Search

Importance: Studies have shown that adverse events are associated with increasing inpatient care expenditures, but contemporary data on the association between expenditures and adverse events beyond inpatient care are limited., Objective: To evaluate whether hospital-specific adverse event rates are associated with hospital-specific risk-standardized 30-day episode-of-care Medicare expenditures for fee-for-service patients discharged with acute myocardial infarction (AMI), heart failure (HF), or pneumonia., Design, Setting, and Participants: This cross-sectional study used the 2011 to 2016 hospital-specific risk-standardized 30-day episode-of-care expenditure data from the Centers for Medicare & Medicaid Services and medical record-abstracted in-hospital adverse event data from the Medicare Patient Safety Monitoring System. The setting was acute care hospitals treating at least 25 Medicare fee-for-service patients for AMI, HF, or pneumonia in the United States. Participants were Medicare fee-for-service patients 65 years or older hospitalized for AMI, HF, or pneumonia included in the Medicare Patient Safety Monitoring System in 2011 to 2016. The dates of analysis were July 16, 2017, to May 21, 2018., Main Outcomes and Measures: Hospitals' risk-standardized 30-day episode-of-care expenditures and the rate of occurrence of adverse events for which patients were at risk., Results: The final study sample from 2194 unique hospitals included 44 807 patients (26.1% AMI, 35.6% HF, and 38.3% pneumonia) with a mean (SD) age of 79.4 (8.6) years, and 52.0% were women. The patients represented 84 766 exposures for AMI, 96 917 exposures for HF, and 109 641 exposures for pneumonia. Patient characteristics varied by condition but not by expenditure category. The mean (SD) risk-standardized expenditures were $22 985 ($1579) for AMI, $16 020 ($1416) for HF, and $16 355 ($1995) for pneumonia per hospitalization. The mean risk-standardized rates of occurrence of adverse events for which patients were at risk were 3.5% (95% CI, 3.4%-3.6%) for AMI, 2.5% (95% CI, 2.5%-2.5%) for HF, and 3.0% (95% CI, 2.9%-3.0%) for pneumonia. An increase by 1 percentage point in the rate of occurrence of adverse events was associated with an increase in risk-standardized expenditures of $103 (95% CI, $57-$150) for AMI, $100 (95% CI, $29-$172) for HF, and $152 (95% CI, $73-$232) for pneumonia per discharge., Conclusions and Relevance: Hospitals with high adverse event rates were more likely to have high 30-day episode-of-care Medicare expenditures for patients discharged with AMI, HF, or pneumonia.

Guideline implementation tools are designed to improve uptake of guideline recommendations in clinical settings but do not uniformly accompany the clinical practice guideline documents. Performance measures are a type of guideline implementation tool with the potential to catalyze behavior change and greater adherence to clinical practice guidelines. However, many performance measures suffer from serious flaws in their design and application, prompting the American Thoracic Society (ATS) to define its own performance measure development standards in a previous workshop in 2012. This report summarizes the proceedings of a follow-up workshop convened to advance the ATS's work in performance measure development and guideline implementation. To illustrate the application of the ATS's performance measure development framework, we used the example of a low-tidal volume ventilation performance measure created de novo from the 2017 ATS/European Society of Intensive Care Medicine/Society of Critical Care Medicine mechanical ventilation in acute respiratory distress syndrome clinical practice guideline. We include a detailed explanation of the rationale for the specifications chosen, identification of areas in need of further validity testing, and a preliminary strategy for pilot testing of the performance measure. Pending additional resources and broader performance measure expertise, issuing "preliminary performance measures" and their specifications alongside an ATS clinical practice guideline offers a first step to further the ATS's guideline implementation agenda. We recommend selectively proceeding with full performance measure development for those measures with positive early user feedback and the greatest potential impact in accordance with ATS leadership guidance.

Background: This document provides evidence-based clinical practice guidelines on the management of adult patients with community-acquired pneumonia. Methods: A multidisciplinary panel conducted pragmatic systematic reviews of the relevant research and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology for clinical recommendations. Results: The panel addressed 16 specific areas for recommendations spanning questions of diagnostic testing, determination of site of care, selection of initial empiric antibiotic therapy, and subsequent management decisions. Although some recommendations remain unchanged from the 2007 guideline, the availability of results from new therapeutic trials and epidemiological investigations led to revised recommendations for empiric treatment strategies and additional management decisions. Conclusions: The panel formulated and provided the rationale for recommendations on selected diagnostic and treatment strategies for adult patients with community-acquired pneumonia.

Background: Bronchiectasis is a condition of increasing incidence and prevalence in the United States, defined by the presence of bronchial dilatation on chest-computed tomography. Most patients suffer from chronic daily cough and sputum production. Patients suffering from this disease often have a poor health-related quality of life (HRQoL), with increased morbidity and mortality, and increased health care burden. Little is known about trends in HRQoL among patients with bronchiectasis, therefore, we examined these trends over 2 years using a bronchiectasis-specific HRQoL instrument., Methods: We present data obtained from administering the Quality of Life-Bronchiectasis (QOL-B) questionnaires at three time points: (I) baseline at the time of first visit to the University of Connecticut Center for Bronchiectasis Care; (II) 1 year follow-up; and (III) a 2-year follow-up. Responses from the 36-item questionnaire evaluate eight scales (Physical Functioning, Role Functioning, Vitality, Emotional Functioning, Social Functioning, Treatment Burden, Health Perceptions, and Respiratory Symptoms); scores are standardized on a 0-100 point scale with higher scores indicating better HRQoL., Results: Twenty-six patients provided baseline QOL-B data, with seven lost to follow-up, leaving nineteen patients in the longitudinal study. Statistically significant improvement between the initial visit and the one-year follow-up visit was shown in three of the eight domains: Physical Functioning, Role Functioning, and Health Perceptions. At 2 years, these improved HRQoL scores were generally maintained., Conclusions: This study demonstrates patients with bronchiectasis can demonstrate improved HRQoL after treatment at a specialized care center and these improvements are maintained for most patients 2 years after the initial visit., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Objective: This study compares and contrasts the clinical features of non-cystic fibrosis bronchiectasis with 3 uncommon disorders known to be associated with bronchiectasis but with distinctly different underlying defined pathophysiologic derangements, namely severe alpha-1 antitrypsin deficiency (AATD), common variable immunodeficiency (CVI) and primary ciliary dyskinesia (PCD)., Methods: The Bronchiectasis Research Registry provides a central database for studying patients with non-cystic fibrosis bronchiectasis. This report consists of information from 13 U.S. sites pertaining to the 3 study diagnoses. Patients with AATD (SZ and ZZ phenotypes only), CVI (patients with IgG≤500), PCD (history of physician diagnosed Kartagener's syndrome or PCD), and patients with confirmed absence of the above 3 diagnoses (idiopathic control group) were included in the study. Descriptive statistics were computed for the main demographic and clinical characteristics of the sample stratified by group. Values between the groups were compared using Kruskal-Wallis test, and Chi-squared/ Fisher's exact tests respectively. The significance level was set at 0.05. Software SAS 9.4 was used to perform the statistical analyses., Results: Of the 2170 participants in the database enrolled as of January 2017, 615 respondents had sufficient data and were included in the analyses. Patients with PCD (n=79, mean age 41.9 years [standard deviation (SD)=14.5]) were significantly younger than patients with AATD (n=58, mean age 66.9 [SD=10.7]), CVI (n=18, mean age 66.7 years [SD=10.5]) or the idiopathic group (n=460, mean age 64.2 [SD=15.9]), p <.0001. Compared to other groups, those with PCD had lower pulmonary function (forced expiratory volume in 1 second [FEV 1 ] forced vital capacity [FVC] and FEV1/FVC ratio) ( p <0.01), and a greater proportion of them reported having exacerbations and/or hospitalizations in the past 2 years ( p <0.01). Overall, Pseudomonas aeruginosa and Staphylococcus aureus were the organisms most commonly isolated from sputum. Mycobacterial infection was most commonly reported in those with AATD., Conclusion: This report from the U.S. Bronchiectasis Research Registry compares and contrasts differences in the clinical features of patients suffering from 3 rare conditions, with different underlying causes, to those without. The group with PCD had more symptoms, greater morbidity, lower lung function and more commonly were infected by Pseudomonas aeruginosa . A greater percentage of those with AATD reported mycobacterial lung involvement., Competing Interests: Kenneth Olivier is supported in part by the Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health. Doreen Addrizzo-Harris reports personal fees from AIT Therapeutics and Insmed. Alan Barker is supported in part by a grant provided by the COPD Foundation. Charles Daley is supported in part by a grant provided by the COPD Foundation. Leigh Anne Daniels reports personal fees from Insmed and Spark Partners as well as grants from Zambon and Parion/Vertex. Mark Metersky is supported in part by a grant provided by the COPD Foundation. Anne O’Donnell is supported in part by a grant provided by the COPD Foundation. Matthias Salathe is supported in part by a grant provided by the COPD Foundation. Byron Thomashow reports personal fees from Boehringer Ingelheim, GlaxoSmithKline, and AstraZeneca. Additionally, Byron Thomashow helped co-found the COPD Foundation and served as Board Chairman for the COPD Foundation for several years. Gregory Tino reports personal fees from Bayer, Grifols, Aradigm, and Cipla. Additionally, Gregory Tino is supported in part by a grant provided by the COPD Foundation. Kevin Winthrop reports grants and personal fees from Insmed and Bayer. All other authors have nothing to declare., (JCOPDF © 2019.)

Two recent major guidelines on diagnosis and treatment of ventilator-associated pneumonia (VAP) recommend consideration of local antibiotic resistance patterns and individual patient risks for resistant pathogens when formulating an initial empiric antibiotic regimen. One recommends against invasive diagnostic techniques with quantitative cultures to determine the cause of VAP; the other recommends either invasive or noninvasive techniques. Both guidelines recommend short-course therapy be used for most patients with VAP. Although neither guideline recommends use of procalcitonin as an adjunct to clinical judgment when diagnosing VAP, they differ with respect to use of serial procalcitonin to shorten the length of antibiotic treatment., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Pneumonia is a complex pulmonary disease in need of new clinical approaches. Although triggered by a pathogen, pneumonia often results from dysregulations of host defense that likely precede infection. The coordinated activities of immune resistance and tissue resilience then dictate whether and how pneumonia progresses or resolves. Inadequate or inappropriate host responses lead to more severe outcomes such as acute respiratory distress syndrome and to organ dysfunction beyond the lungs and over extended time frames after pathogen clearance, some of which increase the risk for subsequent pneumonia. Improved understanding of such host responses will guide the development of novel approaches for preventing and curing pneumonia and for mitigating the subsequent pulmonary and extrapulmonary complications of pneumonia. The NHLBI assembled a working group of extramural investigators to prioritize avenues of host-directed pneumonia research that should yield novel approaches for interrupting the cycle of unhealthy decline caused by pneumonia. This report summarizes the working group's specific recommendations in the areas of pneumonia susceptibility, host response, and consequences. Overarching goals include the development of more host-focused clinical approaches for preventing and treating pneumonia, the generation of predictive tools (for pneumonia occurrence, severity, and outcome), and the elucidation of mechanisms mediating immune resistance and tissue resilience in the lung. Specific areas of research are highlighted as especially promising for making advances against pneumonia.

Objectives: Studies on treatment of community-acquired pneumonia (CAP) in China are scarce. We performed a study to investigate empiric antibiotic practices for patients hospitalized with CAP in China and the risk factors for treatment failure., Methods: Data were collected from a national Chinese hospitalization database. Adult patients who were diagnosed with CAP between 1 October 2014 and 30 September 2015 were identified. We studied initial empiric antibiotic regimens, microbiologic sampling, treatment failure, in-hospital mortality and length of hospital stay., Results: We included 18 043 adult patients from 185 hospitals who met all the study inclusion criteria. The most common initial antibiotic regimen for CAP was monotherapy with a fluoroquinolone (14.8%, 2671/18 043). The most common initial antibiotic (used alone or in combination with other antibiotics) was levofloxacin (15.7%, 4597/29 278 (this denominator represents the total number of initial antibiotics)). The microbiologic sampling rate was 26.9% (4851/18 043). A total of 4050 (22.4%) of 18 043 patients experienced treatment failure. Multivariate logistic regression demonstrated that older age, male sex, coexisting lung cancer and use of regimens not covering atypical pathogens were risk factors for treatment failure. In-hospital mortality was 2.1% (380/18 043). The median hospital length of stay was 11 days (interquartile range, 8-15 days)., Conclusions: Patients receiving Chinese guideline-adherent regimens had better outcomes, and atypical pathogen active regimens were associated with a lower treatment failure rate and shorter length of hospital stay., (Copyright © 2017 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Rationale: Staphylococcus aureus is commonly cultured from the sputum of patients with bronchiectasis; however, little is known about the prevalence of the organism in these patients, the characteristics of patients who have grown the organism, or its implications., Objectives: Determine the relationship between S. aureus and pulmonary function, frequency of exacerbations, and frequency of hospitalization in patients with bronchiectasis Methods: The Bronchiectasis Research Registry is a database of adults with non-cystic fibrosis bronchiectasis identified from 13 sites within the United States. Baseline and follow-up demographic, spirometric, microbiologic, and therapeutic data were entered into a central web-based database. Patients were grouped into three cohorts based on their previous respiratory cultures at the time of entry into the Registry: 1) no prior S. aureus or glucose-nonfermenting gram-negative bacilli (NF-GNB) (Pseudomonas, Stenotrophomonas, or Burkholderia spp.); 2) prior S. aureus at least once; or 3) no prior S. aureus but prior NF-GNB at least once. The association between S. aureus isolation and pulmonary function and frequency of exacerbations and hospital admissions was assessed, both at baseline and after 1 year of follow-up., Results: S. aureus was cultured from 94 of 830 patients (11.3%) included in the analysis. Patients who had grown S. aureus before entry into the Registry had a frequency of prior exacerbations and baseline pulmonary function that was between that of patients who had grown NF-GNB and those who had grown neither NF-GNB or S. aureus. Similarly, at the first follow-up visit after study entry, patients who had grown S. aureus had a frequency of exacerbations and hospitalizations that was between those of patients who had grown NF-GNB and those who had grown neither NF-GNB nor S. aureus. However, in multivariate analysis, S. aureus was not associated with pulmonary function, frequency of exacerbation, or hospital admissions. There were no significant differences in patient characteristics or outcomes between patients who had methicillin-sensitive and methicillin-resistant S. aureus., Conclusions: Staphylococcus aureus does not appear to be an independent risk factor for severe disease in patients with bronchiectasis enrolled in the Bronchiectasis Research Registry.

We and our patients have been aware of the high cost of medications in the United States for decades; however, we are now witnessing a relatively new phenomenon: exponential price increases for some older pharmaceuticals that have been available for years. To assist practitioners in how to respond to the issue of higher priced pharmaceuticals, an interprofessional session was developed and held at CHEST 2016 in Los Angeles. The session proceedings and a few updates are presented here to summarize what pulmonologists; a sarcoidosis expert; a retired executive of a medical society, an executive of a pharmaceutical company and of a pharmacy; and an ethicist advise that we do about the problem. Because the comments presented at the session and in this manuscript represent the opinions of each author, this commentary in essence is a compilation of nine editorials. It does not represent a comprehensive discussion of the field of pricing of drugs. In reflecting upon the answers to the questions posed, and regardless of their sector of health care, all participants stated that they focused on the patient. However, actually providing patient-focused care (ie, the care defined from the patient's perspective) is another matter. To significantly improve patient satisfaction and health-care outcomes, patient-focused care needs to embody the 3 Cs of (1) communication, (2) continuity of care, and (3) concordance of expectations (ie, finding the common ground). Therefore, we discuss how the 3 Cs apply to responses to higher priced pharmaceuticals., (Copyright © 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: The beneficial effect of macrolides for the treatment of community-acquired pneumonia (CAP) in combination with beta-lactams may be due to their anti-inflammatory activity. In patients with pneumococcal meningitis, the use of steroids improves outcomes only if they are administered before beta-lactams. The objective of this study was to compare outcomes in hospitalized patients with CAP when macrolides were administered before, simultaneously with, or after beta-lactams., Methods: Secondary data analysis of the Community-Acquired Pneumonia Organization (CAPO) International Cohort Study database. Study groups were defined based on the sequence of administration of macrolides and beta-lactams. The study outcomes were time to clinical stability (TCS), length of stay (LOS) and in-hospital mortality. Accelerated failure time models were used to evaluate the adjusted impact of sequential antibiotic administration and time-to-event outcomes, while a logistic regression model was used to evaluate their adjusted impact on mortality., Results: A total of 99 patients were included in the macrolide before group and 305 in the macrolide after group. Administration of a macrolide before a beta-lactam compared to after a beta-lactam reduced TCS (3 vs. 4 days, p = .011), LOS (6 vs. 7 days, p = .002) and mortality (3 vs. 7.2%, p = .228)., Conclusions: The administration of macrolides before beta-lactams was associated with a statistically significant decrease in TCS and LOS and a non-statistically significant decrease in mortality. The beneficial effect of macrolides in hospitalized patient with CAP may occur only if administered before beta-lactams.

Background: Non-cystic fibrosis bronchiectasis ("bronchiectasis") is a chronic inflammatory lung disease often associated with nontuberculous mycobacteria (NTM) infection. Very little data exist to guide bronchiectasis management decisions. We sought to describe patterns of inhaled corticosteroid (ICS) and antibiotic therapy in the United States., Methods: We invited 2,000 patients through NTM Info & Research (NTMir) to complete an anonymous electronic survey. We separately queried baseline clinical and laboratory data from the US Bronchiectasis and NTM Research Registry (BRR)., Results: Among 511 NTMir survey responders with bronchiectasis, whose median age was 67 years, 85 (17%) reported asthma and 99 (19%) reported COPD. History of ICS use was reported by 282 (55%), 171 (61%) of whom were treated 1 year or longer, and 150 (53%) were currently taking ICSs. Fewer reported ever taking azithromycin for non-NTM bronchiectasis (203 responders [40%]) or inhaled tobramycin (78 responders [15%]). The median age of 1,912 BRR patients was 69 years; 528 (28%) had asthma and 360 (19%) had COPD. Among 740 patients (42%) without NTM, 314 were taking ICSs at baseline. Among patients without NTM who were taking ICSs, only 178 (57%) had a concurrent diagnosis of COPD or asthma that could explain ICS use. Fewer were taking suppressive macrolides (96 patients [13%]), and of the 70 patients (10%) taking inhaled suppressive antibiotics, 48 (68%) had chronic Pseudomonas aeruginosa infection., Conclusions: ICS use was common in two national samples of patients with bronchiectasis, with relatively few patients taking suppressive antibiotic therapies. Further research is needed to clarify the safety and effectiveness of these therapies in patients with bronchiectasis., (Copyright © 2017 American College of Chest Physicians. All rights reserved.)

Purpose of Review: Hospital-acquired pneumonia and ventilator-associated pneumonia remain significant causes of morbidity, mortality, and financial burden in the United States and around the globe. Although guidelines for the management of patients with these conditions have been available for several years, implementation remains challenging. Here, we review the most common barriers faced by clinicians in implementing the current guidelines and offer suggestions for improved adherence., Recent Findings: Recent studies have identified barriers to the implementation of the guidelines regarding management of hospital-acquired and ventilator-associated pneumonia. The most common difficulties encountered are lack of awareness of the guidelines, practice variation among providers delivering care to affected patients, lack of antibiogram information, and lack of antibiotic stewardship programs., Summary: Translating the current hospital-acquired and ventilator-associated pneumonia guidelines to the bedside requires understanding of the current barriers affecting care of patients with these conditions. Adopting clinical guidelines facilitates the management of these patients and improves outcomes. Dissemination of the guidelines, provider education, antibiotic stewardship programs, access to local antibiogram information, audit and feedback, electronic tools and leadership commitment are likely to play important roles in guideline implementation. More studies on hospital-acquired and ventilator-associated pneumonia guideline implementation are necessary to identify the most effective interventions.

Background: It is unclear if bladder catheterization and catheter-associated urinary tract infection (CAUTI) rates have changed since the implementation of public reporting in 2011., Methods: We analyzed data from the Medicare Patient Safety Monitoring System, a national, chart abstraction-based surveillance system, for hospitalized adults with a principal discharge diagnosis of heart failure (HF), acute myocardial infarction (AMI), or pneumonia and patients who had undergone certain major surgeries. We assessed bladder catheterization frequency (percentage of patients catheterized) and risk-adjusted CAUTI frequency (percentage of catheterized patients developing CAUTI) from 2009-2014., Results: Bladder catheterization frequency declined significantly (6.6% for AMI patients, 8.0% for HF patients, and 5.7% for surgical patients). For pneumonia patients, there was a nonsignificant increase of 1.1%. The risk-adjusted CAUTI rate among AMI patients decreased by 9.7% each year relative to the year before. For surgical patients, the decrease was 9.1% per year. There was no significant decline among HF or pneumonia patients. The overall burden of CAUTI among surgical patients was higher than for the other conditions because surgical patients were more likely to be catheterized., Conclusions: There were statistically significant declines in observed bladder catheterization frequency and adjusted CAUTI frequency in some patient populations between 2009 and 2014., (Copyright © 2017 Association for Professionals in Infection Control and Epidemiology, Inc. All rights reserved.)

Background: Many patients hospitalized with pneumonia are treated with combination macrolide/cephalosporin therapy. Macrolides have immunomodulatory effects and do not directly cause bacterial lysis. These effects suggest the possibility that initial treatment with a macrolide before a cephalosporin could improve patient outcomes by preventing the inflammatory response to rapid bacterial lysis that can be caused by cephalosporin treatment. This study explores whether initial treatment for pneumonia with a macrolide before a cephalosporin is associated with better patient outcomes than treatment with a cephalosporin before a macrolide., Methods: This is a retrospective cohort study using a clinically rich database derived from electronic health records of 71 hospitals. We compared outcomes for pneumonia patients who received intravenous treatment with a macrolide at least 1 hour before a cephalosporin, versus patients who received a cephalosporin at least 1 hour before a macrolide. Propensity matching was performed for 527 patients in each group., Results: Among the propensity-matched cohorts, for the macrolide first group, in-hospital mortality was 4.2% vs 5.5% for the cephalosporin first group ( P = .31), combined in-hospital mortality/hospice discharge was 6.3% vs 9.3% ( P = .06), median hospital length of stay was 101.5 hours vs 109.5 hours ( P = .09), and 30-day readmission was 12.9% vs 10.6% ( P = .27)., Conclusions: Treatment of pneumonia with a macrolide before a cephalosporin was not associated with significantly improved outcomes when compared with treatment with a cephalosporin first; however, the lower rate of mortality/discharge to hospice and the large confidence intervals allow for the possibility of a clinically significant benefit.

Purpose of Review: Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) remain important causes of morbidity and mortality in hospitalized patients. New evidence-based guidelines for the diagnosis and treatment of these entities were released by the Infectious Diseases Society of America and the American Thoracic Society in 2016. This review summarizes the recommendations contained within these guidelines and their supporting rationale., Recent Findings: With respect to diagnosis of HAP and VAP, the guidelines suggest using semiquantitative cultures of noninvasively obtained respiratory samples instead of quantitative cultures of invasively obtained samples. With respect to antibiotic treatment, the guidelines separate the treatment approach for VAP and HAP (non-VAP), and stress the importance of devising an appropriate empiric regimen based on an appropriate hospital or unit-specific antibiogram. For VAP, coverage of methicillin-resistant Staphylococcus aureus is recommended only when patients have specific risk factors for multidrug-resistant (MDR) pathogens or in units where greater than 10-20% of Staphylococcus aureus isolates are methicillin resistant. Single coverage for MDR gram-negative pathogens can be used in many HAP and VAP patients without risk factors for MDR pathogens when the antibiogram demonstrates that at least 90% of gram negatives are sensitive to the agent being considered for monotherapy. A 7-day course of antibiotics was recommended for most patients, including those with glucose nonfermenting gram-negative organisms., Summary: New guidelines for the diagnosis and treatment of HAP and VAP contain several novel recommendations regarding the diagnosis and treatment of these entities.

Purpose: Recent data have not demonstrated improved outcomes when guideline-concordant (GC) antibiotics are given to patients with health care-associated pneumonia (HCAP). This study was designed to evaluate the relationship between health outcomes and GC therapy in patients admitted to an intensive care unit (ICU) with HCAP., Materials and Methods: We performed a population-based cohort study of patients admitted to greater than 150 hospitals in the US Veterans Health Administration system to compare baseline characteristics, bacterial pathogens, and health outcomes in ICU patients with HCAP receiving GC-HCAP therapy, GC community-acquired pneumonia (GC-CAP) therapy, or non-GC therapy. The primary outcome was 30-day patient mortality. Risk factors for the primary outcome were assessed in a multivariable logistic regression model., Results: A total of 3593 patients met inclusion criteria and received GC-HCAP therapy (26%), GC-CAP therapy (23%), or non-GC therapy (51%). Patients receiving GC-HCAP had higher 30-day patient mortality compared to GC-CAP patients (34% vs 22%; P< .0001). After controlling for confounders, risk factors for 30-day patient mortality were vasopressor use (odds ratio, 1.67; 95% confidence interval, 1.30-2.13), recent hospital admission (1.53; 1.15-2.02), and receipt of GC-HCAP therapy (1.51; 1.20-1.90)., Conclusions: Our data do not demonstrate improved outcomes among ICU patients with HCAP who received GC-HCAP therapy., Competing Interests: Statements: Russell Attridge: none Christopher Frei: Dr. Frei has received grants outside the submitted work from Bristol Myers Squibb, Pfizer, and Ortho-McNeill Janssen. Mary Jo Pugh: none Kenneth Lawson: none Laurajo Ryan: none Antonio Anzueto: none Mark Metersky: Dr. Metersky has served as a speaker for Pfizer (relationship ended in 2011). Marcos Restrepo: Dr. Restrepo’s time is partially protected by Award Number K23HL096054 from the National Heart, Lung, and Blood Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, And Blood Institute, the National Institutes of Health or the Department of Veterans Affairs. Eric Mortensen: Dr. Mortensen reports grants from NIH received during the conduct of the study., (Published by Elsevier Inc.)

We evaluated whether community-level home health agencies and nursing home performance is associated with community-level hospital 30-day all-cause risk-standardized readmission rates for Medicare patients used data from the Centers for Medicare & Medicaid Service from 2010 to 2012. Our final sample included 2,855 communities that covered 4,140 hospitals with 6,751,713 patients, 13,060 nursing homes with 1,250,648 residents, and 7,613 home health agencies providing services to 35,660 zipcodes. Based on a mixed effect model, we found that increasing nursing home performance by one star for all of its 4 measures and home health performance by 10 points for all of its 6 measures is associated with decreases of 0.25% (95% CI 0.17-0.34) and 0.60% (95% CI 0.33-0.83), respectively, in community-level risk-standardized readmission rates., Competing Interests: Financial Disclosures: The other authors report no conflicts of interest.

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.These guidelines are intended for use by healthcare professionals who care for patients at risk for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), including specialists in infectious diseases, pulmonary diseases, critical care, and surgeons, anesthesiologists, hospitalists, and any clinicians and healthcare providers caring for hospitalized patients with nosocomial pneumonia. The panel's recommendations for the diagnosis and treatment of HAP and VAP are based upon evidence derived from topic-specific systematic literature reviews., (© The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail journals.permissions@oup.com.)

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.These guidelines are intended for use by healthcare professionals who care for patients at risk for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), including specialists in infectious diseases, pulmonary diseases, critical care, and surgeons, anesthesiologists, hospitalists, and any clinicians and healthcare providers caring for hospitalized patients with nosocomial pneumonia. The panel's recommendations for the diagnosis and treatment of HAP and VAP are based upon evidence derived from topic-specific systematic literature reviews., (© The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail journals.permissions@oup.com.)

Background: Little is known regarding the relationship between hospital performance on adverse event rates and hospital performance on 30-day mortality and unplanned readmission rates for Medicare fee-for-service patients hospitalized for acute myocardial infarction (AMI)., Methods and Results: Using 2009-2013 medical record-abstracted patient safety data from the Agency for Healthcare Research and Quality's Medicare Patient Safety Monitoring System and hospital mortality and readmission data from the Centers for Medicare & Medicaid Services, we fitted a mixed-effects model, adjusting for hospital characteristics, to evaluate whether hospital performance on patient safety, as measured by the hospital-specific risk-standardized occurrence rate of 21 common adverse event measures for which patients were at risk, is associated with hospital-specific 30-day all-cause risk-standardized mortality and unplanned readmission rates for Medicare patients with AMI. The unit of analysis was at the hospital level. The final sample included 793 acute care hospitals that treated 30 or more Medicare patients hospitalized for AMI and had 40 or more adverse events for which patients were at risk. The occurrence rate of adverse events for which patients were at risk was 3.8%. A 1% point change in the risk-standardized occurrence rate of adverse events was associated with average changes in the same direction of 4.86% points (95% CI, 0.79-8.94) and 3.44% points (95% CI, 0.19-6.68) for the risk-standardized mortality and unplanned readmission rates, respectively., Conclusions: For Medicare fee-for-service patients discharged with AMI, hospitals with poorer patient safety performance were also more likely to have poorer performance on 30-day all-cause mortality and on unplanned readmissions., (© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: The optimum international normalized ratio (INR) monitoring frequency for hospitalized patients receiving warfarin is unknown., Objective: Assess relationship between daily versus less frequent INR monitoring and overanticoagulation and warfarin-related adverse events., Design: Retrospective cohort study using Medicare Patient Safety Monitoring System data., Setting: Randomly selected acute care hospitals across the United States., Patients: Patients hospitalized from 2009 to 2013 for pneumonia, acute cardiac disease, or surgery who received warfarin., Interventions: None., Measurements: (1) Association between frequency of INR monitoring and an INR ≥6.0 or warfarin-related adverse event. (2) Association between the rate of change of the INR and a subsequent INR ≥5.0 and ≥6.0., Results: Among 8529 patients who received warfarin for ≥3 days, for 1549 (18.2%) the INR was not measured on 2 or more days. These patients had higher propensity-adjusted odds ratios (ORs) of having a warfarin-associated adverse event (OR: 1.48, 95% confidence interval [CI]: 1.02-2.17) for cardiac patients and surgical patients (OR: 1.73, 95% CI: 1.20-2.48), with no significant association for pneumonia patients. Cardiac and pneumonia patients with 1 day or more without an INR measurement had higher propensity-adjusted ORs of having an INR ≥6.0 (OR: 1.61, 95% CI: 1.07-2.41 and OR: 1.92, 95% CI: 1.36-2.71, respectively). A 1-day increase in the INR of ≥0.9 occurred in 621 patients (12.5%) and predicted a subsequent INR of ≥6.0 (positive likelihood ratio of 4.2)., Conclusion: Daily INR measurement and recognition of a rapidly rising INR might decrease the frequency of warfarin-associated adverse events in hospitalized patients., (© 2015 Society of Hospital Medicine.)

Background and Objective: Patients with healthcare-associated pneumonia (HCAP) are at high risk of infection with multidrug-resistant (MDR) pathogens. Factors discriminating infection with MDR Gram-negative (MDR-GN) organism from infection with methicillin-resistant Staphylococcus aureus (MRSA) are not well understood and patients are often treated for both organisms. This study was performed to determine risk factors predicting pneumonia due to Pseudomonas versus MRSA., Methods: Veterans age ≥65 hospitalized with HCAP between 2002 and 2012 were identified from the Veterans Affairs administrative databases. Patients were identified with Pseudomonas pneumonia, MRSA pneumonia or neither according to the International Classification of Diseases, 9th Revision, Clinical Modification codes. We assessed unadjusted and adjusted associations of patient characteristics and HCAP due to Pseudomonas or MRSA., Results: Of the 61,651 patients with HCAP, 1156 (1.9%) were diagnosed with Pseudomonas pneumonia, 641 (1.0%) with MRSA pneumonia and 59,854 (97.1%) with neither. MRSA pneumonia was positively associated with male gender, age >74, diabetes, chronic obstructive pulmonary disease (COPD), recent nursing home or hospital stay, recent exposure to fluoroquinolone or antibiotics treating Gram-positive organisms, and severe pneumonia. MRSA pneumonia was negatively associated with complicated diabetes. Pseudomonas pneumonia was positively associated with recent hospital stay, immunocompromise, COPD, hemiplegia, recent exposure to inhaled corticosteroids, β-lactam/cephalosporin/carbapenem antibiotics, antibiotics against Gram-positive organisms, 'other antibiotics' and severe pneumonia. Pseudomonas pneumonia was negatively associated with age >84, higher socioeconomic status, drug abuse and diabetes., Conclusions: Patient characteristics may assist in identifying patients at risk for HCAP due to Pseudomonas or MRSA., (© 2015 Asian Pacific Society of Respirology.)

Purpose of Review: Patients with noncystic fibrosis bronchiectasis (NCFB) share many of the respiratory symptoms of cystic fibrosis and often are provided therapies effective in cystic fibrosis, often without clear evidence of benefit. There are currently no approved therapies for NCFB, but in recent years, there has been increased interest in developing new therapies due to the increasing prevalence and perceived unmet needs. This review is meant to provide the most recent information to clinicians about currently available and pipeline therapies for NCFB., Recent Findings: Inhaled antibiotics may provide effective bacterial suppressive therapy with an acceptable safety profile in adults with NCFB, although evidence of improved outcomes is limited. Inhaled hyperosmolar agents such as hypertonic saline and mannitol are promising but study results have been mixed. Macrolide antibiotics have anti-inflammatory properties and, in several randomized controlled trials, demonstrated the benefit of chronic low-dose treatment. Other anti-inflammatory agents that have shown promising preliminary results include statins and neutrophil elastase inhibitors., Summary: There is high-quality evidence supporting chronic low-dose macrolide therapy in patients with NCFB. There is limited evidence of benefit of other therapies, including inhaled antibiotics and pharmacologic agents to enhance mucus clearance.

Objective: To define the relationships between age, sex and hospital-acquired infection (HAI) rates in a national cohort of hospitalized patients., Methods: Analysis of chart-abstracted Medicare Patient Safety Monitoring System data from randomly selected medical records of patients hospitalized between January 1, 2009, and December 31, 2011, for acute cardiovascular disease, pneumonia, or major surgery associated with 1 of 6 HAIs. Patients were stratified into 6 groups. We then analyzed the association of age, sex, and 2 outcomes; the rate of occurrence of HAI for patients who were at risk and the rate of patients having at least 1 HAI., Results: Among 85,461 patients, all groups except younger female surgical patients had higher catheter-associated urinary tract infection (CAUTI) rates than male patients. After adjustment for comorbidities, there was no overall evidence of higher HAI rates among elderly patients. In patients with acute cardiovascular disease, women had higher rates of HAIs. Among patients with pneumonia, there was no significant difference in the rate of HAIs among most age and sex groups. Among surgical patients, all age and sex groups had a significantly higher adjusted rate of developing at least 1 HAI except females 65 years of age or older. Similar results were seen for the outcome of the occurrence rate of HAIs., Conclusions: There was not an overall increased risk of HAIs among older patients hospitalized for acute cardiovascular disease, pneumonia, and major surgery after adjustment for comorbidities. The relationship between sex and the rate of HAIs varied depending upon the underlying acute reason for hospitalization.

Background: Little is known about racial and ethnic disparities in the occurrence of healthcare-associated infections (HAIs) in hospitalized patients., Objective: To determine whether racial/ethnic disparities exist in the rate of occurrence of HAIs captured in the Medicare Patient Safety Monitoring System (MPSMS)., Methods: Chart-abstracted MPSMS data from randomly selected all-payer hospital discharges of adult patients (18 years old or above) between January 1, 2009, and December 31, 2011, for 3 common medical conditions: acute cardiovascular disease (composed of acute myocardial infarction and heart failure), pneumonia, and major surgery for 6 HAI measures (hospital-acquired antibiotic-associated Clostridium difficile, central line-associated bloodstream infections, postoperative pneumonia, catheter-associated urinary tract infections, hospital-acquired methicillin-resistant Staphylococcus aureus, and ventilator-associated pneumonia)., Results: The study sample included 79,019 patients who had valid racial/ethnic information divided into 6 racial/ethnic groups-white non-Hispanic (n = 62,533), black non-Hispanic (n = 9,693), Hispanic (n = 4,681), Asian (n = 1,225), Native Hawaiian/Pacific Islander (n = 94), and other (n = 793)-who were at risk for at least 1 HAI. The occurrence rate for HAIs was 1.1% for non-Hispanic white patients, 1.3% for non-Hispanic black patients, 1.5% for Hispanic patients, 1.8% for Asian patients, 1.7% for Native Hawaiian/Pacific Islander patients, and 0.70% for other patients. Compared with white patients, the age/gender/comorbidity-adjusted odds ratios of occurrence of HAIs were 1.1 (95% confidence interval [CI], 0.99-1.23), 1.3 (95% CI, 1.15-1.53), 1.4 (95% CI, 1.07-1.75), and 0.7 (95% CI, 0.40-1.12) for black, Hispanic, Asian, and a combined group of Native Hawaiian/Pacific Islander and other patients, respectively., Conclusions: Among patients hospitalized with acute cardiovascular disease, pneumonia, and major surgery, Asian and Hispanic patients had significantly higher rates of HAIs than white non-Hispanic patients.

Background: The Quality of Life Questionnaire-Bronchiectasis (QOL-B) is the first disease-specific, patient-reported outcome measure for patients with bronchiectasis. Content validity, cognitive testing, responsivity to open-label treatment, and psychometric analyses are presented., Methods: Reviews of literature, existing measures, and physician input were used to generate the initial QOL-B. Modifications following preliminary cognitive testing (N = 35 patients with bronchiectasis) generated version (V) 1.0. An open-ended patient interview study (N = 28) provided additional information and was content analyzed to derive saturation matrices, which summarized all disease-related topics mentioned by each participant. This resulted in QOL-B V2.0. Psychometric analyses were carried out using results from an open-label phase 2 trial, in which 89 patients were enrolled and treated with aztreonam for inhalation solution. Responsivity to open-label treatment was observed. Additional analyses generated QOL-B V3.0, with 37 items on eight scales: respiratory symptoms; physical, role, emotional, and social functioning; vitality; health perceptions; and treatment burden. For each scale, scores are standardized on a 0-to-100-point scale; higher scores indicate better health-related quality of life. No total score is calculated. A final cognitive testing study (N = 40) resulted in a minor change to one social functioning scale item (QOL-B V3.1)., Results: Content validity, cognitive testing, responsivity to open-label treatment, and initial psychometric analyses supported QOL-B items and structure., Conclusions: This interim QOL-B is a promising tool for evaluating the efficacy of new therapies for patients with bronchiectasis and for measuring symptoms, functioning, and quality of life in these patients on a routine basis. A final psychometric validation study is needed and is forthcoming., Trial Registry: ClinicalTrials.gov; No.: NCT00805025; URL: www.clinicaltrials.gov.

Background: Mortality after pneumonia in immunocompromised patients is higher than for immunocompetent patients. The use of non-invasive mechanical ventilation for patients with severe pneumonia may provide beneficial outcomes while circumventing potential complications associated with invasive mechanical ventilation. The aim of our study was to determine if the use of non-invasive mechanical ventilation in elderly immunocompromised patients with pneumonia is associated with higher all-cause mortality., Methods: In this retrospective cohort study, data were obtained from the Department of Veterans Affairs administrative databases. We included veterans age ≥65 years who were immunocompromised and hospitalized due to pneumonia. Multilevel logistic regression analysis was used to determine the relationship between the use of invasive versus non-invasive mechanical ventilation and 30-day and 90-day mortality., Results: Of 1,946 patients in our cohort, 717 received non-invasive mechanical ventilation and 1,229 received invasive mechanical ventilation. There was no significant association between all-cause 30-day mortality and non-invasive versus invasive mechanical ventilation in our adjusted model (odds ratio (OR) 0.85, 95% confidence interval (CI) 0.66-1.10). However, those patients who received non-invasive mechanical ventilation had decreased 90-day mortality (OR 0.66, 95% CI 0.52-0.84). Additionally, receipt of guideline-concordant antibiotics in our immunocompromised cohort was significantly associated with decreased odds of 30-day mortality (OR 0.31, 95% CI 0.24-0.39) and 90-day mortality (OR 0.41, 95% CI 0.31-0.53)., Conclusions: Our findings suggest that physicians should consider the use of non-invasive mechanical ventilation, when appropriate, for elderly immunocompromised patients hospitalized with pneumonia.

Background: Changes in adverse-event rates among Medicare patients with common medical conditions and conditions requiring surgery remain largely unknown., Methods: We used Medicare Patient Safety Monitoring System data abstracted from medical records on 21 adverse events in patients hospitalized in the United States between 2005 and 2011 for acute myocardial infarction, congestive heart failure, pneumonia, or conditions requiring surgery. We estimated trends in the rate of occurrence of adverse events for which patients were at risk, the proportion of patients with one or more adverse events, and the number of adverse events per 1000 hospitalizations., Results: The study included 61,523 patients hospitalized for acute myocardial infarction (19%), congestive heart failure (25%), pneumonia (30%), and conditions requiring surgery (27%). From 2005 through 2011, among patients with acute myocardial infarction, the rate of occurrence of adverse events declined from 5.0% to 3.7% (difference, 1.3 percentage points; 95% confidence interval [CI], 0.7 to 1.9), the proportion of patients with one or more adverse events declined from 26.0% to 19.4% (difference, 6.6 percentage points; 95% CI, 3.3 to 10.2), and the number of adverse events per 1000 hospitalizations declined from 401.9 to 262.2 (difference, 139.7; 95% CI, 90.6 to 189.0). Among patients with congestive heart failure, the rate of occurrence of adverse events declined from 3.7% to 2.7% (difference, 1.0 percentage points; 95% CI, 0.5 to 1.4), the proportion of patients with one or more adverse events declined from 17.5% to 14.2% (difference, 3.3 percentage points; 95% CI, 1.0 to 5.5), and the number of adverse events per 1000 hospitalizations declined from 235.2 to 166.9 (difference, 68.3; 95% CI, 39.9 to 96.7). Patients with pneumonia and those with conditions requiring surgery had no significant declines in adverse-event rates., Conclusions: From 2005 through 2011, adverse-event rates declined substantially among patients hospitalized for acute myocardial infarction or congestive heart failure but not among those hospitalized for pneumonia or conditions requiring surgery. (Funded by the Agency for Healthcare Research and Quality and others.).

Purpose: Studies have found different rates of antimicrobial resistance among patients in medical and surgical intensive care units (ICUs). We studied whether these differences were a function of geography or differences in the patient populations, by comparing resistance rates among bacteria isolated from a combined medical/surgical ICU., Materials and Methods: We retrospectively evaluated the results of bacterial cultures of each patient admitted to the ICU between February 2005 and September 2006. Data collection included patient demographics and culture and sensitivity results. Intensive care unit populations were compared using the Fisher exact test and the Student t test., Results: One hundred seventy-one medical and 94 surgical patients with positive cultures were studied. Organisms were grouped into 4 classes: Staphylococcus aureus, nonlactose fermenting gram-negative bacilli, Enterococcus species, and gram-negative enteric bacteria. In the 4 classes, no significant difference in antibiotic resistance was found between medical and surgical patients., Conclusion: Reported differences in resistance patterns among bacteria cultured from medical and surgical patients may be due to geographic separation of the ICUs as opposed to differences in the patient characteristics. This study suggests that ICU-specific antibiograms remain a useful tool to guide the choice of antimicrobial therapy, even in medical/surgical ICUs., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To determine the effect of bosentan on subjects with poorly controlled asthma., Methods: This was a double-blind, placebo-controlled crossover pilot study. Subjects were poorly controlled on anti-inflammatory and long acting β-agonist therapy, and had a baseline forced expiratory volume in 1 second (FEV1) percent of predicted of 40 -70%. Subjects were randomized to receive either bosentan or placebo at the therapeutic dose of 125 mg twice a day for 4 weeks, and then crossed over to the alternate therapy. The asthma control test, asthma symptom scores, rescue albuterol use, and FEV1 were measured at baseline and during the last week of bosentan and placebo. Acute changes in FEV1 were measured after the initial therapeutic bosentan and placebo dose., Results: Seven of eleven randomized subjects completed the protocol. There was no difference in change in FEV1 after the bosentan phase when compared with placebo (+0.08 ± 0.31 L and +0.23 ± 0.26 L p = .34). Changes from baseline values in the asthma control test and asthma symptom scores were also similar in bosentan and placebo phases (+1.71 ± 3.99 and +4.57 ± 4.39 p = .16) and (+0.14 ± 9.3 and -0.29 ± 5.28 p = .93). Rescue β-agonist use did not change significantly during the last week of the bosentan phase when compared with placebo phase (-5.86 ± 0.94 puffs and -5.14 ± 16.85 puffs p = .94). Additionally, there was no difference in the change in FEV1 4 hours after bosentan 125 mg and placebo (-0.08 L ± 0.07 vs. +0.04 L ± 0.20 p = .20)., Conclusions: In this pilot study, 4 weeks of bosentan did not improve FEV1, β-agonist use, asthma symptom score, or asthma control test score in patients with poorly controlled asthma when compared with placebo.

Health care-associated pneumonia (HCAP) is associated with an increased risk of infection with multidrug-resistant pathogens compared with community-acquired pneumonia. Recent studies suggest that the designation of HCAP is a poor predictor of resistant pathogens and that antibiotic coverage for multidrug-resistant pathogens is not necessary in all patients with HCAP. This article reviews existing literature on HCAP, discusses the utility of the current definition of HCAP in identifying patients at risk for potentially drug-resistant pathogens, and compares how well the current HCAP designation predicts the risk of drug-resistant pathogens with other proposed algorithms for doing so., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Introduction: Hypersensitivity pneumonitis (HP) is a rare adverse event with flavocoxid (Limbrel) use. Patients present with nonspecific symptoms after exposure to an inciting agent., Case Presentation: A 42-year-old female presented with worsening dyspnea on exertion and pleuritic midsternal chest pain. Her symptoms failed to abate with outpatient azithromycin for a diagnosis of community-acquired pneumonia. She was seen again at the emergency department (ED) due to symptom progression and exertional hypoxia. Chest reoentgenogram (x-ray) and computed tomography (CT) chest revealed bilateral infiltrates. Her history was significant for initiation of flavocoxid (Limbrel) two weeks prior, and a diagnosis of hypersensitivity pneumonitis was made. Once flavocoxid was discontinued, symptoms and radiologic studies improved without requiring biopsy or steroids., Conclusion: Hypersensitivity pneumonitis is associated with many pharmacological agents and is challenging to diagnose, given nonspecific symptoms and radiologic findings. In the absence of specific indications to use corticosteroids, symptoms of HP might resolve with cessation of the offending agent, as proven by this case.

As health care expenditures increase, payers, including the Centers for Medicare and Medicaid Services, are moving away from reimbursement based on types and volume of services to an emphasis on quality of provided care, an approach called value-based purchasing (VBP). Because it is tied to reimbursement, VBP creates economic motivation to measure and improve care. VBP is proceeding without high-level evidence supporting its effectiveness in improving health care quality. Rising health care costs, however, make VBP an attractive approach for curtailing costs and emphasizing improved quality, and VBP is likely to become a more prevalent mechanism of reimbursement for providers and facilities., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Bronchiectasis is classically defined as irreversible bronchial dilatation that represents the sequelae of chronic airway inflammation and is permanent, reflecting the presence of bronchiectasis. It is increasingly being recognized with the wider availability of high-resolution computed tomography. In contrast to adults, children with noncystic fibrosis bronchiectasis may have resolution or significant improvement in bronchial dilatation. We report a case of reversible bronchial dilatation in an adult as evidenced by high-resolution computed tomography, which demonstrates that, although quite rare in adults, spontaneous resolution may occur.

Background: Although marital status has been shown to affect the outcomes of many conditions, there are limited data on the relationships between marital status and the presentation and outcomes of pneumonia., Methods: We used Veterans Affairs administrative databases to identify a retrospective cohort of male veterans age ≥ 65 years hospitalized for pneumonia between 2002 and 2007. We assessed unadjusted and adjusted associations between marital status and mortality, hospital length of stay, and readmission to the hospital using generalized linear mixed-effect models with admitting hospital as a random effect and adjusted for baseline patient characteristics., Results: There were 48,635 patients (26,558 married and 22,077 unmarried) in the study. Married men had a slightly higher Charlson comorbidity score (3.0 vs 2.8, P < .0001) but were less likely to require ICU admission, ventilator support, and vasopressor treatment during the first 48 h of hospitalization. Married patients had significantly lower crude and adjusted in-hospital mortality (9.4% vs 10.6%; adjusted OR, 0.87; 95% CI, 0.81-0.93) and mortality during the 90 days after hospital discharge (14.7% vs 16.0%; adjusted OR, 0.92; 95% CI, 0.88-0.98). Their adjusted incidence rate ratio length of stay was also lower (0.92; 95% CI, 0.91-0.92)., Conclusions: Unmarried elderly men admitted to the hospital with pneumonia have a higher risk of in-hospital and postdischarge mortality, despite having a lower degree of comorbidity. Although marital status may be a surrogate marker for other predictors, it is an easily identifiable one. These results should be considered by those responsible for care-transition decisions for patients hospitalized with pneumonia.