Chest
Volume 138, Issue 6, December 2010, Pages 1371-1376
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Original Research
Pneumonia
Validity of Severity Scores in Hospitalized Patients With Nursing Home-Acquired Pneumonia

https://doi.org/10.1378/chest.10-0494Get rights and content

Background

Several severity scores have been advanced to predict a patient's outcome from community-acquired pneumonia (CAP). The purpose of this study is to compare the accuracy of confusion, urea, respiratory rate, BP (CURB); CURB plus age ≥ 65 years (CURB-65); CURB-65 minus urea (CRB-65); and systolic BP, oxygenation, age, and respiratory rate (SOAR) scoring systems in predicting 30-day mortality and ICU admission in patients with nursing home-acquired pneumonia (NHAP).

Methods

A retrospective analysis of a prospectively collected database of 457 nursing home residents hospitalized with pneumonia at two university-affiliated tertiary care facilities. Clinical and laboratory features were used to compute severity scores using the British Thoracic Society severity rules and the SOAR criteria. The sensitivity, specificity, and positive and negative predictive values were compared for need for ICU admission and 30-day mortality.

Results

The overall 30-day mortality and ICU admission rates were 23% and 25%, respectively. CURB, CURB-65, and CRB-65 performed similarly in predicting mortality with areas under the receiver operating characteristic curves (AUCs) of 0.605 (95% CI, 0.559-0.650), 0.593 (95% CI, 0.546-0.638), and 0.592 (95% CI, 0.546-0.638), respectively, whereas SOAR showed superior accuracy with an AUC of 0.765 (95% CI, 0.724-0.803) (P < .001). The need for ICU care was also better identified with the SOAR model compared with the other scoring rules.

Conclusions

All three British Thoracic Society rules had lower performance accuracy in predicting 30-day mortality of hospitalized NHAP than SOAR. SOAR is also a superior alternative for better identification of severe NHAP. An improved rule for severity assessment of hospitalized NHAP is needed.

Section snippets

Study Population

The Institutional Review Board approved the study and waived the need for informed consent. All nursing home patients presenting to one of the study hospitals (Erie County Medical Center and Millard Fillmore Hospital) with pneumonia were abstracted from a database collected prospectively. Exclusion criteria were as follows: (1) acquisition of pneumonia after hospital admission; (2) hospitalization in the last 90 days; (3) chemotherapy during the previous 60 days, therapy with corticosteroids >

Patient Population

A total of 478 patients with NHAP were identified. Eighteen patients were excluded because pneumonia occurred as a terminal event or the patient had clear advance directives limiting therapy. An additional three patients fit the definition of immunosuppression. Four hundred fifty-seven patients of mean age 77.4 years were available for analysis. The baseline demographic and clinical characteristics are shown in Table 1. One hundred twelve (25%) required ICU admission; 101 were admitted directly

Discussion

The results of this study demonstrate that SOAR has a superior discriminatory power compared with CURB, CURB-65, and CRB-65 in predicting ICU admission and 30-day mortality from NHAP. The current study is the first, to our knowledge, to examine the accuracy of CURB and its derivatives in patients with NHAP. Previously, Mylotte and colleagues19 established that the pneumonia severity index successfully stratified low- and high-risk groups for 30-day mortality in a cohort of 158 pneumonic

Acknowledgments

Author contributions: Dr El-Solh: contributed to concept and design, analysis and interpretation of data, and final revision of the manuscript.

Dr Alhajhusain: contributed to acquisition and tabulation of data.

Dr Abou Jaoude: contributed to acquisition and tabulation of data.

Dr Drinka: contributed to critical revision of the manuscript for important intellectual content.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any

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