Journal of General Internal Medicine

, Volume 33, Issue 4, pp 437–444 | Cite as

A Composite of Functional Status and Pneumonia Severity Index Improves the Prediction of Pneumonia Mortality in Older Patients

  • Francisco Sanz
  • María Morales-Suárez-Varela
  • Estrella Fernández
  • Luis Force
  • María José Pérez-Lozano
  • Vicente Martín
  • Mikel Egurrola
  • Jesús Castilla
  • Jenaro Astray
  • Diana Toledo
  • Ángela Domínguez
  • Project PI12/02079 Working Group
Original Research



The baseline health status may be a determinant of interest in the evolution of pneumonia.


Our objective was to assess the predictive ability of community-acquired pneumonia (CAP) mortality by combining the Barthel Index (BI) and Pneumonia Severity Index (PSI) in patients aged ≥ 65 years.

Design, patients and main measures

In this prospective, observational, multicenter analysis of comorbidities, the clinical data, additional examinations and severity of CAP were measured by the PSI and functional status by the BI. Two multivariable models were generated: Model 1 including the PSI and BI and model 2 with PSI plus BI stratified categorically.

Key results

The total population was 1919 patients, of whom 61% had severe pneumonia (PSI IV–V) and 40.4% had some degree of dependence (BI ≤ 90 points). Mortality in the PSI V–IV group was 12.5%. Some degree of dependence was associated with increased mortality in both the mild (7.2% vs. 3.2%; p = 0.016) and severe (14% vs. 3.3%; p < 0.001) pneumonia groups. The combination of PSI IV–V and BI ≤ 90 was the greatest risk factor for mortality (aOR 4.17; 95% CI 2.48 to 7.02) in our series.


The use of a bimodal model to assess CAP mortality (PSI + BI) provides more accurate prognostic information than the use of each index separately.


functional status community-acquired pneumonia severity assessment 



The members of the Project PI12/02079 Working Group are: Andalusia: J.M. Mayoral (Servicio de Vigilancia de Andalucía), J. Díaz-Borrego (Servicio Andaluz de Salud), A. Morillo (Hospital Universitario Virgen del Rocío), M.J. Pérez-Lozano (Hospital Universitario Virgen de Valme), J. Gutiérrez (Hospital Universitario Puerta del Mar), M. Pérez-Ruiz, M.A. Fernández-Sierra (Complejo Hospitalario Universitario de Granada). Castile and Leon: S. Tamames (Dir. General de Salud Pública, Investigación, Desarrollo e Innovación, Junta de Castilla y León), S. Rojo-Rello (Hospital Clínico Universitario de Valladolid), R. Ortiz de Lejarazu (Universidad de Valladolid), M.I. Fernández-Natal (Complejo Asistencial Universitario de León), T. Fernández-Villa (GIIGAS-Grupo de Investigación en Interacción Gen-Ambiente y Salud, Universidad de León), A. Pueyo (Hospital Universitario de Burgos), V. Martin (Universidad de León; CIBERESP). Catalonia: A. Vilella (Hospital Clínic), M. Campins, A. Antón (Hospital Universitari Vall d’Hebron; Universitat Autónoma de Barcelona), G. Navarro (Corporació Sanitària i Universitaria Parc Taulí), M. Riera (Hospital Universitari MútuaTerrassa), E. Espejo (Hospital de Terrassa), M.D. Mas, R. Pérez (ALTHAIA, Xarxa Hospitalaria de Manresa), J.A. Cayla, C. Rius (Agència de Salut Pública de Barcelona; CIBERESP), P. Godoy (Agència de Salut Pública de Catalunya; Institut de Recerca Biomèdica de Lleida, Universitat de Lleida; CIBERESP), N. Torner (Agència de Salut Pública de Catalunya; Universitat de Barcelona; CIBERESP), C. Izquierdo, R. Torra (Agència de Salut Pública de Catalunya), L. Force (Hospital de Mataró), A. Domínguez, N. Soldevila, D. Toledo, I. Crespo (Universitat de Barcelona; CIBERESP). Madrid: J. Astray, M.F. Domínguez-Berjon, M.A. Gutiérrez, S. Jiménez, E. Gil, F. Martín, R.Génova-Maleras (Consejería de Sanidad), M.C. Prados, F. Enzzine de Blas, M.A. Salvador, J. Rodríguez, M. Romero (Hospital Universitario la Paz), J.C Galán, E. Navas, L. Rodríguez-Rojas (Hospital Ramón y Cajal), C.J. Álvarez, E. Banderas, S. Fernández (Hospital Universitario 12 de Octubre). Navarra: J. Chamorro (Complejo Hospitalario de Navarra), I. Casado, J. Díaz (Instituto de Salud Pública, Instituto de Investigación Sanitaria de Navarra; CIBERESP), J. Castilla (Instituto de Salud Pública, Instituto de Investigación Sanitaria de Navarra; CIBERESP). The Basque Country: M. Egurrola, M.J. López de Goicoechea (Hospital de Galdakao). Valencia Community: M. Morales-Suárez-Varela (Universidad de Valencia; CIBERESP), F. Sanz (Consorci Hospital General Universitari de Valencia).

Prior presentations

This work has not been presented in any meeting or conference.

Author Contributions

Substantial contributions to conception or design of the work: FS, MM, EF, LF, MJP, VM, ME, JC, JA, DT, AD. Substantial contributions to the acquisition, analysis, and interpretation of data for the work: FS and EF. Drafting of the work or revising it critically for important intellectual content: FS, MM, EF, LF, MJP, VM, ME, JC, JA, DT, AD. Final approval of the version to be published: FS, MM, EF, LF, MJP, VM, ME, JC, JA, DT, AD. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: FS, MM, EF, LF, MJP, VM, ME, JC, JA, DT, AD


This study was funded by the National Plan of I+D+I 2008-2011 and ISCIII-Subdirección General de Evaluación y Fomento de la Investigación (Project PI12/02079) and co-funded by Fondo Europeo de Desarrollo Regional (FEDER) and the Catalan Agency for the Management of Grants for University Research (AGAUR grant no. 2014/ SGR 1403).

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.


  1. 1.
    Capelastegui A, España PP, Bilbao A, et al. Poblational Study of Pneumonia (PSoP) Group. Study of community-acquired pneumonia: incidence, patterns of care, and outcomes in primary and hospital care. J Infect. 2010;61:364-71.CrossRefPubMedGoogle Scholar
  2. 2.
    Kaplan V, Angus DC, Griffin MF, et al. Hospitalized Community-acquired pneumonia in the elderly: age and sex-related patterns of care and outcome in the United States. Am J Respir Crit Care Med. 2002;165: 766-772.CrossRefPubMedGoogle Scholar
  3. 3.
    Kothe H, Bauer T, Marre R, Suttorp N, Welte T, Dalhoff K; Competence Network for Community-Acquired Pneumonia study group. Outcome of community-acquired pneumonia: influence of age, residence status and antimicrobial treatment. Eur Respir J. 2008;32:139-46.CrossRefPubMedGoogle Scholar
  4. 4.
    Spoorenberg SM, Bos WJ, Heijligenberg R, et al. Microbial aetiology, outcomes, and costs of hospitalisation for community-acquired pneumonia; an observational analysis. BMC Infect Dis. 2014;14:335.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997;3364:243–50.CrossRefGoogle Scholar
  6. 6.
    Lim W, van der Eerden MM, Laing R, et al. Defining community-acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003;58(5):377-382.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Marrie TJ. Community-acquired pneumonia in the elderly. Clin Infect Dis. 2000;31:1066-78.CrossRefPubMedGoogle Scholar
  8. 8.
    Cabré M, Serra-Prat M, Force L, Palomera E, Pallarés R. Functional status as a risk factor for mortality in very elderly patients with pneumonia. Med Clin (Barc). 2008;131:167-70.CrossRefGoogle Scholar
  9. 9.
    Ma HM, Tang WH, Woo J. Predictors of in-hospital mortality of older patients admitted for community-acquired pneumonia. Age Ageing. 2011;40:736-41.CrossRefPubMedGoogle Scholar
  10. 10.
    Briggs R, Coughlan T, Collins R, O’Neill D, Kennelly SP. Nursing home residents attending the emergency department: clinical characteristics and outcomes. QJM. 2013;106:803-8.CrossRefPubMedGoogle Scholar
  11. 11.
    Brito V, Niederman MS. Predicting mortality in the elderly with community-acquired pneumonia: should we design a new car or set a new ‘speed limit’?. Thorax. 2010;65:944-5.CrossRefPubMedGoogle Scholar
  12. 12.
    Zalacain R, Torres A, Celis R, et al; Pneumonia in the elderly working group, Area de Tuberculosis e Infecciones Respiratorias. Community-acquired pneumonia in the elderly: Spanish multicentre study. Eur Respir J. 2003;21(2):294-302.Google Scholar
  13. 13.
    Chong CP, Street PR. Pneumonia in the elderly: a review of severity assessment, prognosis, mortality, prevention, and treatment. South Med J. 2008;101:1134-40.CrossRefPubMedGoogle Scholar
  14. 14.
    Ewig S, Welte T, Chastre J, Torres A. Rethinking the concepts of community-acquired and health-care-associated pneumonia. Lancet Infect Dis. 2010;10:279-87.CrossRefPubMedGoogle Scholar
  15. 15.
    Chan TC, Hung IF, Luk JK, et al. Functional status of older nursing home residents can affect the efficacy of influenza vaccination. J Gerontol A BiolSci Med Sci. 2013 ;68:324-30.CrossRefGoogle Scholar
  16. 16.
    de Morton NA, Keating JL, Davidson M. Rasch analysis of the Barthel Index in the assessment of hospitalized older patients after admission for an acute medical condition. Arch Phys Med Rehabil. 2008;89:641-7.CrossRefPubMedGoogle Scholar
  17. 17.
    Uematsu H, Kunisawa S, Yamashita K, Imanaka Y. The impact of patient profiles and procedures on hospitalization costs through length of stay in community-acquired pneumonia patients based on a Japanese administrative database. PLoS One. 2015;10: e0125284.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Matzen LE, Jepsen DB, Ryg J, Masud T. Functional level at admission is a predictor of survival in older patients admitted to an acute geriatric unit. BMC Geriatr. 2012;12:32.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Murcia J, Llorens P, Sánchez-Payá J, et al. Functional status determined by Barthel Index predicts community-acquired pneumonia mortality in general population. J Infect. 2010;61:458-64.CrossRefPubMedGoogle Scholar
  20. 20.
    Mody L, Sun R, Bradley SF. Assessment of pneumonia in older adults: effect of functional status. J Am Geriatr Soc. 2006;54:1062-7.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Lim WS, Baudouin SV, George RC, et al. Pneumonia Guidelines Committee of the BTS Standards of Care Committee. BTS guidelines for the management of community-acquired pneumonia in adults: update 2009. Thorax. 2009; 64(Suppl. 3): iii1–55.PubMedGoogle Scholar
  22. 22.
    Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md Med J. 1965;14: 61-65.Google Scholar
  23. 23.
    Kolditz M, Ewig S, Klapdor B, et al; CAPNETZ study group. Community-acquired pneumonia as medical emergency: predictors of early deterioration. Thorax. 2015;70(6):551-8.CrossRefPubMedGoogle Scholar
  24. 24.
    Yalçinli S, Ersel M, Karbek Akarca F,Can O, Midik S. Can Barthel Index predict mortality in geriatric patients admitted to the emergency department with a high fever? Turk J Geriatr. 2015;18(4):266-272.Google Scholar
  25. 25.
    Shiao CC, Hsu HC, Chen IL, et al. Lower Barthel Index is associated with higher risk of hospitalization-requiring pneumonia in long-term care facilities. Tohoku J Exp Med. 2015;236:281-8.CrossRefPubMedGoogle Scholar
  26. 26.
    Dhawan N, Pandya N, Khalili M, et al. Predictors of mortality for nursing home-acquired pneumonia: a systematic review. Biomed Res Int. 2015;2015:285983.Google Scholar
  27. 27.
    Torres OH, Muñoz J, Ruiz D, et al. Outcome predictors of pneumonia in elderly patients: importance of functional assessment. J Am Geriatr Soc. 2004;52:1603-9.CrossRefPubMedGoogle Scholar
  28. 28.
    Calle A, Márquez MA, Arellano M, Pérez LM, Pi-Figueras M, Miralles R. Geriatric assessment and prognostic factors of mortality in very elderly patients with community-acquired pneumonia. Arch Bronconeumol.2014 ;50:429-34.CrossRefPubMedGoogle Scholar
  29. 29.
    Corrales-Medina VF, Alvarez KN, Weissfeld LA et al. Association between hospitalization for pneumonia and subsequent risk of cardiovascular disease. JAMA 2015; 313(3):264–274.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Violi F, Cangemi R, Falcone M, et al. Cardiovascular complications and short-term mortality risk in community-acquired pneumonia. Clin Infect Dis 2017;64:1486-1493.CrossRefPubMedGoogle Scholar
  31. 31.
    Marrie TJ, Wu L. Factors influencing in-hospital mortality in community-acquired pneumonia: a prospective study of patients not initially admitted to the ICU. Chest. 2005;127:1260-70.PubMedGoogle Scholar
  32. 32.
    Oken M, Creech R, Tormey D, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol. 1982;5:649-655.CrossRefPubMedGoogle Scholar
  33. 33.
    Yeon Lee S, Cha SI, Seo H, et al. Multimarker prognostication for hospitalized patients with community-acquired pneumonia. Intern Med. 2016;55:887-93.CrossRefPubMedGoogle Scholar
  34. 34.
    Wójkowska-Mach J, Gryglewska B, Romaniszyn D, et al. Age and other risk factors of pneumonia among residents of Polish long-term care facilities. Int J Infect Dis. 2013;17:e37-43.CrossRefPubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2017

Authors and Affiliations

  • Francisco Sanz
    • 1
  • María Morales-Suárez-Varela
    • 2
    • 3
  • Estrella Fernández
    • 1
  • Luis Force
    • 4
  • María José Pérez-Lozano
    • 5
  • Vicente Martín
    • 6
  • Mikel Egurrola
    • 7
  • Jesús Castilla
    • 3
    • 8
  • Jenaro Astray
    • 9
  • Diana Toledo
    • 3
    • 10
  • Ángela Domínguez
    • 3
    • 10
  • Project PI12/02079 Working Group
  1. 1.Consorci Hospital General Universitari de ValènciaValènciaSpain
  2. 2.Universitat de ValènciaValènciaSpain
  3. 3.CIBER Epidemiología y Salud Pública (CIBERESP)MadridSpain
  4. 4.Hospital de MataróMataróSpain
  5. 5.Hospital Universitario Virgen de ValmeSevillaSpain
  6. 6.Universidad de LeónLeónSpain
  7. 7.Hospital de GaldakaoUsansoloSpain
  8. 8.Instituto de Salud Pública de NavarraIdiSNAPamplonaSpain
  9. 9.Consejería de SanidadMadridSpain
  10. 10.Departament de Salut PúblicaUniversitat de BarcelonaBarcelonaSpain

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