥ 65 years, Confusion, blood Urea nitrogen ≥7 mmol/L, Respiratory rate > 30 per minute, and Blood pressure < 90 mmHg in systole or ≤ 60 mmHg in diastole, N.S. not significant