The Burden of CABP in the United States

In this podcast, Christian Sandrock, MD, MPH, talks about the burden of community-acquired bacterial pneumonia (CABP) in the United States, including the financial burden, the burden on hospitals, and readmission rates. This is part 1 of 3 podcasts on CABP from Dr Sandrock.

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Christian Sandrock, MD, MPH, is a pulmonary, critical care, and infectious disease physician and professor of medicine at the University of California Davis in Sacramento, California.



Amanda Balbi: Hello everyone, and welcome to another installment of Podcasts360, your go-to resource for medical news and clinical updates. I’m your moderator, Amanda Balbi with Consultant360.

Our guest today is Dr Christian Sandrock, who is a pulmonary, critical care, and infectious disease physician and professor of medicine at the University of California Davis in Sacramento, California. Today he joins us to share his thoughts on the burden of community-acquired bacterial pneumonia (or CABP) in the United States.

CABP is the most common infectious cause of death in the United States. Can you talk more about the burden of CABP on morbidity and mortality in the United States?

Christian Sandrock: Community-acquired bacterial pneumonia, and if we even just talk about community-acquired pneumonia in general, which has some viral components, they go hand-in-hand. They create a moderately high morbidity and mortality in the US. Now in relative terms, their morbidity tends to outweigh their mortality. What I mean by that is the most common cause of infectious death is pneumonia, both viral and bacterial.

It's probably number 6 or 7 or 8, depending on the year, overall causes of death. But then when you look at things such as morbidity, deconditioning, rehospitalization/readmissions, nursing home stays … that's where you know the morbidity portion is relatively high.

It's not totally isolated to the older population, but it certainly plays a bigger role in the older population, so we always had this phrase, when I was a fellow, which is, “You know if someone lives long enough, they're going to eventually die of pneumococcus.” It essentially means that that risk factor of as you continue to get older, the likelihood of you getting bacterial pneumonia just continues to rise to the point where it's otherwise inevitable. So, we certainly see that morbidity and mortality play a role, particularly in older individuals.

As we've obviously learned with COVID-19 and other things, it's playing an active role in our middle-aged and younger adults as well now.

Amanda Balbi: For US adults, pneumonia is the second-most common cause of hospital admissions, after women giving birth. What is the overall burden of CABP on the US health system?

Christian Sandrock: It obviously plays a really big role of admission, and we can talk about that in a second as well. Its burden is relatively high now. Before the COVID-19 pandemic, many US health systems were already on the edge of having issues with space and ability to manage all of their patients. That has obviously been exacerbated by the pandemic.

Having that burden, where you have patients getting admitted with community-acquired pneumonia when they otherwise may not need to be admitted, then that takes away an opportunity for us to provide care, maybe orthopedic care for hip fracture. It might actually mean cancer care for some of our patients.

So, I think that burden is No. 1 financial, and you have a lot of patients coming in with community-acquired pneumonia. They often outstay what we would call their “financial limit” of where we would be able to take care of them, so it burdens hospitals financially. It's certainly, and I think more importantly, burdens hospitals in communities where you now don't have an overall bed available.

The cost is obviously in the 10s of billions of dollars. Then the excess cost of prolonged hospitalizations or inability to provide care for a non-community-acquired bacterial pneumonia patient is sort of immeasurable but obviously present as well.

Amanda Balbi: How are hospital readmission rates impacted by CABP?

Christian Sandrock: CMS, Medicare and Medicaid services, many other insurance companies, and other hospital ratings really look at readmission rates, specifically readmission rates related to community-acquired pneumonia and, in this case, community-acquired bacterial pneumonia.

Those readmission rates tend to be relatively high among that group. It's a bit higher if you have somebody with coexisting underlying lung disease, such as COPD, or heart disease. So, those readmission rates are much more impacted by age and comorbidities, but they are relatively high overall.

There are multiple factors that go into that impact of readmission. It might be antimicrobial choices at the time of discharge. It might be length of antimicrobial choices, as I mentioned comorbidities like COPD or heart disease. It might be age-related impacts as well. Underlying other structural lung diseases, they all play a role.

And then, most importantly, is the social support network. Patients with community-acquired pneumonia who maybe don't have the social support—they otherwise can't get up or move around. They don't have the mobility they need. They're not getting the care they need at home—that also really affects the readmission rates as well.

Amanda Balbi: How does this all affect the financial cost of CABP?

Christian Sandrock: The overall cost of community-acquired bacterial pneumonia, and community-acquired pneumonia in general, is exceedingly high, as we talked about. It's in the 10s of billions of dollars.

But there's really a big immeasurable component that's hard to quantitate as well. When you look at admission from CAP, it's the second-most common cause of hospital admissions on average, the seventh or eighth most-common cause of death. Those are very high numbers, but again, as we mentioned, these are sometimes admissions that may not need to happen if preventive care or good options were there.

If they do happen, you may be able to shorten those lengths of admissions. By having a longer length of stay by having an admission, it limits our ability to provide care for other people in the community, and that financial cost is a little bit harder to measure but is really also pretty impactful.

There is a financial cost of the patient as well, so if it takes longer for you to recover from your pneumonia, if you're admitted for your pneumonia, that's time you're away from, work that's time you're away from school, whatever it may be. So, there is that financial cost of the patient as well. It's not just days you're in the hospital. It's time being out of work and time unable to provide what you need for yourself and your family.

Amanda Balbi: In your opinion, how can these challenges be overcome?

Christian Sandrock: That's a great question. How can these challenges of the financial and morbidity, mortality burdens of community-acquired pneumonia be overcome? So, there are a couple different ways.

One is doing your best to standardized care. Many of us as physicians or health care providers are always leery about the word “guidelines.” But providing at least a standard of what our expectations are for antimicrobial management, for post-diagnosis management, and then, most importantly, for prevention. Still the best way to manage this is to not get community-acquired bacterial pneumonia.

So, aggressive vaccination to prevent invasive disease. Obviously pneumococcal vaccines don't cover every strain of Pneumococcus that we see, but it certainly is going to help reduce that burden overall by vaccination. That's certainly one way.

Number 2 is early diagnosis and recognition. So again, making sure that those patients have access to health care, if they can get early intervention before they actually arrive at the hospital and the health care system on their first entry, this can reduce their overall costs and their complications.

And lastly, making sure that they have the antimicrobial therapy, albeit short. The guidelines recommend 5 days, but we want to make sure that that's adequate. It's going to work best for the patient with minimal adverse events and it's going to cover the organisms. Then in that period afterwards, if they actually have what they need to prevent further worsening of their community-acquired pneumonia or recurrence that leads to admission.

So, I think it's a mixture of vaccination and then standardizing how we manage these patients, both in a prediagnosis and post-diagnosis way with antimicrobial therapy for as short as possible to reduce adverse events, but then, most importantly, other preventive measures.

A beautiful example is actually pulmonary rehab. So, if you look at patients admitted with exacerbations of COPD, particularly if they have a bacterial component to their exacerbation, they enter into pulmonary rehab. Their likelihood of readmission is really low, and I think that's an example of having a systemic approach to managing some of these patients.

Amanda Balbi: Great, thank you so much for joining us today, Dr Sandrock. And for our listeners, we do have 2 other parts of this podcast to come. Stay tuned for more!

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