Original Research: Chest Infections |

Epidemiology and Long-term Clinical and Biologic Risk Factors for Pneumonia in Community-Dwelling Older AmericansRisk Factors for Pneumonia Hospitalization: Analysis of Three Cohorts

Sachin Yende, MD; Karina Alvarez, MS; Laura Loehr, MD, PhD; Aaron R. Folsom, MD; Anne B. Newman, MD, MPH; Lisa A. Weissfeld, PhD; Richard G. Wunderink, MD, FCCP; Stephen B. Kritchevsky, PhD; Kenneth J. Mukamal, MD; Stephanie J. London, MD; Tamara B. Harris, MD; Doug C. Bauer, MD; Derek C. Angus, MD, MPH, FCCP; for the Atherosclerosis Risk in Communities Study, the Cardiovascular Health Study, and the Health, Aging, and Body Composition Study
Author and Funding Information

From The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center (Drs Yende, Weissfeld, and Angus and Ms Alvarez), the Department of Critical Care Medicine (Drs Yende and Angus), the Department of Biostatistics (Ms Alvarez and Dr Weissfeld), and the Department of Epidemiology (Dr Newman), University of Pittsburgh, Pittsburgh, PA; the Department of Epidemiology (Dr Loehr), UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC; the School of Public Health (Dr Folsom), University of Minnesota, Minneapolis, MN; the Division of Pulmonary and Critical Care Medicine (Dr Wunderink), Northwestern University Feinberg School of Medicine, Chicago, IL; The Sticht Center on Aging (Dr Kritchevsky), Wake Forest School of Medicine, Winston-Salem, NC; the Department of Medicine (Dr Mukamal), Beth Israel Deaconess Medical Center, Boston, MA; the Epidemiology Branch (Dr London), National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, NC; the Laboratory of Epidemiology, Demography, and Biometry (Dr Harris), National Institute on Aging, Bethesda, MD; and the Departments of Medicine and Epidemiology and Biostatistics (Dr Bauer), University of California, San Francisco, CA.

Correspondence to: Sachin Yende, MD, University of Pittsburgh, 606D Scaife Hall, 3550 Terrace St, Pittsburgh, PA 15261; e-mail: yendes@upmc.edu

Funding/Support: The Atherosclerosis Risk in Communities Study is carried out as a collaborative study supported by the National Heart, Lung, and Blood Institute (NHLBI) [Contracts N01-HC-55015, N01-HC-55016, N01-HC-55018, N01-HC-55019, N01-HC-55020, N01-HC-55021, and N01-HC-55022]. This research was supported by NHLBI [Contracts HHSN268201200036C, HHSN268200800007C, N01-HC-55222, N01-HC-85079, N01-HC-85080, N01-HC-85081, N01-HC-85082, N01-HC-85083, H01-HC-85086 and Grant HL080295], with additional contribution from National Institute of Neurological Disorders and Stroke. Additional support was provided by the National Institute on Aging (NIA) [Grant AG-023629]. A full list of principal Cardiovascular Health Study investigators and institutions can be found at CHS-NHLBI.org. The Health, Aging, and Body Composition Study is supported by NIA [Contracts N01-AG-6-2101, N01-AG-6-2103, N01-AG-6-2106, R01-AG028050, and R01-NR012459]. This study was in part funded by National Institutes of Health [Grant K23GM083215 to Dr Yende] and Intramural Research Programs of the National Institute of Environmental Health Sciences and NIA.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

Chest. 2013;144(3):1008-1017. doi:10.1378/chest.12-2818
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Background:  Preventing pneumonia requires better understanding of incidence, mortality, and long-term clinical and biologic risk factors, particularly in younger individuals.

Methods:  This was a cohort study in three population-based cohorts of community-dwelling individuals. A derivation cohort (n = 16,260) was used to determine incidence and survival and develop a risk prediction model. The prediction model was validated in two cohorts (n = 8,495). The primary outcome was 10-year risk of pneumonia hospitalization.

Results:  The crude and age-adjusted incidences of pneumonia were 6.71 and 9.43 cases/1,000 person-years (10-year risk was 6.15%). The 30-day and 1-year mortality were 16.5% and 31.5%. Although age was the most important risk factor (range of crude incidence rates, 1.69-39.13 cases/1,000 person-years for each 5-year increment from 45-85 years), 38% of pneumonia cases occurred in adults < 65 years of age. The 30-day and 1-year mortality were 12.5% and 25.7% in those < 65 years of age. Although most comorbidities were associated with higher risk of pneumonia, reduced lung function was the most important risk factor (relative risk = 6.61 for severe reduction based on FEV1 by spirometry). A clinical risk prediction model based on age, smoking, and lung function predicted 10-year risk (area under curve [AUC] = 0.77 and Hosmer-Lemeshow [HL] C statistic = 0.12). Model discrimination and calibration were similar in the internal validation cohort (AUC = 0.77; HL C statistic, 0.65) but lower in the external validation cohort (AUC = 0.62; HL C statistic, 0.45). The model also calibrated well in blacks and younger adults. C-reactive protein and IL-6 were associated with higher pneumonia risk but did not improve model performance.

Conclusions:  Pneumonia hospitalization is common and associated with high mortality, even in younger healthy adults. Long-term risk of pneumonia can be predicted in community-dwelling adults with a simple clinical risk prediction model.

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