Pneumonia Readmissions in Nursing Home Residents Over 65

Overview: The Population and the Problem

"Pneumonia is a leading cause of death among nursing home residents" (Zimmerman et al., 2016). This statement summarizes the severity of this healthcare issue. Pneumonia is so common in nursing homes that it has its own technical terminology: nursing home–acquired pneumonia (NHAP). This refers to pneumonia that afflicts an occupant of a long-term care facility for the elderly, and it has long been a major factor in the mortality and morbidity of these occupants. NHAP appears to afflict the weakened immune systems of the elderly quite easily, showing no bias toward gender or race. "The median reported incidence of pneumonia in this population is 1 to 1.2 per 1,000 patient-days" (Casey et al., 2015).

NHAP generally manifests in ways more consistent with community-acquired pneumonia (CAP) than nosocomial pneumonia (NP) (Cunha, 2015). This is largely because both types of illness arise in situations where people live in close quarters and germs are easily transferable. One of the major challenges in treating and preventing pneumonia in the elderly is that older residents often have co-existing conditions that further tax their limited strength and immune resources. Additionally, because nursing homes frequently circulate air through shared ventilation systems, germs travel easily, and close contact between residents and staff compounds this risk.

To further complicate the issue, elderly patients may not present the classic symptoms that typically identify pneumonia, making early detection difficult. However, a key strength in managing this condition is that nursing homes often have full medical staffs and strategic infection-control plans in place—such as face mask protocols, "cover your cough" campaigns, antiseptic cleaning of common areas, and hand sanitizer availability. Even so, it is important to understand the nature, causes, and severity of pneumonia readmissions among this vulnerable population of nursing home residents aged 65 and older.

Epidemiology, Demography, and Impact

Pneumonia presents a major global challenge, representing a significant cause of morbidity and mortality in adults. "According to recent estimates, lower respiratory tract infections, including pneumonia, are the fourth most common cause of death, and 1.9 million adults aged 15 years and older die from lower respiratory infections every year" (Morimoto et al., 2015). The reported frequency of NHAP ranges from 0.3 to 2.5 episodes per 1,000 days of resident care (Yoshikawa & Mylotte, 2002). Pinning down a more precise rate is complicated by variations in how pneumonia manifests across nursing homes, differences in research study designs, the number of facilities assessed, the effectiveness of surveillance tools, and whether a facility has a special affiliation—such as serving veterans—versus operating as a standard nursing home.

Some of the most significant studies in this area, though dated by today's standards, still shed important light on the frequency of this disease in nursing home settings. A study conducted between 1984 and 1987 found that NHAP occurred at a rate of once per 1,000 days of care (Yoshikawa & Mylotte, 2002). A more comprehensive study from the 1990s, spanning five nursing homes, found a lower rate of 0.7 episodes per 1,000 days of care—many of which involved readmissions (Yoshikawa & Mylotte, 2002).

In terms of demographic data, pneumonia does not discriminate by gender or ethnicity. However, elderly nursing home residents are at significantly elevated risk of contracting pneumonia and suffering pneumonia-related death, as individuals over 65 are the most frequent and repeated sufferers of this disease—a problem that is only growing. Pneumonia is also an expensive disease to treat. Experts have calculated the cost of inpatient pneumonia treatment in the United States at over $200 per person or more (Prina et al., 2015), and costs in nursing homes may be higher still, since elderly residents frequently have multiple co-occurring conditions.

Viruses, bacteria, and fungi are the primary causes of pneumonia. A recent study found that the long-term repercussions of pneumonia can be more damaging than those of a heart attack (Davydow et al., 2014). Elderly patients who receive inpatient care for pneumonia face an elevated risk of additional health problems that negatively affect their autonomy and capacity for self-care (Davydow et al., 2014). For an elderly nursing home resident, pneumonia represents not simply a life-threatening event but also a major life-altering one. "The potentially substantial chronic care needs and diminished quality of life for survivors are comparable to the effects of heart disease, yet we invest far fewer resources in pneumonia prevention" (Davydow et al., 2014).

While research specifically examining the demographic breakdown of nursing home pneumonia patients is limited, other studies offer useful insights. One study found that between 2003 and 2004, "the average annual incidence of bacteremic pneumonia was 24.2 episodes per 100,000 Black adults versus 10.1 per 100,000 White adults (RR = 2.40; 95% CI = 2.24, 2.57). Incidence among Black residents of census tracts with 20% or more of persons in poverty was 4.4 times the incidence among White residents of census tracts with less than 5% of persons in poverty" (Burton et al., 2010). This indicates that elderly adults living in poverty or impoverished conditions are at an increased risk of contracting pneumonia and should be targeted for proactive prevention efforts. Applied to the nursing home context, a facility that is underfunded or operating in an impoverished area may present greater pneumonia risk to its residents. While clear racial or gender variations in the disease's manifestation among the elderly remain inconclusive, socioeconomic status appears to correlate with risk level.

According to the Centers for Disease Control and Prevention (CDC), nearly one million Americans contract pneumonia each year, with 5–7% of those cases resulting in death. Among invasive pneumococcal disease cases, 90% involve adults, and 95% of pneumonia deaths in the United States occur in adults, with people over 65 at the greatest risk (CDC, 2017). These figures underscore the duty of professional medical teams in nursing homes to engage in proactive preventive efforts.

Clinical Quality Measures

The clinical assessment best suited for improving outcomes in this area is the PQRI—the Physician Quality Reporting Initiative (also known as the Physician Quality Reporting System). This healthcare quality improvement program was enacted in 2006. Although participation is voluntary, it has demonstrated the potential to dramatically improve outcomes for Medicare patients. To encourage participation, organizers eliminated formal enrollment or application processes, keeping engagement as accessible as possible. The program connects Medicare recipients with higher-quality care and rewards participating physicians with a financial incentive—a small percentage of total Medicare-approved billed charges. This approach is realistic and pragmatic: financially incentivizing physicians who are already overburdened creates a stronger likelihood that they will invest in proactive quality-improvement efforts.

Within the PQRI program, seven specific measure groups exist; one of these focuses on preventive care and contains nine measures. Several of these measures address routine screenings designed to catch serious illnesses before they fully develop. Critically, one measure specifically involves administering the pneumonia vaccine to adults over 65. If this measure were applied uniformly across the country, it could substantially reduce rates of the disease. Other preventive measures within the program—such as alcohol and tobacco consumption screenings—also contribute to overall healthy living and can help identify patients who may be more vulnerable to conditions like pneumonia. Taken together, PQRI reporting options hold considerable promise for reducing nursing home pneumonia rates over the coming years.

References

Burton, D. C., Flannery, B., Bennett, N. M., Farley, M. M., Gershman, K., Harrison, L. H., ... & Thomas, A. (2010). Socioeconomic and racial/ethnic disparities in the incidence of bacteremic pneumonia among US adults. American Journal of Public Health, 100(10), 1904–1911.

Casey, C., Fullerton, M. J., & Somerville, N. (2015). Common questions about pneumonia in nursing home residents. American Family Physician, 92(7).

CDC. (2017). Pneumococcal disease: Facts about pneumonia. Centers for Disease Control and Prevention.

Cunha, B. (2017, November 17). Nursing home acquired pneumonia: Types of pneumonia, mode of infection, history and physical examination. Retrieved from https://emedicine.medscape.com/article/234916-overview

Davydow, D. S., Hough, C. L., Levine, D. A., Langa, K. M., & Iwashyna, T. J. (2013). Functional disability, cognitive impairment, and depression after hospitalization for pneumonia. The American Journal of Medicine, 126(7), 615–624.

Morimoto, K., Suzuki, M., Ishifuji, T., Yaegashi, M., Asoh, N., Hamashige, N., ... & Adult Pneumonia Study Group–Japan. (2015). The burden and etiology of community-onset pneumonia in the aging Japanese population: A multicenter prospective study. PLoS One, 10(3), e0122247.

Prina, E., Ranzani, O. T., & Torres, A. (2015). Community-acquired pneumonia. The Lancet, 386(9998), 1097–1108.

Yoshikawa, T. T., & Mylotte, J. M. (2002). Nursing home–acquired pneumonia. Clinical Infectious Diseases, 35(10), 1205–1211.

Zimmerman, S., Cohen, L. W., Scales, K., Reed, D., Horsford, C., Weber, D. J., & Sloane, P. D. (2015). Pneumonia identification using nursing home records. Research in Gerontological Nursing, 9(3), 109–114.