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Ann Am Thorac Soc. 2018 May;15(5):562-569. doi: 10.1513/AnnalsATS.201709-728OC.

Variation in the Diagnosis of Aspiration Pneumonia and Association with Hospital Pneumonia Outcomes.

Author information

1
1 Institute for Healthcare Delivery and Population Science, and.
2
2 Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts.
3
3 Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts.
4
4 Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.
5
5 University of Connecticut School of Medicine, Farmington, Connecticut.
6
6 Section of General Internal Medicine.
7
8 Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, and.
8
7 Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut; and.
9
10 Robert Wood Johnson Clinical Scholars Program, Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut.
10
9 School of Medicine, Yale University, New Haven, Connecticut.

Abstract

RATIONALE:

National efforts to compare hospital outcomes for patients with pneumonia may be biased by hospital differences in diagnosis and coding of aspiration pneumonia, a condition that has traditionally been excluded from pneumonia outcome measures.

OBJECTIVES:

To evaluate the rationale and impact of including patients with aspiration pneumonia in hospital mortality and readmission measures.

METHODS:

Using Medicare fee-for-service claims for patients 65 years and older from July 2012 to June 2015, we characterized the proportion of hospitals' patients with pneumonia diagnosed with aspiration pneumonia, calculated hospital-specific risk-standardized rates of 30-day mortality and readmission for patients with pneumonia, analyzed the association between aspiration pneumonia coding frequency and these rates, and recalculated these rates including patients with aspiration pneumonia.

RESULTS:

A total of 1,101,892 patients from 4,263 hospitals were included in the mortality measure analysis, including 192,814 with aspiration pneumonia. The median proportion of hospitals' patients with pneumonia diagnosed with aspiration pneumonia was 13.6% (10th-90th percentile, 4.2-26%). Hospitals with a higher proportion of patients with aspiration pneumonia had lower risk-standardized mortality rates in the traditional pneumonia measure (12.0% in the lowest coding and 11.0% in the highest coding quintiles) and were far more likely to be categorized as performing better than the national mortality rate; expanding the measure to include patients with aspiration pneumonia attenuated the association between aspiration pneumonia coding rate and hospital mortality. These findings were less pronounced for hospital readmission rates.

CONCLUSIONS:

Expanding the pneumonia cohorts to include patients with a principal diagnosis of aspiration pneumonia can overcome bias related to variation in hospital coding.

KEYWORDS:

aspiration pneumonia; clinical coding; outcome assessment; pneumonia; selection bias

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