Association of Diagnostic Coding With Trends in Hospitalizations and Mortality of Patients With Pneumonia, 2003-2009
Association of Diagnostic Coding With Trends in Hospitalizations and Mortality of Patients With Pneumonia, 2003-2009
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DOI：
10.1001/jama.2012.384
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发表时间：
2012-04-04
影响因子：
120.7
通讯作者：
Rothberg, Michael B.
中科院分区：
文献类型：
--
作者：
Lindenauer, Peter K.;Lagu, Tara;Rothberg, Michael B.
背景最近的报告表明，肺炎住院患者的死亡率稳步下降。虽然这可能是临床护理的进步或质量提高的结果，但它也可能是诊断代码变化的产物。目的比较两种病例定义方法对肺炎患者住院和住院死亡率趋势的估计：一种方法仅限于主要诊断为肺炎的患者，另一种方法包括主要诊断为败血症或呼吸衰竭的肺炎患者。设计、设置和参与者趋势研究使用2003-2009年全国住院患者样本发布的数据。主要结果衡量年度住院率和住院患者死亡率随时间的变化。结果：主要诊断为肺炎的患者的年住院率下降了27.4%，从5.5‰下降到4.0‰，而年龄和性别调整后的死亡率从5.8%下降到4.2%(绝对风险降低[ARR]，1.6%；95%可信区间1.4%~1.9%；相对风险降低28.2%；95%可信区间25.2%~31.2%)。在同一时期，主要诊断为败血症和继发肺炎的患者的住院率从177.6.4‰上升到1.1‰，而住院死亡率从25.1%下降到22.2%(ARR，3.0%；95%CI，1.6%-4.4%；RRR，12%；95%CI，7.5%-16.1%)；主要诊断为呼吸衰竭和继发肺炎的患者的住院率从0.44/1000上升到0.48/1000，死亡率从25.1%下降到19.2%(ARR，6.0%；95%CI，4.6%-7.3%；RRR，23.7%；95%CI，19.7%-27.8%)。然而，当3组合并使用时，住院率仅下降12.5%，从6.3/1000降至5.6/1000，而调整年龄和性别的住院死亡率从8.3%上升至8.8%(AR增加，0.5%；95%CI，0.1%~0.9%；RR增加，6.0%；95%CI，3.3%~8.8%)。在同一时间段内，年龄、性别和合并症调整后的死亡率从8.3%下降到7.8%(ARR，0.5%；95%CI，0.2%-0.9%；RRR，6.3%；95%CI，3.8%-8.8%)。结论从2003年到2009年，主要诊断为肺炎的患者的住院和住院死亡率大幅下降，而主要诊断为败血症或呼吸衰竭合并肺炎的住院人数增加，死亡率下降。然而，当三种肺炎诊断结合在一起时，住院率的下降得到了缓解，住院死亡率几乎没有变化，这表明这些结果与诊断编码的时间趋势有关。贾玛2012；307(13)：1405-1413
Context Recent reports suggest that the mortality rate of patients hospitalized with pneumonia has steadily declined. While this may be the result of advances in clinical care or improvements in quality, it may also represent an artifact of changes in diagnostic coding.Objective To compare estimates of trends in hospitalizations and inpatient mortality among patients with pneumonia using 2 approaches to case definition: one limited to patients with a principal diagnosis of pneumonia, and another that includes patients with a secondary diagnosis of pneumonia if the principal diagnosis is sepsis or respiratory failure.Design, Setting, and Participants Trends study using data from the 2003-2009 releases of the Nationwide Inpatient Sample.Main Outcome Measures Change in the annual hospitalization rate and change in inpatient mortality over time.Results From 2003 to 2009, the annual hospitalization rate for patients with a principal diagnosis of pneumonia declined 27.4%, from 5.5 to 4.0 per 1000, while the age-and sex-adjusted mortality decreased from 5.8% to 4.2% (absolute risk reduction [ARR], 1.6%; 95% CI, 1.4%-1.9%; relative risk reduction [RRR], 28.2%; 95% CI, 25.2%-31.2%). Over the same period, hospitalization rates of patients with a principal diagnosis of sepsis and a secondary diagnosis of pneumonia increased 177.6% from 0.4 to 1.1 per 1000, while inpatient mortality decreased from 25.1% to 22.2% (ARR, 3.0%; 95% CI, 1.6%-4.4%; RRR, 12%; 95% CI, 7.5%-16.1%); hospitalization rates for patients with a principal diagnosis of respiratory failure and a secondary diagnosis of pneumonia increased 9.3% from 0.44 to 0.48 per 1000 and mortality declined from 25.1% to 19.2% (ARR, 6.0%; 95% CI, 4.6%-7.3%; RRR, 23.7%; 95% CI, 19.7%-27.8%). However, when the 3 groups were combined, the hospitalization rate declined only 12.5%, from 6.3 to 5.6 per 1000, while the age-and sex-adjusted inpatient mortality rate increased from 8.3% to 8.8% (AR increase, 0.5%; 95% CI, 0.1%-0.9%; RR increase, 6.0%; 95% CI, 3.3%-8.8%). Over this same time frame, the age-, sex-, and comorbidity-adjusted mortality rate declined from 8.3% to 7.8% (ARR, 0.5%; 95% CI, 0.2%-0.9%; RRR, 6.3%; 95% CI, 3.8%-8.8%).Conclusions From 2003 to 2009, hospitalization and inpatient mortality rates for patients with a principal diagnosis of pneumonia decreased substantially, whereas hospitalizations with a principal diagnosis of sepsis or respiratory failure accompanied by a secondary diagnosis of pneumonia increased and mortality declined. However, when the 3 pneumonia diagnoses were combined, the decline in the hospitalization rate was attenuated and inpatient mortality was little changed, suggesting an association of these results with temporal trends in diagnostic coding. JAMA. 2012;307(13):1405-1413