The effect of comorbidities for the prognosis of community-acquired pneumonia: an epidemiologic study using a hospital surveillance in Japan

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Although the effect of severity at admission on outcome has been well reported, the role of comorbidity is still not widely understood. The Charlson Comorbidity Index measures comorbidity with a well-established history of predicting long-term outcome but its utility in pneumonia prognosis is still limited. Here, we use the Charlson Comorbidity Index and hospital surveillance data to investigate associations between comorbidities and in-hospital mortality due to community-acquired pneumonia. Results Among the 535 eligible adult patients (69.0% male, median [IQR] age, 79 [70-84] years), 100 (18.7%) acquired severe to extremely severe pneumonia. The median [IQR] CCI was 1[1-3]. Malignancy (129 of 535, 24.1%), chronic pulmonary diseases (113 of 535, 21.1%) and congestive heart failure (103 of 535, 19.3%) were frequent. Higher Charlson Comorbidity Index scores were associated with higher risk of in-hospital mortality (OR 1.28; 95% CI 1.07-1.53). These results support the inclusion of comorbid burden in predicting community-acquired pneumonia outcome. Health Economics & Outcomes Research Epidemiology community-acquired pneumonia mortality comorbidity Charlson Comorbidity Index Introduction Despite the universal availability of antibiotics and adherence to recommended treatment guidelines, pneumonia continues to present significant morbidity and mortality. Pneumonia and influenza combined ranked eighth among the most common causes of death in the United States and pneumonia alone accounted for more than 60,000 deaths in 2005 [1]. In an international systematic review, the overall mortality was 13.7%, ranging from 5.1% in hospitalized and ambulatory patients to 36.5% for the intensive care unit patients [2]. Based on the surveillance data, the estimated annual number of adult community-acquired pneumonia (CAP) was 1.9 million for entire Japan, 69 percent of which were in the elderly [3]. In-hospital death rates sharply increase with age, making CAP the third leading cause of death among older adults in Japan. Influenza vaccine and pneumococcal vaccine are both recommended for the elderly by the national guideline in Japan. However, the coverages of these vaccinations are insufficient. Recent studies reported the estimated coverage of 57% for influenza vaccination [4] and 34% for pneumococcal vaccine among the elderly in Japan [5]. Comorbidity is essential in risk prediction and risk adjustment modeling. Previous works have suggested using a diagnosis-based index, such as the Charlson Comorbidity Index (CCI), in studies where the outcome of interest is mortality [6]. The CCI contains 19 conditions, each of which is assigned a weight of 1, 2, 3 or 6 based on adjusted hazard ratios for each comorbid condition derived from Cox’s proportional hazards model [7]. These weighted scores are then summed into a total score. Numerous adaptions of the CCI have been developed for use in administrative databases [8,9,10], all of whom independently developed coding algorithms using the International Classification of Diseases, Ninth Revision (ICD–9). In 2005, Quan and colleagues [11] identified the ICD–10 codes corresponding to the Deyo ICD–9 adaption and updated their index in 2011, creating the latest version of CCI [12]. This updated CCI index has been proven competent at predicting mortality in various disease subgroups, including cancer, renal disease, stroke, or in patients undergoing surgical procedures. However, in spite of various efforts to utilize the index to predict CAP prognosis from 1 year to up to 7 years after hospital discharge, studies have tended to focus on long-term rather than short-term outcomes. Accordingly, reports on the influence of CCI on CAP in-hospital mortality and its application to clinical settings are scarce. This study thus aimed to investigate the association between comorbidities, as assessed by CCI, and in-hospital mortality due to community-acquired pneumonia. Main text This was a retrospective cohort study conducted at the 600-bed Nippon Medical School Chiba Hokusoh Hospital that specializes in cancer and emergency care. Information was extracted from the Diagnosis Procedure Combination database (DPC) and discharge database. DPC is a nationwide administrative database for acute-care inpatients, which first emerged in 2003, and is linked to a lump-sum payment system. As of 2012, the DPC is estimated to cover approximately 53% of general hospital beds in Japan [13]. In this study, the DPC database provided information on the severity of the pneumonia in the form of an A-DROP score. Remaining data were obtained from the discharge database, including identification codes, main and subcategorized diagnoses, patient demographics, past medical history, summarized clinical courses, admission and discharge status and discharge medication. Diagnoses were coded using ICD–10. Study subjects The present study included data of patients admitted between August 1, 2011 to June 30, 2017. All consecutive emergency room admissions ≥ 18 years of age with the diagnosis of pneumonia (ICD–10 codes: J18.0, J18.1, J18.2, J18.8, J18.9) were considered for inclusion. To validate community-acquired pneumonia (CAP) diagnoses, all cases were reviewed and those with clinical symptoms of pneumonia (e.g., dyspnea, cough, fever, sputum production, chest pain) that demonstrated infiltration on chest radiography within 48 hours of admission were selected. Patients were excluded if they were later defined as having health care-associated pneumonia or hospital-acquired pneumonia, if they presented with cardiopulmonary arrest on admission, consented to a do-not-resuscitate order or had incomplete data. Patients referred from or transferred to another hospital were also excluded. Measures The primary outcome was all-cause, in-hospital mortality. Independent variables of interest were age, sex, pneumonia severity (A-DROP score), the primary predictor of CCI and its comorbid conditions component. Between one and six points were awarded for each condition and summed, with higher scores correlating to higher severity of comorbidity. Comorbid diseases were retrieved from past medical histories and, for each disease, the corresponding ICD–10 code was identified [14]. From this ICD code, the CCI was calculated by applying the coding algorithm and weight assignment [11,12]. The severity of pneumonia on admission was evaluated using the A-DROP prognostic score, a modified version of the CURB–65 scoring system proposed by the Japanese Respiratory Society that is well-established and has a proven ability to predict mortality [15,16]. Age, dehydration status, respiratory failure, orientation disturbance, and blood pressure were assessed before stratifying patients into four severity classes based on total score. Age, the length of stay (LOS) and CCI were recorded and analyzed as continuous variables. Data analysis Due to potential bias concerns, analysis was performed twice: first, with all participants and then after excluding severe and extremely severe cases with no record of comorbidity (CCI = 0). Categorical variables are presented in absolute numbers and proportions while continuous variables are expressed as median (interquartile range). Univariate logistic regression analyses were first performed to evaluate each covariate’s individual effect on the outcome. All covariates of interest, together with their interaction term, were then entered into the multivariable logistic models and analyses were repeated after exclusion of severe to extremely severe patients with no comorbidity records. Model diagnostics were also performed which tested for the assumptions of linearity of logit (for variable age and CCI), multicollinearity, and influential cases. Odds ratios are reported with 95% confidence intervals and p values are 2-sided with a p<0.05 cutoff for statistical significance. All analyses were performed with SPSS (version 23, IBM Inc., USA). Results Data from 660 individuals who were admitted to the emergency department with a pneumonia diagnosis from August 2011 to June 2017 were extracted. Of the 125 excluded cases, 64 had other principal diagnoses (e.g., lung cancer, interstitial lung diseases), 33 were later classified as either hospital-acquired or health-care associated pneumonia, 5 had an incomplete record, 6 had cardiopulmonary arrest on admission, 4 consented to a do-not-resuscitate order, and 13 were either transferred from or transferred to another hospital. Thus, a total of 535 cases were left for analysis. The median age (IQR) of patients was 79 (70–84) years, 369 of 535 (69.0%) were men, and all-cause, in-hospital mortality rate was 12 percent (Table 1). The cohort stayed for approximately 14 days in the hospital. In term of pneumonia severity, the majority was classified into the moderate group (338 individuals, 68.0%) whereas 100 patients (18.7%) had pneumonia at severe or extremely severe levels. The median CCI (IQR) was 1 (1–3) with roughly a quarter of the patients (131 individuals, 24.5%) scoring 2 points. The most common co-morbidities found in the CCI were malignancies (129 of 535, 24.1%), chronic pulmonary diseases (113 of 535, 21.1%) and congestive heart failure (103 of 535, 19.3%). In general, excluding cases with no record of comorbidities, there was a trend towards increasing mortality as the CCI score increased. The number rose from 6.8 percent in patients with CCI = 1 to 25.0 percent with CCI = 5. Table 1 . General characteristics of study subjects Characteristics N = 535 Age in years, median (IQR) 79 (70-84) Sex, male, n (%) 369 (69.0) Length of stay in days, median (IQR) 14 (9-27) Charlson Comorbidity Index, median (IQR) 1 (1-3) In-hospital mortality, % (n/N) 12.2 (64/535) Abbreviation: IQR, interquartile range Univariable logistic regression modeling showed that older patients who presented with more severe pneumonia at admission were at higher risk for in-hospital death as each 1-year increase in age heightened the risk by 4 percent (odds ratio [OR] 1.04; 95% confidence interval [CI] 1.01 to 1.07). There was a trend towards increasing mortality in patients with malignancy, congestive heart failure, renal disease, diabetes with complication and dementia. The correlation between pneumonia severity and the CCI was weak, i.e., Spearman’s correlation coefficient = 0.139, p = 0.002. The multivariable regression model showed there was a tendency toward increasing mortality as A-DROP score increased but only in the extremely severe patients showed a significant difference. Among mild pneumonia patients, the prognostic impacts of CCI were marginally significant after adjustments for age and sex as a 1-point rise in CCI increased odds of death by 2-fold (OR 2.09; 95% CI 1.03–4.25). This impact, however, was reduced significantly as pneumonia severity increased (supplementary Table S1). Considering a potential bias, we conducted the final analysis after excluding severe and extremely severe patients whose CCI was zero (60/353; 17.0%) and found that each per unit increase in CCI resulted in a 35% increase in odds of death (OR 1.35; 95% CI 1.16 to 1.58) (Table 2). Renal disease, followed by malignancy, showed the strongest association with mortality (OR 2.42; 95% CI 1.13 to 5.21 and OR 2.25; 95% CI 1.21 to 4.17). Age, sex, A-DROP categories, CCI and their interaction terms were added as predictors for multivariate analysis but no meaningful interactions were observed. The prognostic impacts of CCI were consistent across pneumonia severity categories and a 1-point increase in CCI increased odds of death by 28 percent (OR 1.28; 95% CI 1.07–1.53) (Table 3). Table 2 . Univariate analysis for in-hospital mortality Variables n (%) OR (95% CI) p-value Age, years a 475 (88.8) 1.04 (1.01 – 1.07) 0.01 Sex Male 329 (61.5) reference Female 146 (27.3) 1.18 (0.63 – 2.24) 0.61 Pneumonia severity Mild A-DROP=0 68 (12.7) reference Moderate A-DROP=1-2 338 (63.2) 1.28 (0.43-3.80) 0.66 Severe A-DROP=3 52 (9.7) 4.29 (1.28-14.39) 0.02 Extremely severe A-DROP=4-5 17 (3.2) 11.20 (2.77-45.31) <0.01 Charlson Comorbidity Index (CCI) b 475 (88.7) 1.35 (1.16-1.58) <0.01 Charlson Comorbidity Index components c Any malignancy No 349 (73.5) reference Yes 126 (26.5) 2.25 (1.21-4.17) 0.01 Chronic pulmonary disease No 367 (77.3) reference Yes 108 (22.7) 1.04 (0.51-2.13) 0.91 Congestive heart failure No 375 (78.9) reference Yes 100 (21.1) 1.89 (0.98-3.65) 0.06 Renal disease No 422 (88.8) reference Yes 53 (11.2) 2.42 (1.13-5.21) 0.02 Diabetes with complication No 434 (91.4) reference Yes 41 (8.6) 2.03 (0.84-4.87) 0.11 Dementia No 435 (91.6) reference Yes 40 (8.4) 2.10 (0.87-5.04) 0.10 Rheumatologic disease No 459 (96.6) reference Yes 16 (3.4) 1.31 (0.29-5.97) 0.72 Mild liver disease No 460 (96.8) reference Yes 15 (3.2) 0.64 (0.08-5.00) 0.67 Abbreviations: OR, odds ratio; CI, confidence interval a OR for one year increasing in age; b OR for one point increasing in CCI; c Conditions which has less than 10 cases were not analyzed. Table 3. Multivariable logistic regression analysis for in-hospital mortality Variables No. of deaths/total number B OR (95% CI) p-value Age, years a 47/475 0.03 1.03 (0.99 – 1.07) 0.08 Sex Male 31/329 reference Female 16/146 0.34 1.41 (0.71-2.83) 0.33 Pneumonia severity Mild A-DROP=0 4/68 reference Moderate A-DROP=1-2 25/338 -0.31 0.73 (0.22-2.41) 0.61 Severe A-DROP=3 11/52 0.59 1.80 (0.47-6.96) 0.39 Extremely severe A-DROP=4-5 7/17 1.60 4.92 (1.11-21.98) 0.04 Charlson Comorbidity Index (CCI) b 47/475 0.25 1.28 (1.07-1.53) <0.01 Abbreviations: B, beta coefficient; OR, odds ratio; CI, confidence interval a OR for one year increasing in age; b OR for one point increasing in CCI Discussion This study found that higher CCI scores were associated with increased risk for all-cause, in-hospital mortality and this association persisted after adjustment for potential confounders. This interesting result stems from the fact that, although the index has been proven reliable for the long-term prognosis of CAP, there has been little discussion on how it influences short-term outcomes. In their study of 108 patients, Franzen and colleagues [17] reported that pneumonia in-hospital mortality trended upward as CCI rose (HR 1.10; 95% CI 0.99 to 1.23). In another study conducted on 373 Japanese patients, Torres and colleagues [18] were unable to find any impact of CCI on the mortality of elderly patients with CAP but details regarding A-DROP scores and direction of the associations were not reported. Notably high proportions of this population suffered from malignancy (24.1%), chronic pulmonary diseases (21.1%) and congestive heart failure (19.3%). Studies conducted in other Japanese teaching hospitals have reported that approximately 8.8% to 19.0% of patients had malignancy while 5.4% to 12.7% suffered from congestive heart failure [19,20,21]. Our result was not unexpected, as the Chiba Hokusoh Hospital serves as a Chiba Cancer Treatment Regional Base Hospital and therefore has a considerable number of patients undergoing cancer treatment. In addition, since the average age was 79 years old, this would have contributed to increased complications. We surprisingly discovered that patients with severe conditions (A-DROP = 3–5) but no comorbidities had the highest mortality rate at 48.0 percent. Contrary to expectations, individuals in the most severe group who had higher CCI seemed to survive better while those who scored zero on the CCI tended to die. One possible explanation is that these severe cases might receive treatment priority due to physician triage and collecting the past medical history was only done once the emergency situation was resolved. Patients who died quickly were more likely to have their disease history recorded incompletely and, as a result, they would tend to score 0 on the CCI. We posit that if information had been more thoroughly collected in these patients, their CCI scores would have been higher and have truly reflected their comorbidities. Sensitivity analyses were carried out to minimize this classification bias and, although a notable improvement observed in the results has strengthened our hypothesis, further studies with large representative samples are required to confirm our observation. Limitations This study was conducted using retrospective data of a rural tertiary teaching hospital in Japan. The inclusion criteria were limited only to patients with a principal diagnosis of pneumonia. Several factors associated with mortality were not considered. Furthermore, the study could not identify deaths outside of the hospital that may have been tied to the pneumonia diagnosis. Abbreviations CAP: community-acquired pneumonia; CCI: Charlson comorbidity index; CI: confidence interval; DPC: Diagnosis procedure combination database; ICD: International classification of diseases; ICU: intensive care unit; IQR: interquartile range OR: odds ratio Declarations Authors’ contributions MTNN lead study conceptualization, data analysis and writing of the munuscript. NS was involved in data prepatation and interpretation of data analysis. YW was involved in study conceptualization, interpretation of data analysis, and contributed to the writing of the manuscript. All authors read and approved the final manuscript. Author details 1 Department of Clinical Trials and Clinical Epidemiology, Graduate School of Comprehensive Human Sciences, University of Tsukuba, 1–1–1 Tennodai, Tsukuba, Ibaraki 305–8575, Japan. 2 The Shock and Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba 270–1694, Japan. 3 Department of Clinical Trials and Clinical Epidemiology, Faculty of Medicine, University of Tsukuba, 1–1–1 Tennodai, Tsukuba, Ibaraki 305–8575, Japan. Acknowledgements We would like to extend our appreciation to the staff of Chiba Hokusoh Hospital who contributed for the hospital surveillance system. Competing interests The authors declare that they have no competing interests. Availability of data and materials The datasets used and/or analyzed during the study are available from the corresponding author on reasonable request. Consent for publication Not applicable. Ethics approval and consent to participate This study was approved by the Institutional Review Board of Nippon Medical University Chiba Hokusoh Hospital (Approval No. 590). Because of the anonymous nature of data, the need for informed consent was waived. Funding This work was funded in part by the Research and Education Fund of Faculty of Medicine, University of Tsukuba. The funding body had no role in the design of the study and collection, analysis and interpretation of data, and in writing the manuscript. References File TM, Jr., Marrie TJ. Burden of community-acquired pneumonia in North American adults. Postgraduate medicine. 2010;122:130-41. Fine MJ, Smith MA, Carson CA, Mutha SS, Sankey SS, Weissfeld LA, Kapoor WN. Prognosis and outcomes of patients with community-acquired pneumonia. Ameta-analysis. JAMA. 1996;275:134-41. Morimoto K, Suzuki M, Ishifuji T, Yaegashi M, Asoh N, Hamashige N, Abe M,Aoshima M, Ariyoshi K; Adult Pneumonia Study Group-Japan (APSG-J). The burden andetiology of community-onset pneumonia in the aging Japanese population: amulticenter prospective study. PLoS One. 2015;10:e0122247. Kajikawa N, Kataoka Y, Goto R, Maeno T, Yokota S, Umeyama S, Takahashi S, Maeno T. Factors associated with influenza vaccination in Japanese elderly outpatients. Infect Dis Health. 2019;24:212-21. Shono A, Hoshi SL, Kondo M. The impact on vaccination coverage following introduction of a routine pneumococcal vaccination programme for the elderly in Japan. Vaccine. 2018;36:5886-90. 6. Yurkovich M, Avina-Zubieta JA, Thomas J, Gorenchtein M, Lacaille D. A systematic review identifies valid comorbidity indices derived from administrative health data. Journal of clinical epidemiology. 2015;68:3-14. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. Journal of chronic diseases. 1987;40:373-83. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. Journal of clinical epidemiology. 1992;45:613-19. Romano PS, Roos LL, Jollis JG. Adapting a clinical comorbidity index for use with ICD-9-CM administrative data: differing perspectives. Journal of clinical epidemiology. 1993;46:1075-1079; discussion 1081-90. D'Hoore W, Bouckaert A, Tilquin C. Practical considerations on the use of the Charlson comorbidity index with administrative data bases. Journal of clinical epidemiology. 1996;49:1429-33. Quan H, Sundararajan V, Halfon P, Fong A, Burnand B, Luthi JC, Saunders LD,Beck CA, Feasby TE, Ghali WA. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care. 2005;43:1130-9. Quan H, Li B, Couris CM, Fushimi K, Graham P, Hider P, Januel JM, SundararajanV. Updating and validating the Charlson comorbidity index and score for riskadjustment in hospital discharge abstracts using data from 6 countries. Am J Epidemiol. 2011;173:676-82. Health and Global Policy Institute. Payment System. Japan Health Policy NOW 2016; http://japanhpn.org/en/finan2/ . Accessed September 10, 2019. World Health Organization. ICD-10 Version : 2016. 2016; http://apps.who.int/classifications/icd10/browse/2016/en#/I48 . Accessed September 10, 2019. Miyashita N, Matsushima T, Oka M, Japanese Respiratory S. The JRS guidelines for the management of community-acquired pneumonia in adults: an update and new recommendations. Internal medicine (Tokyo, Japan). 2006;45:419-28. Neill AM, Martin IR, Weir R, Anderson R, Chereshsky A, Epton MJ, Jackson R,Schousboe M, Frampton C, Hutton S, Chambers ST, Town GI. Community acquiredpneumonia: aetiology and usefulness of severity criteria on admission. Thorax.1996;51:1010-6. Franzen D, Lim M, Bratton DJ, Kuster SP, Kohler M. The Roles of the Charlson Comorbidity Index and Time to First Antibiotic Dose as Predictors of Outcome in Pneumococcal Community-Acquired Pneumonia. Lung. 2016;194:769-75. Torres OH, Muñoz J, Ruiz D, Ris J, Gich I, Coma E, Gurguí M, Vázquez G.Outcome predictors of pneumonia in elderly patients: importance of functionalassessment. J Am Geriatr Soc. 2004;52:1603-9. Matsunuma R, Asai N, Ohkuni Y, Nakashima K, Iwasaki T, Misawa M, Norihiro K.I-ROAD could be efficient in predicting severity of community-acquired pneumonia or healthcare-associated pneumonia. Singapore Med J. 2014;55:318-24. Tashiro M, Fushimi K, Takazono T, Kurihara S, Miyazaki T, Tsukamoto M,Yanagihara K, Mukae H, Tashiro T, Kohno S, Izumikawa K. A mortality predictionrule for non-elderly patients with community-acquired pneumonia. BMC Pulm Med. 2016;16:39. Ogasawara T, Umezawa H, Naito Y, Takeuchi T, Kato S, Yano T, Kasamatsu N,Hashizume I. Procalcitonin-guided antibiotic therapy in aspiration pneumonia and an assessment of the continuation of oral intake. Respir Investig. 2014;52:107-13. Supplementary Files SupplementaryTableS1revised.pdf Cite Share Download PDF Status: Published Journal Publication published 19 Dec, 2019 Read the published version in BMC Research Notes → Version 3 posted Submission checks completed at journal 08 Dec, 2019 Editorial decision: Accept 06 Dec, 2019 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6779","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research note","associatedPublications":[],"authors":[{"id":245873,"identity":"cbc1cc83-d8f4-43f6-bb4a-8097a9649489","order_by":1,"name":"Mai Thi Ngoc Nguyen","email":"","orcid":"","institution":"Tsukuba Daigaku","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mai","middleName":"Thi Ngoc","lastName":"Nguyen","suffix":""},{"id":245874,"identity":"2434257d-4048-4824-a9cc-33d013666503","order_by":2,"name":"Nobuyuki Saito","email":"","orcid":"","institution":"Nihon Ika Daigaku","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Nobuyuki","middleName":"","lastName":"Saito","suffix":""},{"id":245875,"identity":"5c414de2-a956-49fa-849b-b793ab309dc2","order_by":3,"name":"Yukiko Wagatsuma","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDElEQVRIiWNgGAWjYBADOQaGBBCdwGAAEWAjoCGBwRhIMDaQpCWxAU0LbmBwI/nxi58/6tLXtiewP/zZlpa4nf0A44cfDHx5uLWkmVn2JBzO3XbmAWMzb1tO4s6eBGbJHga2YpxabieYGfAkHMjddiOBsZmxrSJxw4EEBmmgX4BOxaUl/Zvhn4S6dDOglsafIC3nHzD/xq8lx/gxTwJzAkhLA8hhG24ksOG1RfL+mzJmmbTDhtvOPGyczXMuzXjnjIdtlj0GuP3Cd+b45o9vbOrkzY4nH/j4oyxZdjt/8uEbPyqO4QwxhQMMbBIQJiPMJSCGwbEEXFrkGxiYP2CTqMGpZRSMglEwCkYcAACHJ2K24gWMbwAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-8056-9998","institution":"University of Tsukuba","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Yukiko","middleName":"","lastName":"Wagatsuma","suffix":""}],"badges":[],"createdAt":"2019-10-11 11:30:01","currentVersionCode":3,"declarations":"","doi":"10.21203/rs.2.16128/v3","doiUrl":"https://doi.org/10.21203/rs.2.16128/v3","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13104-019-4848-1","type":"published","date":"2019-12-19T12:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":13482335,"identity":"03e239a2-83fd-4669-936f-62f00c5d61c2","added_by":"auto","created_at":"2021-09-16 21:50:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":192314,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6779/v3/5dcc02e1-5aa5-4998-9492-fc84cc9d57a7.pdf"},{"id":276282,"identity":"03fd5fa3-407c-4bb4-a3e0-5aba9007e6c9","added_by":"auto","created_at":"2019-12-18 14:03:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":78534,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTableS1revised.pdf","url":"https://assets-eu.researchsquare.com/files/8d915f3c-c8d5-4dd1-a559-119d26ee1710/v3/Supplementary Table S1_revised.pdf"}],"financialInterests":"","formattedTitle":"The effect of comorbidities for the prognosis of community-acquired pneumonia: an epidemiologic study using a hospital surveillance in Japan","fulltext":[{"header":"Introduction","content":"\n\u003cp\u003eDespite the universal availability of antibiotics and adherence to recommended treatment guidelines, pneumonia continues to present significant morbidity and mortality. Pneumonia and influenza combined ranked eighth among the most common causes of death in the United States and pneumonia alone accounted for more than 60,000 deaths in 2005 [1]. In an international systematic review, the overall mortality was 13.7%, ranging from 5.1% in hospitalized and ambulatory patients to 36.5% for the intensive care unit patients [2].\u003c/p\u003e\n\u003cp\u003eBased on the surveillance data, the estimated annual number of adult community-acquired pneumonia (CAP) was 1.9 million for entire Japan, 69 percent of which were in the elderly [3]. In-hospital death rates sharply increase with age, making CAP the third leading cause of death among older adults in Japan. Influenza vaccine and pneumococcal vaccine are both recommended for the elderly by the national guideline in Japan. However, the coverages of these vaccinations are insufficient. Recent studies reported the estimated coverage of 57% for influenza vaccination [4] and 34% for pneumococcal vaccine among the elderly in Japan [5].\u003c/p\u003e\n\u003cp\u003eComorbidity is essential in risk prediction and risk adjustment modeling. Previous works have suggested using a diagnosis-based index, such as the Charlson Comorbidity Index (CCI), in studies where the outcome of interest is mortality [6]. The CCI contains 19 conditions, each of which is assigned a weight of 1, 2, 3 or 6 based on adjusted hazard ratios for each comorbid condition derived from Cox’s proportional hazards model [7]. These weighted scores are then summed into a total score. Numerous adaptions of the CCI have been developed for use in administrative databases [8,9,10], all of whom independently developed coding algorithms using the International Classification of Diseases, Ninth Revision (ICD–9). In 2005, Quan and colleagues [11] identified the ICD–10 codes corresponding to the Deyo ICD–9 adaption and updated their index in 2011, creating the latest version of CCI [12].\u003c/p\u003e\n\u003cp\u003eThis updated CCI index has been proven competent at predicting mortality in various disease subgroups, including cancer, renal disease, stroke, or in patients undergoing surgical procedures. However, in spite of various efforts to utilize the index to predict CAP prognosis from 1 year to up to 7 years after hospital discharge, studies have tended to focus on long-term rather than short-term outcomes. Accordingly, reports on the influence of CCI on CAP in-hospital mortality and its application to clinical settings are scarce. This study thus aimed to investigate the association between comorbidities, as assessed by CCI, and in-hospital mortality due to community-acquired pneumonia.\u003c/p\u003e\n\n"},{"header":"Main text","content":"\n\u003cp\u003eThis was a retrospective cohort study conducted at the 600-bed Nippon Medical School Chiba Hokusoh Hospital that specializes in cancer and emergency care. Information was extracted from the Diagnosis Procedure Combination database (DPC) and discharge database. DPC is a nationwide administrative database for acute-care inpatients, which first emerged in 2003, and is linked to a lump-sum payment system. As of 2012, the DPC is estimated to cover approximately 53% of general hospital beds in Japan [13]. In this study, the DPC database provided information on the severity of the pneumonia in the form of an A-DROP score. Remaining data were obtained from the discharge database, including identification codes, main and subcategorized diagnoses, patient demographics, past medical history, summarized clinical courses, admission and discharge status and discharge medication. Diagnoses were coded using ICD–10.\u003c/p\u003e\n\n\u003cp\u003e\u003cem\u003eStudy subjects\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe present study included data of patients admitted between August 1, 2011 to June 30, 2017. All consecutive emergency room admissions ≥ 18 years of age with the diagnosis of pneumonia (ICD–10 codes: J18.0, J18.1, J18.2, J18.8, J18.9) were considered for inclusion. To validate community-acquired pneumonia (CAP) diagnoses, all cases were reviewed and those with clinical symptoms of pneumonia (e.g., dyspnea, cough, fever, sputum production, chest pain) that demonstrated infiltration on chest radiography within 48 hours of admission were selected. Patients were excluded if they were later defined as having health care-associated pneumonia or hospital-acquired pneumonia, if they presented with cardiopulmonary arrest on admission, consented to a do-not-resuscitate order or had incomplete data. Patients referred from or transferred to another hospital were also excluded.\u003c/p\u003e\n\n\u003cp\u003e\u003cem\u003eMeasures\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe primary outcome was all-cause, in-hospital mortality. Independent variables of interest were age, sex, pneumonia severity (A-DROP score), the primary predictor of CCI and its comorbid conditions component. Between one and six points were awarded for each condition and summed, with higher scores correlating to higher severity of comorbidity. Comorbid diseases were retrieved from past medical histories and, for each disease, the corresponding ICD–10 code was identified [14]. From this ICD code, the CCI was calculated by applying the coding algorithm and weight assignment [11,12].\u003c/p\u003e\n\u003cp\u003eThe severity of pneumonia on admission was evaluated using the A-DROP prognostic score, a modified version of the CURB–65 scoring system proposed by the Japanese Respiratory Society that is well-established and has a proven ability to predict mortality [15,16]. Age, dehydration status, respiratory failure, orientation disturbance, and blood pressure were assessed before stratifying patients into four severity classes based on total score. Age, the length of stay (LOS) and CCI were recorded and analyzed as continuous variables.\u003c/p\u003e\n\n\u003cp\u003e\u003cem\u003eData analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDue to potential bias concerns, analysis was performed twice: first, with all participants and then after excluding severe and extremely severe cases with no record of comorbidity (CCI = 0). Categorical variables are presented in absolute numbers and proportions while continuous variables are expressed as median (interquartile range). Univariate logistic regression analyses were first performed to evaluate each covariate’s individual effect on the outcome. All covariates of interest, together with their interaction term, were then entered into the multivariable logistic models and analyses were repeated after exclusion of severe to extremely severe patients with no comorbidity records. Model diagnostics were also performed which tested for the assumptions of linearity of logit (for variable age and CCI), multicollinearity, and influential cases. Odds ratios are reported with 95% confidence intervals and p values are 2-sided with a p\u0026lt;0.05 cutoff for statistical significance. All analyses were performed with SPSS (version 23, IBM Inc., USA).\u003c/p\u003e\n\n"},{"header":"Results","content":"\u003cp\u003eData from 660 individuals who were admitted to the emergency department with a pneumonia diagnosis from August 2011 to June 2017 were extracted. Of the 125 excluded cases, 64 had other principal diagnoses (e.g., lung cancer, interstitial lung diseases), 33 were later classified as either hospital-acquired or health-care associated pneumonia, 5 had an incomplete record, 6 had cardiopulmonary arrest on admission, 4 consented to a do-not-resuscitate order, and 13 were either transferred from or transferred to another hospital. Thus, a total of 535 cases were left for analysis.\u003c/p\u003e\n\u003cp\u003eThe median age (IQR) of patients was 79 (70–84) years, 369 of 535 (69.0%) were men, and all-cause, in-hospital mortality rate was 12 percent (Table 1). The cohort stayed for approximately 14 days in the hospital. In term of pneumonia severity, the majority was classified into the moderate group (338 individuals, 68.0%) whereas 100 patients (18.7%) had pneumonia at severe or extremely severe levels. The median CCI (IQR) was 1 (1–3) with roughly a quarter of the patients (131 individuals, 24.5%) scoring 2 points. The most common co-morbidities found in the CCI were malignancies (129 of 535, 24.1%), chronic pulmonary diseases (113 of 535, 21.1%) and congestive heart failure (103 of 535, 19.3%). In general, excluding cases with no record of comorbidities, there was a trend towards increasing mortality as the CCI score increased. The number rose from 6.8 percent in patients with CCI = 1 to 25.0 percent with CCI = 5.\u003c/p\u003e\n\n\u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eTable \u003c/span\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e1\u003c/span\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e. General characteristics of study subjects\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"border-collapse: collapse;\"\u003e\n\u003ctbody\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 234.7pt; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"313\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eCharacteristics\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 216.1pt; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"288\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eN = 535\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 234.7pt; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"313\"\u003e\n\u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eAge in years, median (IQR) \u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 216.1pt; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"288\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e79 (70-84)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 234.7pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"313\"\u003e\n\u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eSex, male, n (%)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 216.1pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"288\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e369 (69.0)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 234.7pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"313\"\u003e\n\u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eLength of stay in days, median (IQR)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 216.1pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"288\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e14 (9-27)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 234.7pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"313\"\u003e\n\u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eCharlson Comorbidity Index, median (IQR)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 216.1pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"288\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e1 (1-3)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 234.7pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"313\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eIn-hospital mortality, % (n/N)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 216.1pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"288\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e12.2 (64/535)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cspan style=\"font-size: 11.0pt; line-height: 150%;\"\u003eAbbreviation: IQR, interquartile range\u003c/span\u003e\u003c/p\u003e\n\n\u003cp\u003eUnivariable logistic regression modeling showed that older patients who presented with more severe pneumonia at admission were at higher risk for in-hospital death as each 1-year increase in age heightened the risk by 4 percent (odds ratio [OR] 1.04; 95% confidence interval [CI] 1.01 to 1.07). There was a trend towards increasing mortality in patients with malignancy, congestive heart failure, renal disease, diabetes with complication and dementia. The correlation between pneumonia severity and the CCI was weak, i.e., Spearman’s correlation coefficient = 0.139, p = 0.002. The multivariable regression model showed there was a tendency toward increasing mortality as A-DROP score increased but only in the extremely severe patients showed a significant difference. Among mild pneumonia patients, the prognostic impacts of CCI were marginally significant after adjustments for age and sex as a 1-point rise in CCI increased odds of death by 2-fold (OR 2.09; 95% CI 1.03–4.25). This impact, however, was reduced significantly as pneumonia severity increased (supplementary Table S1).\u003c/p\u003e\n\u003cp\u003eConsidering a potential bias, we conducted the final analysis after excluding severe and extremely severe patients whose CCI was zero (60/353; 17.0%) and found that each per unit increase in CCI resulted in a 35% increase in odds of death (OR 1.35; 95% CI 1.16 to 1.58) (Table 2). Renal disease, followed by malignancy, showed the strongest association with mortality (OR 2.42; 95% CI 1.13 to 5.21 and OR 2.25; 95% CI 1.21 to 4.17). Age, sex, A-DROP categories, CCI and their interaction terms were added as predictors for multivariate analysis but no meaningful interactions were observed. The prognostic impacts of CCI were consistent across pneumonia severity categories and a 1-point increase in CCI increased odds of death by 28 percent (OR 1.28; 95% CI 1.07–1.53) (Table 3).\u003c/p\u003e\n\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 10.0pt;\"\u003eTable 2\u003c/span\u003e\u003cspan style=\"font-size: 10.0pt;\"\u003e. Univariate analysis for in-hospital mortality\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"border-collapse: collapse;\" width=\"623\"\u003e\n\u003ctbody\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eVariables\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003en (%)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eOR\u003c/span\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e (95% CI)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003ep-value\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eAge, years\u003csup\u003ea\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e475 (88.8)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e1.04 (1.01 \u0026ndash; 1.07)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e0.01\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eSex\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 22.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"30\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 167.05pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"223\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eMale\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e329 (61.5)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003ereference\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 22.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"30\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 167.05pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"223\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eFemale\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e146 (27.3)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"margin-left: .15in; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e1.18 (0.63 \u0026ndash; 2.24)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e0.61\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003ePneumonia severity\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 22.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"30\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 167.05pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"223\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eMild\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eA-DROP=0\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e68 (12.7)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003ereference\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 22.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"30\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 167.05pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"223\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eModerate \u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eA-DROP=1-2\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e338 (63.2)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"margin-left: 15.3pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e1.28 (0.43-3.80)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e0.66\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 22.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"30\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 167.05pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"223\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eSevere\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eA-DROP=3\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e52 (9.7)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"margin-left: 15.3pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e4.29 (1.28-14.39)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e0.02\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 22.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"30\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 167.05pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"223\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eExtremely severe\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eA-DROP=4-5\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e17 (3.2)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"margin-left: 15.3pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e11.20 (2.77-45.31)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026lt;0.01\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eCharlson Comorbidity Index (CCI)\u003csup\u003eb\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e475 (88.7)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e1.35 (1.16-1.58)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026lt;0.01\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 467.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"5\" width=\"623\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eCharlson Comorbidity Index components\u003csup\u003ec\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eAny malignancy\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"margin-left: 26.1pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eNo\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e349 (73.5)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003ereference\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"margin-left: 26.1pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eYes\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e126 (26.5)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"margin-left: 15.3pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e2.25 (1.21-4.17)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e0.01\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eChronic pulmonary disease\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"margin-left: 26.1pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eNo\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e367 (77.3)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003ereference\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"margin-left: 26.1pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eYes\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e108 (22.7)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"margin-left: 15.3pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e1.04 (0.51-2.13)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e0.91\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eCongestive heart failure\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"margin-left: 26.1pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eNo\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e375 (78.9)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003ereference\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"margin-left: 26.1pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eYes\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e100 (21.1)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"margin-left: 15.3pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e1.89 (0.98-3.65)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e0.06\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eRenal disease\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"margin-left: 26.1pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eNo\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e422 (88.8)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003ereference\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"margin-left: 26.1pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eYes\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e53 (11.2)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"margin-left: 15.3pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e2.42 (1.13-5.21)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e0.02\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eDiabetes with complication\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"margin-left: 26.1pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eNo\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e434 (91.4)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003ereference\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"margin-left: 26.1pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eYes\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e41 (8.6)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"margin-left: 15.3pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e2.03 (0.84-4.87)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e0.11\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eDementia\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"margin-left: 26.1pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eNo\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e435 (91.6)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003ereference\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"margin-left: 26.1pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eYes\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e40 (8.4)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"margin-left: 15.3pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e2.10 (0.87-5.04)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e0.10\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eRheumatologic disease\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"margin-left: 26.1pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eNo\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e459 (96.6)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003ereference\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"margin-left: 26.1pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eYes\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e16 (3.4)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"margin-left: 15.3pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e1.31 (0.29-5.97)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e0.72\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eMild liver disease\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"margin-left: 26.1pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eNo\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e460 (96.8)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003ereference\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 189.55pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"253\"\u003e\n\u003cp style=\"margin-left: 26.1pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eYes\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 90.85pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"121\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e15 (3.2)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 133.35pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"178\"\u003e\n\u003cp style=\"margin-left: 15.3pt; text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e0.64 (0.08-5.00)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 53.75pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"72\"\u003e\n\u003cp style=\"text-align: left; line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003e0.67\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style=\"line-height: 130%;\"\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eAbbreviations: OR, odds ratio; CI, confidence interval\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"line-height: 130%;\"\u003e\u003csup\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003ea\u003c/span\u003e\u003c/sup\u003e\u003cspan style=\"font-size: 10.0pt; line-height: 130%;\"\u003eOR for one year increasing in age; \u003csup\u003eb\u003c/sup\u003eOR for one point increasing in CCI; \u003csup\u003ec\u003c/sup\u003eConditions which has less than 10 cases were not analyzed. \u003c/span\u003e\u003c/p\u003e\n\n\u003cp style=\"margin-bottom: .0001pt;\"\u003e\u003cspan style=\"font-size: 11.0pt; line-height: 150%; font-family: 'Century',serif;\"\u003eTable 3. Multivariable logistic regression analysis for in-hospital mortality \u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"border-collapse: collapse;\" width=\"636\"\u003e\n\u003ctbody\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 163.05pt; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"217\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eVariables\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 70.85pt; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"94\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eNo. of deaths/total number\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 42.55pt; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"57\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eB\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 148.8pt; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"198\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eOR\u003c/span\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e (95% CI)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 51.5pt; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"69\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003ep-value\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 163.05pt; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"217\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eAge, years\u003csup\u003ea\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 70.85pt; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"94\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e47/475\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 42.55pt; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"57\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e0.03\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 148.8pt; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"198\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e1.03 (0.99 \u0026ndash; 1.07)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 51.5pt; border: none; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"69\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e0.08\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 163.05pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"217\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eSex\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 70.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"94\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 42.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"57\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 148.8pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"198\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 51.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"69\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 22.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"30\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 140.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"187\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eMale\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 70.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"94\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e31/329\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 42.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"57\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 148.8pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"198\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003ereference\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 51.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"69\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 22.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"30\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 140.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"187\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eFemale\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 70.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"94\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e16/146\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 42.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"57\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e0.34\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 148.8pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"198\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e1.41 (0.71-2.83)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 51.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"69\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e0.33\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 163.05pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"217\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003ePneumonia severity\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 70.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"94\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 42.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"57\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 148.8pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"198\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 51.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"69\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 22.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"30\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 140.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"187\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eMild\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eA-DROP=0\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 70.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"94\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e4/68\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 42.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"57\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 148.8pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"198\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003ereference\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 51.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"69\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 22.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"30\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 140.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"187\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eModerate \u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eA-DROP=1-2\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 70.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"94\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e25/338\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 42.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"57\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e-0.31\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 148.8pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"198\"\u003e\n\u003cp style=\"margin-left: 15.3pt; text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e0.73 (0.22-2.41)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 51.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"69\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e0.61\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 22.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"30\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 140.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"187\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eSevere\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eA-DROP=3\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 70.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"94\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e11/52\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 42.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"57\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e0.59\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 148.8pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"198\"\u003e\n\u003cp style=\"margin-left: 15.3pt; text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e1.80 (0.47-6.96)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 51.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"69\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e0.39\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 22.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"30\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 140.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"187\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eExtremely severe\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eA-DROP=4-5\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 70.85pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"94\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e7/17\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 42.55pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"57\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e1.60\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 148.8pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"198\"\u003e\n\u003cp style=\"margin-left: 15.3pt; text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e4.92 (1.11-21.98)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 51.5pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"69\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e0.04\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 1.0pt;\"\u003e\n\u003ctd style=\"width: 163.05pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" colspan=\"2\" width=\"217\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eCharlson Comorbidity Index (CCI)\u003csup\u003eb\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 70.85pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"94\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e47/475\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 42.55pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"57\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e0.25\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 148.8pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"198\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e1.28 (1.07-1.53)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 51.5pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 1.0pt;\" width=\"69\"\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003e\u0026lt;0.01\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eAbbreviations: B, beta coefficient; OR, odds ratio; CI, confidence interval\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003ea\u003c/span\u003e\u003c/sup\u003e\u003cspan style=\"font-size: 11.0pt;\"\u003eOR for one year increasing in age; \u003csup\u003eb\u003c/sup\u003eOR for one point increasing in CCI\u003c/span\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\n\u003cp\u003eThis study found that higher CCI scores were associated with increased risk for all-cause, in-hospital mortality and this association persisted after adjustment for potential confounders. This interesting result stems from the fact that, although the index has been proven reliable for the long-term prognosis of CAP, there has been little discussion on how it influences short-term outcomes. In their study of 108 patients, Franzen and colleagues [17] reported that pneumonia in-hospital mortality trended upward as CCI rose (HR 1.10; 95% CI 0.99 to 1.23). In another study conducted on 373 Japanese patients, Torres and colleagues [18] were unable to find any impact of CCI on the mortality of elderly patients with CAP but details regarding A-DROP scores and direction of the associations were not reported.\u003c/p\u003e\n\u003cp\u003eNotably high proportions of this population suffered from malignancy (24.1%), chronic pulmonary diseases (21.1%) and congestive heart failure (19.3%). Studies conducted in other Japanese teaching hospitals have reported that approximately 8.8% to 19.0% of patients had malignancy while 5.4% to 12.7% suffered from congestive heart failure [19,20,21]. Our result was not unexpected, as the Chiba Hokusoh Hospital serves as a Chiba Cancer Treatment Regional Base Hospital and therefore has a considerable number of patients undergoing cancer treatment. In addition, since the average age was 79 years old, this would have contributed to increased complications.\u003c/p\u003e\n\u003cp\u003eWe surprisingly discovered that patients with severe conditions (A-DROP = 3–5) but no comorbidities had the highest mortality rate at 48.0 percent. Contrary to expectations, individuals in the most severe group who had higher CCI seemed to survive better while those who scored zero on the CCI tended to die. One possible explanation is that these severe cases might receive treatment priority due to physician triage and collecting the past medical history was only done once the emergency situation was resolved. Patients who died quickly were more likely to have their disease history recorded incompletely and, as a result, they would tend to score 0 on the CCI. We posit that if information had been more thoroughly collected in these patients, their CCI scores would have been higher and have truly reflected their comorbidities. Sensitivity analyses were carried out to minimize this classification bias and, although a notable improvement observed in the results has strengthened our hypothesis, further studies with large representative samples are required to confirm our observation.\u003c/p\u003e\n\n"},{"header":"Limitations","content":"\n\u003cp\u003eThis study was conducted using retrospective data of a rural tertiary teaching hospital in Japan. The inclusion criteria were limited only to patients with a principal diagnosis of pneumonia. Several factors associated with mortality were not considered. Furthermore, the study could not identify deaths outside of the hospital that may have been tied to the pneumonia diagnosis.\u003c/p\u003e\n\n"},{"header":"Abbreviations","content":"\n\u003cp\u003eCAP: community-acquired pneumonia; CCI: Charlson comorbidity index; CI: confidence interval; DPC: Diagnosis procedure combination database; ICD: International classification of diseases; ICU: intensive care unit; IQR: interquartile range OR: odds ratio\u003c/p\u003e\n\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eAuthors’ contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMTNN lead study conceptualization, data analysis and writing of the munuscript. NS was involved in data prepatation and interpretation of data analysis. YW was involved in study conceptualization, interpretation of data analysis, and contributed to the writing of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthor details\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eDepartment of Clinical Trials and Clinical Epidemiology, Graduate School of Comprehensive Human Sciences, University of Tsukuba, 1–1–1 Tennodai, Tsukuba, Ibaraki 305–8575, Japan. \u003csup\u003e2\u003c/sup\u003eThe Shock and Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba 270–1694, Japan. \u003csup\u003e3\u003c/sup\u003eDepartment of Clinical Trials and Clinical Epidemiology, Faculty of Medicine, University of Tsukuba, 1–1–1 Tennodai, Tsukuba, Ibaraki 305–8575, Japan.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to extend our appreciation to the staff of Chiba Hokusoh Hospital who contributed for the hospital surveillance system.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of Nippon Medical University Chiba Hokusoh Hospital (Approval No. 590). Because of the anonymous nature of data, the need for informed consent was waived.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis work was funded in part by the Research and Education Fund of Faculty of Medicine, University of Tsukuba. The funding body had no role in the design of the study and collection, analysis and interpretation of data, and in writing the manuscript.\u003c/p\u003e\n\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFile TM, Jr., Marrie TJ. Burden of community-acquired pneumonia in North American adults. Postgraduate medicine. 2010;122:130-41.\u003c/li\u003e\n\u003cli\u003eFine MJ, Smith MA, Carson CA, Mutha SS, Sankey SS, Weissfeld LA, Kapoor WN. Prognosis and outcomes of patients with community-acquired pneumonia. Ameta-analysis. JAMA. 1996;275:134-41.\u003c/li\u003e\n\u003cli\u003eMorimoto K, Suzuki M, Ishifuji T, Yaegashi M, Asoh N, Hamashige N, Abe M,Aoshima M, Ariyoshi K; Adult Pneumonia Study Group-Japan (APSG-J). The burden andetiology of community-onset pneumonia in the aging Japanese population: amulticenter prospective study. PLoS One. 2015;10:e0122247.\u003c/li\u003e\n\u003cli\u003eKajikawa N, Kataoka Y, Goto R, Maeno T, Yokota S, Umeyama S, Takahashi S, Maeno T. Factors associated with influenza vaccination in Japanese elderly outpatients. Infect Dis Health. 2019;24:212-21.\u003c/li\u003e\n\u003cli\u003eShono A, Hoshi SL, Kondo M. The impact on vaccination coverage following introduction of a routine pneumococcal vaccination programme for the elderly in Japan. Vaccine. 2018;36:5886-90.\u003c/li\u003e\n\u003cli\u003e6. Yurkovich M, Avina-Zubieta JA, Thomas J, Gorenchtein M, Lacaille D. A systematic review identifies valid comorbidity indices derived from administrative health data. Journal of clinical epidemiology. 2015;68:3-14.\u003c/li\u003e\n\u003cli\u003eCharlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. Journal of chronic diseases. 1987;40:373-83.\u003c/li\u003e\n\u003cli\u003eDeyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. Journal of clinical epidemiology. 1992;45:613-19.\u003c/li\u003e\n\u003cli\u003eRomano PS, Roos LL, Jollis JG. Adapting a clinical comorbidity index for use with ICD-9-CM administrative data: differing perspectives. Journal of clinical epidemiology. 1993;46:1075-1079; discussion 1081-90.\u003c/li\u003e\n\u003cli\u003eD'Hoore W, Bouckaert A, Tilquin C. Practical considerations on the use of the Charlson comorbidity index with administrative data bases. \u003cem\u003eJournal of clinical epidemiology. \u003c/em\u003e1996;49:1429-33.\u003c/li\u003e\n\u003cli\u003eQuan H, Sundararajan V, Halfon P, Fong A, Burnand B, Luthi JC, Saunders LD,Beck CA, Feasby TE, Ghali WA. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care. 2005;43:1130-9.\u003c/li\u003e\n\u003cli\u003eQuan H, Li B, Couris CM, Fushimi K, Graham P, Hider P, Januel JM, SundararajanV. Updating and validating the Charlson comorbidity index and score for riskadjustment in hospital discharge abstracts using data from 6 countries. Am J Epidemiol. 2011;173:676-82.\u003c/li\u003e\n\u003cli\u003eHealth and Global Policy Institute. Payment System. \u003cem\u003eJapan Health Policy NOW\u003c/em\u003e 2016; \u003ca href=\"http://japanhpn.org/en/finan2/\"\u003ehttp://japanhpn.org/en/finan2/\u003c/a\u003e. Accessed September 10, 2019.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. ICD-10 Version : 2016. 2016; \u003ca href=\"http://apps.who.int/classifications/icd10/browse/2016/en#/I48\"\u003ehttp://apps.who.int/classifications/icd10/browse/2016/en#/I48\u003c/a\u003e. Accessed September 10, 2019.\u003c/li\u003e\n\u003cli\u003eMiyashita N, Matsushima T, Oka M, Japanese Respiratory S. The JRS guidelines for the management of community-acquired pneumonia in adults: an update and new recommendations. Internal medicine (Tokyo, Japan). 2006;45:419-28.\u003c/li\u003e\n\u003cli\u003eNeill AM, Martin IR, Weir R, Anderson R, Chereshsky A, Epton MJ, Jackson R,Schousboe M, Frampton C, Hutton S, Chambers ST, Town GI. Community acquiredpneumonia: aetiology and usefulness of severity criteria on admission. Thorax.1996;51:1010-6.\u003c/li\u003e\n\u003cli\u003eFranzen D, Lim M, Bratton DJ, Kuster SP, Kohler M. The Roles of the Charlson Comorbidity Index and Time to First Antibiotic Dose as Predictors of Outcome in Pneumococcal Community-Acquired Pneumonia. \u003cem\u003eLung. \u003c/em\u003e2016;194:769-75.\u003c/li\u003e\n\u003cli\u003eTorres OH, Mu\u0026ntilde;oz J, Ruiz D, Ris J, Gich I, Coma E, Gurgu\u0026iacute; M, V\u0026aacute;zquez G.Outcome predictors of pneumonia in elderly patients: importance of functionalassessment. J Am Geriatr Soc. 2004;52:1603-9.\u003c/li\u003e\n\u003cli\u003eMatsunuma R, Asai N, Ohkuni Y, Nakashima K, Iwasaki T, Misawa M, Norihiro K.I-ROAD could be efficient in predicting severity of community-acquired pneumonia or healthcare-associated pneumonia. Singapore Med J. 2014;55:318-24.\u003c/li\u003e\n\u003cli\u003eTashiro M, Fushimi K, Takazono T, Kurihara S, Miyazaki T, Tsukamoto M,Yanagihara K, Mukae H, Tashiro T, Kohno S, Izumikawa K. A mortality predictionrule for non-elderly patients with community-acquired pneumonia. BMC Pulm Med. 2016;16:39.\u003c/li\u003e\n\u003cli\u003eOgasawara T, Umezawa H, Naito Y, Takeuchi T, Kato S, Yano T, Kasamatsu N,Hashizume I. Procalcitonin-guided antibiotic therapy in aspiration pneumonia and an assessment of the continuation of oral intake. Respir Investig. 2014;52:107-13.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-research-notes","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"resn","sideBox":"Learn more about [BMC Research Notes](http://bmcresnotes.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/resn/default.aspx","title":"BMC Research Notes","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"community-acquired pneumonia, mortality, comorbidity, Charlson Comorbidity Index","lastPublishedDoi":"10.21203/rs.2.16128/v3","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.2.16128/v3","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eObjective \u003c/p\u003e\u003cp\u003ePneumonia is a common but serious illness that continues to present significant morbidity and mortality. Although the effect of severity at admission on outcome has been well reported, the role of comorbidity is still not widely understood. The Charlson Comorbidity Index measures comorbidity with a well-established history of predicting long-term outcome but its utility in pneumonia prognosis is still limited. Here, we use the Charlson Comorbidity Index and hospital surveillance data to investigate associations between comorbidities and in-hospital mortality due to community-acquired pneumonia.\u003c/p\u003e\u003cp\u003eResults \u003c/p\u003e\u003cp\u003eAmong the 535 eligible adult patients (69.0% male, median [IQR] age, 79 [70-84] years), 100 (18.7%) acquired severe to extremely severe pneumonia. The median [IQR] CCI was 1[1-3]. Malignancy (129 of 535, 24.1%), chronic pulmonary diseases (113 of 535, 21.1%) and congestive heart failure (103 of 535, 19.3%) were frequent. Higher Charlson Comorbidity Index scores were associated with higher risk of in-hospital mortality (OR 1.28; 95% CI 1.07-1.53). These results support the inclusion of comorbid burden in predicting community-acquired pneumonia outcome.\u003c/p\u003e","manuscriptTitle":"The effect of comorbidities for the prognosis of community-acquired pneumonia: an epidemiologic study using a hospital surveillance in Japan","msid":"","msnumber":"","nonDraftVersions":[{"code":3,"date":"2019-12-18 14:03:19","doi":"10.21203/rs.2.16128/v3","editorialEvents":[{"type":"communityComments","content":0},{"type":"checksComplete","content":"","date":"2019-12-08T12:00:00+00:00","index":"","fulltext":""},{"type":"decision","content":"Accept","date":"2019-12-06T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-research-notes","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"resn","sideBox":"Learn more about [BMC Research 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revision","date":"2019-12-04T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2019-11-29T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2019-11-28T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2019-11-28T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-research-notes","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"resn","sideBox":"Learn more about [BMC Research Notes](http://bmcresnotes.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/resn/default.aspx","title":"BMC Research Notes","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2019-10-16 23:09:49","doi":"10.21203/rs.2.16128/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2019-11-15T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2019-10-22T12:00:00+00:00","index":1,"fulltext":"Recommendation: Reviewer's comments unavailable due to the journal's policy.\n"},{"type":"checksComplete","content":"","date":"2019-10-11T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2019-10-11T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2019-10-11T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2019-10-11T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2019-10-11T12:00:00+00:00","index":1,"fulltext":""},{"type":"submitted","content":"","date":"2019-10-04T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-research-notes","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"resn","sideBox":"Learn more about [BMC Research Notes](http://bmcresnotes.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/resn/default.aspx","title":"BMC Research Notes","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"55fe58c8-c393-462b-930d-5941a047ba04","owner":[],"postedDate":"December 18th, 2019","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":43548,"name":"Health Economics \u0026 Outcomes Research"},{"id":43549,"name":"Epidemiology"}],"tags":[],"updatedAt":"2020-05-14T08:44:25+00:00","versionOfRecord":{"articleIdentity":"rs-6779","link":"https://doi.org/10.1186/s13104-019-4848-1","journal":{"identity":"bmc-research-notes","isVorOnly":false,"title":"BMC Research Notes"},"publishedOn":"2019-12-19 12:00:00","publishedOnDateReadable":"December 19th, 2019"},"versionCreatedAt":"2019-12-18 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