Community-Acquired Pneumonia In-Hospital Deaths Are Not Indicative of Lapse in Care

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Pre-existing end-of-life limitations, comorbidities, and advanced age were common in patients with community-acquired pneumonia who died.
Pre-existing end-of-life limitations, comorbidities, and advanced age were common in patients with community-acquired pneumonia who died.

Deaths in adults with community-acquired pneumonia (CAP) at tertiary-care hospitals with a low mortality rate were not preventable with current medical therapy, according to the results of a study published in CHEST.

Hospitalization with CAP carries a high risk for mortality. However, it is not apparent whether improvements in pneumonia care would significantly reduce mortality in US hospitals.

To better understand why patients admitted with CAP die in the hospital, Grant W. Waterer, MBBS, PhD, of the University of Western Australia in Perth, and Northwestern University Feinberg School of Medicine in Chicago, Illinois, and colleagues evaluated all in-hospital deaths in a large, prospective study of CAP in the United States to identify the cause of each death and whether or not that death was preventable. 

The investigators enrolled adults hospitalized with CAP at 5 tertiary-care hospitals in the United States and reviewed medical records and the study database for each patient who died to identify the cause of death, the role of CAP in the death, and possible preventable factors that may have contributed to the death.

Of the 2320 enrolled patients, 52 (2.2%) died during the initial hospitalization. Most of the patients who died — 63.4% — were 65 or older and most (61.5%) had 2 or more chronic comorbidities. In 51.9% of these deaths, CAP was the direct cause.  In addition, 10 patients had do-not-resuscitate orders prior to admission. A lapse in quality of care that could have contributed to death was identified in 4 patients, 2 of whom had pre-existing end-of-life limitations. Thus, 2 patients were identified with a lapse in quality of in-hospital pneumonia care that potentially contributed to their deaths.

The low mortality rate and high compliance with CAP guidelines found in this study point toward the specific expertise at these 5 centers. However, the low mortality rate also reflects one of the study's limitations: the requirement for informed consent may have dissuaded some patients at high risk for death from participating in the study.

The investigators concluded that most in-hospital deaths were not preventable with current medical therapy. In patients who died, pre-existing end-of-life limitations, comorbidities, and advanced age were common. The researchers suggested that future studies should be conducted in more diverse settings and that the cause of death should be carefully noted, as well as whether or not care was delivered in accordance with international guidelines, the presence and severity of comorbidities, and whether or not end-of-life limitations were in place at admission.

Reference

Waterer GW, Self WH, Courtney M, et al. In-hospital deaths among adults with community-acquired pneumonia [published online May 30, 2018]. CHEST.doi:10.1016/j.chest.2018.05.021

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