Showing papers by "Michael J. Fine published in 1996"

Prognosis and Outcomes of Patients With Community-Acquired Pneumonia: A Meta-analysis

Abstract: Objective. —To systematically review the medical literature on the prognosis and outcomes of patients with community-acquired pneumonia (CAP). Data Sources. —A MEDLINE literature search of English-language articles involving human subjects and manual reviews of article bibliographies were used to identify studies of prognosis in CAP. Study Selection. —Review of 4573 citations revealed 122 articles (127 unique study cohorts) that reported medical outcomes in adults with CAP. Data Extraction. —Qualitative assessments of studies' patient populations, designs, and patient outcomes were performed. Summary univariate odds ratios (ORs) and rate differences (RDs) and their associated 95% confidence intervals (Cls) were computed to estimate a summary effect size for the association of prognostic factors and mortality. Data Synthesis. —The overall mortality for the 33148 patients in all 127 study cohorts was 13.7%, ranging from 5.1% for the 2097 hospitalized and ambulatory patients (in six study cohorts) to 36.5% for the 788 intensive care unit patients (in 13 cohorts). Mortality varied by pneumonia etiology, ranging from less than 2% to greater than 30%. Eleven prognostic factors were significantly associated with mortality using both summary ORs and RDs: male sex (OR=1.3; 95% Cl, 1.2 to 1.4), pleuritic chest pain (OR=0.5; 95% Cl, 0.3 to 0.8), hypothermia (OR=5.0; 95% Cl, 2.4 to 10.4), systolic hypotension (OR=4.8; 95% Cl, 2.8 to 8.3), tachypnea (OR=2.9; 95% Cl, 1.7 to 4.9), diabetes mellitus (OR=1.3; 95% Cl, 1.1 to 1.5), neoplastic disease (OR=2.8; 95% Cl, 2.4 to 3.1), neurologic disease (OR=4.6; 95% Cl, 2.3 to 8.9), bacteremia (OR=2.8; 95% Cl, 2.3 to 3.6), leukopenia (OR=2.5; 95% Cl, 1.6 to 3.7), and multilobar radiographic pulmonary infiltrate (OR=3.1; 95% Cl, 1.9 to 5.1). Assessments of other clinically relevant medical outcomes such as morbid complications (41 cohorts), symptoms resolution (seven cohorts), return to work or usual activities (five cohorts), or functional status (one cohort) were infrequently performed. Conclusions. —Mortality for patients hospitalized with CAP was high and was associated with characteristics of the study cohort, pneumonia etiology, and a variety of prognostic factors. Generalization of these findings to all patients with CAP should be made with caution because of insufficient published information on medical outcomes other than mortality in ambulatory patients. ( JAMA . 1995;274:134-141)

Preferences for Home vs Hospital Care Among Low-Risk Patients With Community-Acquired Pneumonia

Abstract: Objective: To measure preferences for initial outpatient vs hospital care among low-risk patients who were being actively treated for community-acquired pneumonia (CAP). Methods: Study patients included 159 patients with CAP, 57 (36%) initially hospitalized, who were identified as being at low risk for early mortality using a validated prediction model. Subjects were enrolled from university and community health care facilities located in Boston, Mass, Halifax, Nova Scotia, and Pittsburgh, Pa, participating in the Pneumonia Patient Outcome Research Team prospective cohort study of CAP. Three utility assessment techniques (category scaling, standard gamble, and willingness to pay) were used to measure the strength of patient preferences for the site of care for low-risk CAP. At the time of initial therapy or during the early recuperative period, patient preferences were assessed across a spectrum of potential clinical outcomes using 7 standardized pneumonia clinical vignettes. Results: Responses to the 7 pneumonia scenarios indicated that most patients consistently preferred outpatient-based therapy. This pattern was observed regardless of whether patients had actually been treated initially at home or in a hospital. Patients (74%) who stated that they generally preferred home care for low-risk CAP were willing to pay a mean of 24% of 1 month's household income to be assured of this preference. Preference for home care, as measured by the category scaling and the willingness to pay, persisted after adjustment for sociodemographic and baseline health status covariates. Sixty-nine percent of interviewed patients said that their physician alone determined whether they would be treated in the hospital or at home. Only 11% recalled being asked if they had a preference for either site of care. Conclusions: Most patients, even those treated initially in a hospital, who were at low risk for mortality from CAP prefer outpatient treatment. However, most physicians appear not to involve patients in the site-of-care decision. More explicit discussion of patient preferences for the location of care would likely yield more highly valued care by patients, as well as less costly treatment for CAP. Arch Intern Med. 1996;156:1565-1571

Do pulmonary radiographic findings at presentation predict mortality in patients with community-acquired pneumonia?

Abstract: Background: Previous studies have reported conflicting results on whether pulmonary radiographic findings predict mortality for patients with community-acquired pneumonia (CAP). Objective: To determine whether pulmonary radiographic findings at presentation are independently associated with 30-day mortality in patients with suspected CAP. Methods: This study was conducted as part of the Pneumonia Patient Outcomes Research Team multicenter, prospective cohort study of ambulatory and hospitalized patients with clinical and radiographic evidence of CAP. For each patient with CAP, a structured data form was completed by a panel of radiologists to evaluate the radiographic pattern of infiltrate, number of lobes involved, presence of pleural effusion, and 8 other radiographic characteristics. Cox proportional hazards models were used to evaluate the independent association between radiographic findings and 30-day mortality, while controlling for patient demographic, clinical, and laboratory characteristics with a known association with this outcome. Results: Of 2287 patients enrolled in the Pneumonia Patient Outcomes Research Team cohort study, 1906 patients (83.3%) had a pulmonary radiographic infiltrate confirmed by the radiology panel. Overall, 30-day mortality in this cohort was 4.9%. Univariate regression analyses demonstrated the following radiographic characteristics to be significantly associated with 30-day mortality: (1) bilateral pleural effusions (risk ratio [RR], 7.0; 95% confidence interval [CI], 3.9-12.6); (2) a pleural effusion of moderate or greater size (RR, 3.4; 95% CI, 1.4-8.4); (3) 2 or more lobes involved with infiltrate (RR, 2.5; 95% CI, 1.6-3.8); (4) bilateral infiltrate (RR, 2.8; 95% CI, 1.9-4.2); (5) bronchopneumonia (RR, 1.6; 95% CI, 1.0-2.7); and (6) air bronchograms (RR, 0.5; 95% CI, 0.2-0.9). Multivariate analysis of radiographic features and other clinical characteristics showed the presence of bilateral pleural effusions (RR, 2.8; 95% CI, 1.4-5.8) was independently associated with mortality. Conclusions: In patients with CAP, the presence of bilateral pleural effusions is an independent predictor of short-term mortality. This finding, which is available at presentation, can help guide physicians' assessment of prognosis in CAP. Arch Intern Med. 1996;156:2206-2212

An assessment of the use of the continuity correction for sparse data in meta-analysis

Abstract: A problem which occurs in the practice of meta-analysis is that one or more component studies may have sparse data, such as zero events in the treatment and control groups. Two possible approaches were explored using simulations. The corrected method, in which one half was added to each cell was compared to the uncorrected method. These methods were compared over a range of sparse data situations in terms of coverage rates using three summary statistics:the Mantel-Haenszel odds ratio and the dersimonian and Laird odds ratio and rate difference. The uncorrected method performed better only when using the Mantel-Haenszel odds ratio with very little heterogeneity present. For all other sparse data applications, the continuity correction performed better and is recommended for use in meta-analyses of similar scope

Hospitalized pneumonia. Outcomes, treatment patterns, and costs in urban and rural areas.

Abstract: Objectives To describe discharge rates, geographic and patient characteristics, treatment patterns, costs, and outcomes of patients hospitalized with community-acquired pneumonia (CAP) in Pennsylvania hospitals and compare these patients from rural and urban counties. Design A retrospective database study. Patients Adult patients (age > or = 18) with an ICD-9-CM diagnosis of pneumonia discharged from 193 Pennsylvania hospitals (n = 36,222) in 1991 from the MediQual Systems Pennsylvania database. Measurements Patient characteristics included a pneumonia-specific severity index, microbiologic etiology, and a number of comorbid conditions. Treatment indicators included the specialty of the admitting physician, length of stay, admittance to an intensive care unit, and mechanical ventilation. Cost indicators included charges and estimated costs. Outcomes measured were inpatient mortality and discharge disposition. Counties in Pennsylvania were classified into seven urban or rural groups, and patients were classified by the county of residence. Results The discharge rate for CAP was 4.0 per 1,000 and did not vary systematically across urban or rural counties. Most patients were treated in local hospitals. The average distance between residence and hospital was 5.4 miles and varied with urban or rural classification (range 2.5-9.3 miles). Among CAP patients, 37.8% were at low risk of mortality, with no systematic differences across rural or urban patients with respect to pneumonia severity. Rural patients were more likely to be treated by a family physician and somewhat less likely to be admitted to an intensive care unit or to be mechanically ventilated. Costs of treating rural patients were lower. In-hospital mortality rates, with controls for admission severity, were comparable or better for rural patients than for urban patients. Conclusions Patients with CAP are treated in hospitals located in counties similar to ones in which they reside. The cost of treatment was lower for rural patients than for urban patients, but outcomes were not different.