Estimating the clinical and economic burden of community-acquired pneumonia (CAP) among adult patients in India using the CAP burden of illness questionnaire

doi:10.21203/rs.3.rs-4982731/v1

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Research Article

Estimating the clinical and economic burden of community-acquired pneumonia (CAP) among adult patients in India using the CAP burden of illness questionnaire

https://doi.org/10.21203/rs.3.rs-4982731/v1

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Background

Community-acquired pneumonia (CAP), a prevalent lower respiratory tract infection, poses a significant health and economic burden. This study explores the clinical and economic implications of CAP among adults in diverse medical centers in India, emphasizing the need for a comprehensive understanding of its impact.

Methods

A cross-sectional multicenter survey, employing the CAP-Burden of Illness Questionnaire, was conducted among newly diagnosed severe CAP patients treated in seven participating medical centers. Both inpatient and outpatient cohorts were included, and data on symptoms, comorbidities, treatment patterns, and resource utilization were collected. The study involved 188 patients, and statistical analyses were performed using SPSS® (version 22) statistical software.

Results

The CAP-Burden of Illness Questionnaire revealed the persistence of symptoms, impacting daily life and work productivity. Hospitalized patients faced longer recovery times and increased resource utilization. As per the pulmonologists, the hospitalized patients in a private setting had an average length of stay (LOS) of 9 days in the ICU and 5 days in the general ward, whereas at the government hospital, the average LOS in the ICU was an average of 30 days and 8.5 days in the general ward. Average inpatient costs were INR 2,10,862 per patient in private hospitals and INR 5,575 per patient in government hospitals. Non-hospitalized patients reported an average outpatient treatment cost of INR 4,121 per patient in private settings and INR 200 per patient in government hospitals.

Conclusion

The economic analysis sheds light on the disparities in treatment costs, emphasizing the importance of considering healthcare settings. Addressing the multifaceted challenges of CAP requires a holistic approach, encompassing preventive measures, early detection, and targeted management strategies.

Community-acquired pneumonia (CAP) is a lower respiratory tract infection characterized by cough, fever, chills, fatigue, dyspnea, rigors, and pleuritic chest pain [1, 2, 3]. CAP refers to pneumonia acquired outside of a hospital or long-term care setting [4, 5]. Clinically, CAP can lead to a range of respiratory issues, from mild symptoms to life-threatening conditions, requiring extensive medical intervention, hospitalization, and, in severe cases, intensive care [6, 7]. The most common causes of CAP are bacterial and/or viral pathogens[5, 8] such as Streptococcus pneumoniae accounts for two-thirds of CAP cases [9, 10, 11], other bacteria like Chlamydophila pneumoniae, Mycoplasma pneumoniae, Legionella spp, Haemophilus influenzae, Moraxella catarrhalis, and Staphylococcus aureus are also common causative agents [12–16]. Among viruses, rhinovirus, influenza, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and other respiratory viruses (parainfluenza, respiratory syncytial virus, human metapneumovirus, etc) have become increasingly detected as pathogens based on molecular detection methods. Yet, the etiology of CAP remains unknown in up to 50% of patients in an outpatient setting, related to difficulty in obtaining an adequate sputum sample or diagnostic tests as well as in frequency of testing [17, 18]. The global incidence of CAP varies from 1.5 to 14 cases per 1000 person-years, influenced by geography, season, and population demographics.¹ The reported incidence rate of Community-acquired bacterial pneumonia (CABP) in India is 4 million cases per year. Further, estimates suggest that India accounts for 23% of the global pneumonia burden and 36% of the World Health Organization regional burden. Furthermore, CAP is a common and serious infectious disease among the elderly, associated with high hospitalization rates and mortality, with significant economic implications in terms of both direct and indirect costs [19, 20]. CAP poses a substantial clinical and economic burden on individuals and healthcare systems alike due to its high incidence and potential for severe complications. Most of the existing studies have reported the cost burden among patients diagnosed with CAP overall, combining patients managed in either the inpatient or outpatient setting [21, 22, 23]. Furthermore, other studies have only reported costs for an outpatient cohort using an episodic approach [24, 25, 26]. The majority of CAP episodes are treated in the outpatient setting and CAP may have very different outcomes and associated economic burden based on the setting of care [27]. However, the economic impact of CAP extends beyond direct healthcare costs to include indirect expenses related to lost productivity and decreased quality of life for affected individuals. The financial burden encompasses expenses associated with hospital stays, diagnostic tests, and pharmacological treatments [19]. Additionally, the societal cost of CAP includes the strain on healthcare infrastructure, with increased demand for medical services, medications, and rehabilitation. Addressing the clinical and economic challenges of CAP necessitates a comprehensive approach, including preventive measures, early detection, and effective management strategies to alleviate the considerable impact on both individuals and healthcare systems. There is limited literature regarding the economic burden of CAP symptoms and their impact from the patient perspective in India. Therefore, the main aim of this study was to estimate the burden of CAP in adults ≥ 18 years using the CAP-Burden of Illness Questionnaire (BIQ) which has been previously adapted for India. The secondary objective of the study was to estimate the resource utilization and cost associated with the treatment of CAP in an inpatient and outpatient setting among adults ≥ 18 years of age. A report published in December 2023 claims that over 40 crore people in India lack health insurance due to the country's continued struggles with a 73 percent health protection gap. According to the report, the reasons behind the lack of health insurance include lower penetration, inadequate coverage, and rising healthcare costs in addition to a low perceived need for insurance, the unavailability of customized products and restricted customer accessibility [28].

A cross-sectional multicenter survey using the CAP BIQ was conducted among newly diagnosed CAP patients (i.e. patients who were diagnosed with CAP in the past 90 days) who were treated in one of the seven participating medical centers on an inpatient or outpatient basis, and provided their informed consent. Patients were included if they had symptoms and radiology (Chest X-ray and CT scan of Thorax) consistent with a diagnosis of Pneumonia. A total of 20 pulmonologists from leading hospitals were contacted to participate in the study, of these seven pulmonologists from leading medical centers agreed to participate in the study and served as principal investigators. These centers included M. S. Ramaiah Medical College and Hospital in Bangalore, Calcutta Medical Research Institute in Kolkata, Deccan College of Medical Sciences in Hyderabad, The Madras Medical Mission in Chennai, Chennai Meenakshi Multispeciality Hospital in Chennai, Vora Clinic in Mumbai, and Sher-i-Kashmir Institute of Medical Sciences (SKIMS), in Srinagar. Each participating pulmonologist was requested to provide their informed consent, identify and recruit 30 newly diagnosed CAP patients who they were treating in the inpatient or outpatient setting of the hospital. Patients who had a diagnosis of hospital-acquired pneumonia, or those who were previously hospitalized for reasons other than CAP, or patients with underlying terminal illness, and patients < 18 years of age at the time of diagnosis were excluded from the study.

The investigator along with a trained on-site staff was responsible for data collection at each participating center. Both outpatient and inpatient patients were approached by the study designated staff for explanation about the study and signing the informed consent if the patient agreed to participate in this survey. If the patient was illiterate, his/her LAR (legally authorized representative) signed on the patient's behalf and filled out the required information in the questionnaire. Patients who were admitted to the hospital for CAP treatment completed the CAP-BIQ survey at the time of discharge while patients who were treated on an outpatient basis completed the survey during their clinic visit. The CAP-BIQ was translated in 6 Indian local languages. Patients who could read and speak English were given the English version of the CAP-BIQ while those who preferred completing the survey in their local language were given the translated version based on their preferred language. The CAP-BIQ is a patient-reported outcome measure with content validation, which is used to gather data on the burden of CAP. The questionnaire consisted of 56 multiple-choice questions that were designed to assess the presence of key covered CAP symptoms, comorbid conditions, work productivity index and different implications on daily life and activities [29]. Demographic and clinical characteristics of participating patients such as age, gender, weight, smoking status, etc. were obtained from clinical case report forms. Furthermore, to understand the inpatient and outpatient treatment patterns in CAP patients, the treating physicians/pulmonologists were also requested to complete a brief survey at the start of the study. The physicians were asked to respond to questions pertaining to their practice pattern, tests recommended for the diagnosis of CAP, co-morbidities most commonly associated with CAP patients, treatment patterns for inpatients and outpatients, and the complications that they encountered while attending to the patients. The survey also intended to extract data concerning the cost of resources utilized in the overall treatment of CAP. Ethics committee approvals were obtained from each participating hospital before the start of the study. All data was collected in a de-identified manner to ensure the patients’ anonymity. Data was stored on a password protected secure server with limited access to only those involved in the project. Patients also completed a resource utilization questionnaire which included questions on the number of inpatient and outpatient day visits and the number of diagnostic tests, medications used, etc. Furthermore, the average cost per day/visit related to in-patient and out-patient visits and the average cost for the diagnostic tests were collected from the seven respective hospitals.

Statistical Analysis

Analyses were completed using data gathered from the physician survey and patients who were diagnosed with CAP for a minimum of 90 days. Descriptive statistics were computed for participants’ baseline characteristics including demographics, and presence of CAP symptoms. Mean and standard deviation (SD) as well as median were calculated for time to symptom resolution, days of lost work productivity. Time to return to work, number of days missed at work, and missed routine activities. The frequency of patient-reported CAP symptoms having an impact on family and everyday life, such as difficulty taking care of oneself, difficulty leaving the house or operating a vehicle, and a need for care giver assistance, were also calculated. All analysis was conducted using the SPSS® (version 22) statistical software.

Sample Description

All the seven pulmonologists that participated in this survey had at least 10 years of experience. The physicians were from different geographical areas and most of them practiced in private hospitals. During their practice, the pulmonologists on an average came across 24 patients a month for CAP. A total of 188 individuals out of 210 patients participated in the survey and completed the study questionnaire. Twenty-two patients, who had initially agreed to participate in the study, withdrew their consent at the time of discharge. Table 1 presents the baseline demographic and clinical characteristics for the entire sample. Most participants were elderly, with the average age being 61 years and predominantly females (54%). About 85.6% of participants were hospitalized due to CAP. The overall sample was 45.7% male. 31.3% had formal college education including graduate and post-graduate degrees and 17% of the patients were illiterate. The most common co-morbidities were chronic obstructive pulmonary disease (COPD) (22.6%) and diabetes (22.6%) followed by heart disease (12.9%) among CAP patients. The most observed CAP complications were septicemia or septic shock (22.2%) and severe hemodynamic changes (18.5%) followed by pleural effusion (14.8%).

Table 1

Baseline demographic and clinical characteristics
Parameters	N (%)
Age, years, Mean (SD)	61(16)
< 50, n (%)	46 (24.5)
50–64, n (%)	53 (28.2)
≥ 65, n (%)	89 (47.3)
Gender, n (%)
Male	86 (45.7)
Female	102 (54.3)
BMI (kg/m2), n (%)
≤ 20	24 (15.5)
> 20 to ≤ 25	69 (44.5)
> 25 to ≤ 30	45 (29.3)
> 30	17 (11.0)
Socio-economic status, n (%)
High income	15 (10.5)
Middle income	107 (74.8)
Low income	36 (25.2)
History of smoking, n (%)
Non-smoker	151 (94.4)
Smoker	4 (2.5)
Ex-smoker	5 (3.1)
Comorbid conditions, n %
Asthma	18 (10.7)
Chronic emphysema	1 (0.6)
COPD	32 (19.0)
High blood pressure	37 (22.0)
Chronic bronchitis	6 (3.6)
Heart disease	15 (8.9)
Diabetes	49 (29.2)
Others	10 (6.0)
CAP complications, %
Severe hemodynamic changes	18.5
Pleural effusion	14.8
Septicemia (Septic) shock	22.2
Lung abscess	11.1
Lung cavitation	11.1
Emphysema	11.1
Others	11.1

Findings from the Physician Survey

The findings from the physician survey aimed to gain insights into the treatment patterns for community-acquired pneumonia (CAP) patients in both inpatient and outpatient settings. A total of six private healthcare settings and one government hospital were included in the study. The physician survey on treatment patterns for inpatient and outpatient CAP patients yielded noteworthy insights. Participating pulmonologists reported that they commonly prescribe chest X-ray, CT-scan, blood culture, complete blood count, and sputum culture to diagnose CAP. Diabetes (22.6%), COPD (22.6%), chronic empyema (9.7%), and asthma (9.7%) were some of the most observed comorbid conditions in the CAP patients that they treated. Based on the severity of CAP, pulmonologists treating in private hospital reported that on an average 49% of their patients required hospitalization with an average length of stay (LOS) of 9 days in the intensive care unit (ICU) and 5 days in general ward (GW). In contrast, the pulmonologist treating at the government hospital reported that only 23% of patients are treated on an inpatient basis. However, the pulmonologist reported that these patients have a much longer average LOS in the ICU (30 days) and GW (8.5 days). Patients treated on an outpatient basis were asked to come for at least three follow-up visits for CAP monitoring once they are diagnosed with CAP. The survey also unveiled commonly prescribed medications based on CAP severity. In moderate cases, the most prescribed medications included amoxicillin and clavulanic acid, clarithromycin, beta-lactam and macrolides (cefoperazone + sulbactam), and azithromycin. In patients with severe CAP or advanced stages of CAP associated with respiratory failure or treatment necessitating ICU, the preferred medications included piperacillin plus tazobactam, colistin/polymyxin B/ ceftazidime + avibactum, meropenem, and clarithromycin.

Findings from the CAP-Burden of Illness Questionnaire

Time to Symptom Resolution, Impact of CAP Symptoms on Daily Activities and Work Productivity

Over 85% of the patients reported the presence of respiratory-related symptoms including shortness of breath, thick mucus or phlegm while coughing, wheezing, pain from coughing, and fever during diagnosis. Non-hospitalized patients more frequently experienced weakness, tiredness or low energy, cough, body aches or pain, and thick mucus with phlegm. (Table 2). Time required for resolution of symptoms is reported in Table 3 and was similar in hospitalized and non-hospitalized participants, except for cough, phlegm, fever, and trouble sleeping, wheezing, shortness of breath, diarrhea which on average lasted longer in the outpatients. In hospitalized patients, symptoms like weak appetite (8.0 days), trouble sleeping (7.7 days), tiredness or low energy (7.4 days), shortness of breath (7.4 days) wheezing (7.2 days) took a longer time for resolution as opposed to symptoms like chills (4.3 days), sweat (3.8 days), diarrhea (5.6 days), body ache or pain (5.7 days). In non-hospitalized patients’ diarrhea, nausea or vomiting, dyspnoea, wheezing, trouble sleeping, and cough took a comparatively longer time for resolution (Table 3). CAP patients with other concomitant diseases exhibited a drastically decreased general quality of life. Diabetes, COPD, high blood pressure, asthma, and heart disease were observed to worsen community-acquired pneumonia (CAP). Patients with COPD, had the longest duration to symptom resolution, with an average of 17 days. On the day of diagnosis, moderate to continual coughing was recorded by 72.3% of hospitalized patients and 52% of outpatients. A total of 118 (73.3%) hospitalized patients and 17 (63.0%) of non-hospitalized patients reported that they felt mildly tired to too-tired to get out of bed on the day they were diagnosed with CAP. However, 73.4% of hospitalized patients and 73.3% of outpatients stated having high to moderate energy for all of their daily routine tasks 90 days post their CAP diagnosis. Similarly, 82.1% of the hospitalized patients and 24% of non-hospitalized patients mentioned no pain to mild pain or discomfort other than headache 90 days post diagnosis versus 53% and 31% of hospitalized and non-hospitalized who reported moderate to worst pain at the time of diagnosis.

Table 2

Prevalence of symptoms at diagnosis
Parameters	Overall N = 188	Hospitalized N = 161 (85.6%)	Non-hospitalized N = 27 (14.4%)
Symptoms before the day patients were told about CAP
Yes, n (%)	164 (87.2)	145 (90.1)	19 (70.4)
No, n (%)	24 (12.8)	16 (9.9)	8 (29.6)
Symptoms at Diagnosis, n (%)
Fever (feel warm)	126 (6.9)	114 (7.0)	12 (5.9)
Chills	91 (5.0)	83 (5.1)	8 (3.9)
Sweats	71 (3.9)	67 (4.1)	4 (2.0)
Cough	172 (9.4)	150 (9.3)	21 (10.2)
Pain from coughing	106 (5.8)	95 (5.9)	11 (5.4)
Thick mucus or phlegm with cough	129 (7.0)	113 (7.0)	16 (7.8)
Tiredness or low energy	180 (9.8)	156 (9.6)	24 (11.7)
Headaches	71 (3.9)	66 (4.1)	5 (2.4)
Body aches or a pain	161 (8.8)	132 (8.1)	20 (9.8)
Weakness	173 (9.4)	152 (9.4)	21 (10.2)
Shortness of breath	139 (7.6)	123 (7.6)	16 (7.8)
Confusion or trouble thinking	50 (2.7)	43 (2.7)	7 (3.4)
Weak appetite	99 (5.4)	88 (5.4)	11 (5.4)
Diarrhea, vomiting or nausea	35 (1.9)	33 (2.0)	2 (1.0)
Wheezing	117 (6.4)	103 (6.4)	14 (6.8)
Trouble sleeping	116 (6.3)	103 (6.4)	13 (6.3)

Table 3

Time to symptom resolution in CAP patients
Parameters	Overall N = 188	Hospitalized N = 161 (85.6%)	Non-hospitalized N = 27 (14.4%)	The symptom has not returned to normal Overall (N = 188), n (%)
Time to Symptom Resolution, mean days
Fever (feel warm)	5.1	5.1	5.4	1 (0.8)
Chills	4.7	4.3	8.1	1 (1.0)
Sweats	3.9	3.8	4.3	3 (4.2)
Cough	7.0	6.5	11.4	32 (19.5)
Pain from coughing	5.8	5.6	9.5	8 (7.6)
Thick mucus or phlegm with cough	6.8	6.5	8.5	12 (9.3)
Tiredness or low energy	7.4	7.4	7.2	34 (21.0)
Headaches	5.9	6.0	5.2	0 (0.0)
Body aches or a pain	5.7	5.7	6.0	20 (14.5)
Weakness	7.5	7.4	8.7	35 (21.1)
Shortness of breath	8.3	7.4	16.1	11 (7.9)
Confusion or trouble thinking	6.2	6.0	8.2	4 (7.4)
Weak appetite	8.3	8.0	10.7	4(4.2)
Diarrhea, vomiting or nausea	5.9	5.6	11.0	0 (0.0)
Wheezing	7.7	7.2	11.1	10 (8.4)
Trouble sleeping	8.4	7.7	15.6	12 (10.9)

Table 4

Prevalence of health conditions worsened by CAP
Parameters	Overall N = 188	Hospitalized N = 161 (85.6%)	Non-hospitalized N = 27 (14.4%)
Reported worsening, n (%)
Asthma	18 (10.7)	13 (9.7)	5 (14.7)
Chronic bronchitis	6 (3.6)	4 (3.0)	2 (5.9)
Chronic emphysema	1 (0.6)	0 (0.0)	1 (2.9)
High blood pressure	37 (22.0)	27 (20.1)	10 (29.4)
Diabetes	49 (29.2)	36 (26.9)	13 (38.2)
Heart disease	15 (8.9)	13 (9.7)	2 (5.9)
Chronic obstructive pulmonary disease (COPD)	32 (19.0)	31 (23.1)	1 (2.9)
Others Hypothyroid, Stent in heart, Anxiety, Breast Cancer, Thyroid, Parkinsonism, Dementia, Chronic lymphocytic leukemia	10 (6.0)	10 (7.5)	0

As a result of CAP, 76.6% of hospitalized patients missed an average of 16 days at work and took a longer period to return to their usual job performance and usual activities as opposed to 26% of non-hospitalized patients who missed an average of 9 days at work. The mean number of days to return to usual level of job performance was 21 days. Overall, 97% of the sample reported that they required help from family, friends, or caregivers during their CAP recovery. CAP-related cough and weakness were reported to have broad impact on the participants’ lives that are seldom recorded in medical encounters. Table 5 highlights the impact of CAP symptoms experienced by the hospitalized and non-hospitalized patients on other members in the household and the ability to perform routine tasks. Most patients (57.4%) were concerned that their coughing could wake other members in the household, about 52% were concerned that CAP restricted their ability to go outside their home or visit or talk with others (47.8%) or drive (48.8%).

Table 5

Impact of CAP on daily lives
Parameters	Overall N = 188	Hospitalized N = 161	Non-Hospitalized N = 27
Impact of coughing
Wake others in home
Yes, n (%)	108 (57.4)	97 (60.2)	11 (40.7)
No, n (%)	80 (42.6)	64 (39.8)	16 (59.3) (
Keep from going places
Yes, n (%)	97 (51.6)	87 (54.0)	10 (37.0)
No, n (%)	91 (48.4)	74 (46.0)	17 (63.0)
Keep from driving
Yes, n (%)	88 (48.8)	81 (52.9)	7 (25.9)
No, n (%)	96 (51.1)	72 (47.1)	20 (74.1)
Keep you from talking to or visiting with others?
Yes, n (%)	89 (47.8)	82 (51.6)	7 (25.9)
No, n (%)	96 (51.6)	77 (48.4)	19 (70.4)
Impact of weakness
Lose balance
Yes, n (%)	76 (40.6)	69 (43.1)	7 (25.9)
No, n (%)	111 (59.4)	91 (56.9)	20 (74.1)
Difficult to move around in home
Yes, n (%)	93 (49.5)	87 (54.0)	6 (22.2)
No, n (%)	95 (50.5)	74 (46.0)	21 (77.8)
Interfere with self-care
Yes, n (%)	87 (46.5)	83 (51.9)	4 (14.8)
No, n (%)	100 (53.5)	77 (48.1)	23 (85.2)
Keep from going places
Yes, n (%)	108 (57.8)	100 (62.5)	8 (29.6)
No, n (%)	79 (42.2)	60 (37.5)	19 (70.4)
Keep from visiting others
Yes, n (%)	103 (55.4)	96 (60.4)	7 (25.9)
No, n (%)	83 (44.6)	63 (39.6)	20 (74.1)
Keep from going for walks outside home
Yes, n (%)	110 (59.1)	99 (62.3)	11 (40.7)
No, n (%)	76 (40.9)	60 (37.7)	16 (59.3)
Keep from usual housework
Yes, n (%)	101 (54.0)	95 (59.4)	6 (22.2)
No, n (%)	85 (45.5)	64 (40.0)	21 (77.8)
Other impact
Sweats or chills wake spouse or partner
Yes, n (%)	48 (25.7)	47 (29.4)	1 (3.7)
No, n (%)	118 (63.1)	94 (58.8)	24 (88.9)
Not applicable, n (%)	21 (11.2)	19 (11.9)	2 (7.4)
Pain around eyes keep from reading or watching TV
Yes, n (%)	23 (12.3)	21 (13.1)	2 (7.4)
No, n (%)	116 (62.0)	93 (58.1)	23 (85.2)
Not applicable, n (%)	48 (25.7)	46 (28.8)	2 (7.4)

CAP healthcare resource utilization and cost

CAP Related Health Care Resource Utilization

The mean (± SD) length of stay among all the hospitalized patients in the past 3 months was 7.0 (± 7.9) days of which the patients spent an average of 2.6 (± 4.0) days in the ICU (Table 6). In the past 3-months, the CAP patients in hospital commonly underwent laboratory tests (79.1%), chest X-rays (86.7%), CT scans (70.9%), and procedures such as bronchoscopy (41%), electrocardiogram (ECG) (33.3%), and ultrasound sonography (USG) (21.2%) which was similar to non-hospitalized patients. Non-hospitalized patients were prescribed additional tests that included complete blood count (CBC) (55.6%) and HbA1c (33.3%). These diagnostic tests played an important role in the evaluation and management of patients with CAP, with variations in utilization rates between hospitalized and non-hospitalized cases.

Table 6

Healthcare resource utilization: Hospital stay and physician visits
Parameters	Hospitalized, N = 161	Private N = 84.01%	Government N = 15.9%
Total length of hospital stays in the last 3 months for the present illness
Mean (SD)	7.0 (7.9)	7.1 (8.7)	6.4 (3.2)
Median (range)	6.0 (0–90)	6.0 (0–90)	6.0 (2.0–16.0)
If still hospitalized, no. of days in hospital for the present illness
Mean (SD)	5.3 (3.5)	4.9 (3.6)	6.5 (3.1)
Median (range)	5.0 (0–16)	5.0 (0–16)	6.0 (2.0–16.0)
No. of days spent in ICU in the last 3 months for the present illness
Mean (SD)	2.6 (4.0)	3.2 (4.2)	0.2 (0.9)
Median (range)	0 (0–27)	2 (0–27)	0 (0–5.0)
If still in ICU, no. of days in ICU for the present illness
Mean (SD)	0.7 (2.0)	1.0 (2.4)	-
Median (range)	0 (0–10)	0 (0–10)	-
No. of days spent in General ward in the last 3 months for the present illness
Mean (SD)	3.3 (3.0)	3.6 (3.2)	2.2 (1.2)
Median (range)	3.0 (0–17)	3.0 (0–17)	2.0 (1.0–6.0)
If still in General ward, no. of days in General ward for the present illness
Mean (SD)	3.3 (3.0)	4.0 (3.1)	1.3 (1.7)
Median (range)	3.0 (0–14)	4.0 (0–14)	0 (0–6.0)

The average cost for each hospitalization in a private setting was greater as opposed to those observed in a government hospital. The average inpatient costs were INR 2,10,862 per patient for a private hospital, and 5,775 INR per patient in a government hospital.. The total inpatient treatment cost included the ICU stay, general ward stays, physician visit charges, lab test charges, medication costs, consumable costs, and costs of follow-up visits. The average outpatient treatment cost in a private setting was INR 4,121 per patient as opposed to INR 200 per patient in a government hospital which was inclusive of follow-up lab test charges, subsequent chest X-rays, CT scans, and total follow-up charges.

Community acquired pneumonia implies pneumonia that is contracted outside of a medical facility or a long-term facility [30]. The 2005 American Thoracic Society (ATS) / Infectious disease society of America (IDSA) guidelines for the management of ventilator-associated pneumonia and hospital-acquired pneumonia included healthcare-associated pneumonia (HCAP) as a distinct clinical entity that required special antibiotic treatment. Patients with any of the following potential risk factors for antibiotic-resistant pathogens were classified as having HCAP: living in a nursing home or other long-term care facility; being hospitalized for more than two days within the previous ninety days; receiving chronic dialysis, home infusion therapy, home wound care; or having a family member with a known antibiotic-resistant pathogen. In order to choose extended antibiotic coverage for patients with CAP, the prior categorization of HCAP should be avoided. This primarily motivates a desire to address the misuse of anti-methicillin resistant Staphylococcus aureus (MRSA) and antipseudomonal therapy that has happened since the introduction of the HCAP categorization. The elderly age group is more prone to be affected by CAP and has several co-morbidities, both of which might raise the likelihood of unfavorable outcomes and subsequently result in the excessive use of healthcare resources and cost [31]. According to the ATS, for the treatment of CAP in previously healthy patients without risk factors for drug-resistant Streptococcus pneumoniae (DRSP) infection, the use of a macrolide antibiotic such as azithromycin, clarithromycin, or erythromycin is strongly recommended [32]. Presence of co-morbidities would require the usage of a respiratory fluoroquinolone (moxifloxacin, gemifloxacin or levofloxacin or a combination of β-lactam antibiotics plus a macrolide) [33]. β-lactam antibiotics can either be a high dose amoxicillin or amoxicillin-clavulanate or alternatives like ceftriaxone, cefpodoxime, and cefuroxime. For ICU treatment, a β- lactam antibiotic (cefotaxime, ceftriaxone, or ampicillin-sulbactam, Pipericillin + Tazobactam and Cefoperazone + Sulbactam) plus either azithromycin or fluoroquinolone is strongly recommended [32]. Data from the physician survey reporting commonly prescribed medications support recommendations made by ATS guidelines after ruling out Pulmonary Tuberculosis. The choice of the medications is influenced by the severity of the condition and the presence or absence of risk factors for Pseudomonas and MRSA along with the host’s factors like age and comorbidities which support recommendations made by ATS guidelines.

The study also assessed the clinical progression of CAP in adults by chronicling the burden of CAP in patients’ up to 90 days after diagnosis from patients’ perspective. The study also weighed the economic impact of CAP primarily based on the symptom severity and the correlation between treatment costs and risk variables. The primary results indicate that CAP patients had an array of systemic and respiratory symptoms that impact the development of other concurrent illnesses. Participants also reported worsening of existing co-morbid ailments like high blood pressure, diabetes, COPD due to CAP in both hospitalized and non-hospitalized patients. Hospitalized patients and non-hospitalized patients both experienced cough, tiredness, body ache, pain and weakness. Systemic symptoms like weak appetite, trouble sleeping, wheezing took a longer time to resolve in the non-hospitalized patients as opposed to hospitalized patients. Respiratory symptoms like pain from coughing, thick mucus or phlegm with cough shortness of breath were resolved in a shorter duration of time in hospitalized patients. This might have been on account of the fact that hospitalized individuals were more likely to receive nebulization; and also that there was a lower threshold for the prescription of systemic steroids in such of those patients with a background of asthma and COPD in the hospitalized patients. Additionally, the findings demonstrate that symptoms and their consequences might persist for days to weeks following the onset of sickness, inflicting a strain on patients as well as their caregivers and partners.

Our results can have an impact on a clinical practice since they offer insights from the patients’ point of view on the complexity of CAP symptoms, functional restrictions, and the amount of time required to fully recover. A greater understanding of the natural progression of CAP can help patients and medical professionals manage episodes that extend beyond the acute stage of the condition. Our data reveal a wider spectrum of symptoms that encompasses trouble in sleeping, tiredness, weak appetite, confusion, or trouble in sleeping than the usual pneumonia symptoms of cough, chest discomfort, and shortness of breath, suggesting that clinicians must solicit a wider range of symptoms. Further research might determine whether certain therapies are more efficacious than others at alleviating the various CAP symptoms. The quest for patient-centered outcomes that accurately reflect the patient’s experience is now an indispensable stimulus of health care reform.

Furthermore, even though the CAP-BIQ collects information to provide a thorough picture of the course of illness and impact of the disease from the perspective of the patient, this extensive questionnaire might not prove to be a congruous outcome metric in clinical trials for scrutinizing the therapeutic efficacy of varied treatments for pneumonia. However, the outcomes from this patient-reported outcome questionnaire may assist in the building of a more concise instrument for use in clinical studies assessing the impact of CAP at diagnosis and recovery. The studies that deploy the CAP-BIQ serve as the foundation for studies to generate a prospective patient-reported outcome for clinical trials in patients who have confirmed CAP radiographically. Patients’ awareness of the disease progression allows a more realistic anticipation of their recovery path. It might eliminate superfluous medical care and erroneous antibiotic prescriptions for unexpected recurrent episodes that actually mirror the illness’ typical course. However, this study has a few limitations. Like previous studies, retrospective collection of symptoms was used in this which is prone to recall bias. A window of 90 days between diagnosis and patient survey completion was necessary to recruit an adequate cohort of adults. Furthermore, though the study was conducted at seven medical centers across India, findings from the study were based on data from 188 patients thereby limiting the generalizability of the results. Moreover, the study primarily focused on hospitalized patients, leading to an underrepresentation of non-hospitalized cases, rendering the non-hospitalized cohort too small for drawing significant inferences. Additionally, the study predominantly involved patients from private hospitals, potentially skewing the findings in terms of cost implications and healthcare access, thus presenting a lopsided perspective on the economic burden. Future studies need to be conducted with a larger set of patients. Also, future studies need to be conducted enrolling more government medical centers to get an accurate representation of treatment patterns, symptom burden, healthcare resource utilization and costs. Despite these drawbacks, the study renders an array of pertinent insights regarding the burden of CAP as experienced by patients, a perspective which is often overlooked.

CAP: Community-acquired pneumonia

SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2

CABP: Community-acquired bacterial pneumonia

CAP-BIQ: Community-acquired pneumonia-Burden of Illness Questionnaire

CT: Computed Tomography

SD: Standard deviation

COPD: Chronic obstructive pulmonary disease

LOS: Length of stay

ICU: Intensive care unit

GW: General ward

ECG: Electrocardiogram

USG: Ultrasound sonography

CBC: Complete blood count

ATS: American Thoracic Society

IDSA: Infectious Disease Society of America

HCAP: Healthcare-associated pneumonia

MRSA: Anti-methicillin resistant Staphylococcus aureus

DRSP: Drug-resistant Streptococcus pneumonia

Acknowledgements:

Assistance for conducting the research, developing the model and drafting the manuscript was provided by Shalaka Marfatia of pharmEDGE and her team

Authors' contributions:

P.K., R.D., A.V., A.H., P.K., S.K., H.M., C.M., and S.T. all contributed to the design of the work, acquisition, and analysis of data, and were involved in drafting the manuscript and revising it critically for important intellectual content. All authors have read and agreed to the final and published version of the manuscript

Funding:

This research was supported by the Pfizer India private limited

Availability of data and materials:

All data generated or analyzed during this study are included in this published article

Ethics approval and consent to participate:

The study was conducted in accordance with the ethical standards of the institutional ethics committees of all the seven participating hospitals (Institutional Ethics Committee of Deccan College of Medical Sciences and Allied Hospitals, Chennai Meenakshi Multispeciality Hospital Ethics Committee (CMMHEC), The Madras Medical Mission Ethics Committee, Ethics Committee of M.S. Ramaiah Medical College, INDIRA IVF Hospital Institutional Ethics Committee, Calcutta Medical Research Institute Institutional Ethics Committee (CMRI-IEC), Ethics Committee of Sher-i-Kashmir Institute of Medical Sciences). All participants provided informed consent prior to their inclusion in the study. The study was performed in accordance with the principles of the Declaration of Helsinki.

Consent for publication:

Not Applicable

Competing interests:

The authors have declared that no conflicts of interest exist.

Regunath H, Oba Y. Community-Acquired Pneumonia. StatPearls. November 2022. https://www.ncbi.nlm.nih.gov/books/NBK430749/. Accessed January 8, 2024.
Abdel Dayem AM, Aly AA, Hendawy SF. Pattern of community acquired pneumonia in pregnant ladies in Ain Shams University hospitals. Egyptian Journal of Chest Diseases and Tuberculosis. 2012;61(4):355-359. doi:10.1016/j.ejcdt.2012.08.009
H. Ticona J, M. Zaccone V, M. McFarlane I. Community-Acquired Pneumonia: A Focused Review. Am J Med Case Rep. 2020;9(1):45-52. doi:10.12691/ajmcr-9-1-12
Patterson CM, Loebinger MR. Community acquired pneumonia: assessment and treatment. Clin Med (Lond). 2012;12(3):283-286. doi:10.7861/clinmedicine.12-3-283
Divino V, Schranz J, Early M, Shah H, Jiang M, DeKoven M. The 1-year economic burden of community-acquired pneumonia (CAP) initially managed in the outpatient setting in the USA. J Comp Eff Res. 2020;9(2):127-140. doi:10.2217/cer-2019-0151
Cillóniz C, Menéndez R, García-Vidal C, Péricas JM, Torres A. Defining Community-Acquired Pneumonia as a Public Health Threat: Arguments in Favor from Spanish Investigators. Med Sci (Basel). 2020;8(1). doi:10.3390/medsci8010006
Sligl WI, Marrie TJ. Severe community-acquired pneumonia. Crit Care Clin. 2013;29(3):563-601. doi:10.1016/j.ccc.2013.03.009
Community-Acquired Pneumonia Requiring Hospitalization. New England Journal of Medicine. 2015;373(24):2380-2382. doi:10.1056/NEJMc1511751
Fine MJ, Smith MA, Carson CA, et al. Prognosis and outcomes of patients with community-acquired pneumonia. A meta-analysis. JAMA. 1996;275(2):134-141.
File TM. Clinical implications and treatment of multiresistant Streptococcus pneumoniae pneumonia. Clinical Microbiology and Infection. 2006;12:31-41. doi:10.1111/j.1469-0691.2006.01395.x
Aleemullah MF, Krishnamurthy V, Harish M, Akeel CA. Bacteriological Profile of Patients with AECOPD- Hospital Based Study. Int J Curr Microbiol Appl Sci. 2016;5(4):84-90. doi:10.20546/ijcmas.2016.504.012
File TM. Community-acquired pneumonia. The Lancet. 2003;362(9400):1991-2001. doi:10.1016/S0140-6736(03)15021-0
Niederman MS, Mandell LA, Anzueto A, et al. Guidelines for the Management of Adults with Community-acquired Pneumonia. Am J Respir Crit Care Med. 2001;163(7):1730-1754. doi:10.1164/ajrccm.163.7.at1010
British Thoracic Society Standards of Care Committee. BTS Guidelines for the Management of Community Acquired Pneumonia in Adults. Thorax. 2001;56 Suppl 4(Suppl 4):IV1-64. doi:10.1136/thorax.56.suppl_4.iv1
Jokinen C, Heiskanen L, Juvonen H, et al. Microbial Etiology of Community-Acquired Pneumonia in the Adult Population of 4 Municipalities in Eastern Finland. Clinical Infectious Diseases. 2001;32(8):1141-1154. doi:10.1086/319746
Dowell SF, Anderson LJ, Gary HE, et al. Respiratory Syncytial Virus Is an Important Cause of Community-Acquired Lower Respiratory Infection among Hospitalized Adults. Journal of Infectious Diseases. 1996;174(3):456-462. doi:10.1093/infdis/174.3.456
Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases. 2007;44(Supplement_2):S27-S72. doi:10.1086/511159
Bartlett JG, Dowell SF, Mandell LA, File TM, Musher DM, Fine MJ. Practice Guidelines for the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases. 2000;31(2):347-382. doi:10.1086/313954
Reyes S, Martinez R, Valles JM, Cases E, Menendez R. Determinants of hospital costs in community-acquired pneumonia. European Respiratory Journal. 2008;31(5):1061-1067. doi:10.1183/09031936.00083107
Konomura K, Nagai H, Akazawa M. Economic burden of community-acquired pneumonia among elderly patients: a Japanese perspective. Pneumonia. 2017;9(1):19. doi:10.1186/s41479-017-0042-1
Broulette J, Yu H, Pyenson B, Iwasaki K, Sato R. The incidence rate and economic burden of community-acquired pneumonia in a working-age population. Am Health Drug Benefits. 2013;6(8):494-503.
Bonafede MM, Suaya JA, Wilson KL, Mannino DM, Polsky D. Incidence and cost of CAP in a large working-age population. Am J Manag Care. 2012;18(7):380-387.
McLaughlin JM, Johnson MH, Kagan SA, Baer SL. Clinical and economic burden of community-acquired pneumonia in the Veterans Health Administration, 2011: a retrospective cohort study. Infection. 2015;43(6):671-680. doi:10.1007/s15010-015-0789-3
Llop CJ, Tuttle E, Tillotson GS, LaPlante K, File TM. Antibiotic treatment patterns, costs, and resource utilization among patients with community acquired pneumonia: a US cohort study. Hosp Pract. 2017;45(1):1-8. doi:10.1080/21548331.2017.1279012
Yu H, Rubin J, Dunning S, Li S, Sato R. Clinical and Economic Burden of Community‐Acquired Pneumonia in the Medicare Fee‐for‐Service Population. J Am Geriatr Soc. 2012;60(11):2137-2143. doi:10.1111/j.1532-5415.2012.04208.x
Sato R, Gomez Rey G, Nelson S, Pinsky B. Community-Acquired Pneumonia Episode Costs by Age and Risk in Commercially Insured US Adults Aged ≥50 Years. Appl Health Econ Health Policy. 2013;11(3):251-258. doi:10.1007/s40258-013-0026-0
Wattengel BA, Sellick JA, Skelly MK, Napierala R, Schroeck J, Mergenhagen KA. Outpatient Antimicrobial Stewardship: Targets for Community-acquired Pneumonia. Clin Ther. 2019;41(3):466-476. doi:10.1016/j.clinthera.2019.01.007
’Anurag K, ’ Rakesh S. Health Insurance for India’s Missing Middle. 2021.
Pasquale CB, Vietri J, Choate R, et al. Patient-Reported Consequences of Community-Acquired Pneumonia in Patients with Chronic Obstructive Pulmonary Disease. Chronic Obstr Pulm Dis. 2019;6(2):132-144. doi:10.15326/jcopdf.6.2.2018.0144
Micek ST, Kollef KE, Reichley RM, Roubinian N, Kollef MH. Health care-associated pneumonia and community-acquired pneumonia: a single-center experience. Antimicrob Agents Chemother. 2007;51(10):3568-3573. doi:10.1128/AAC.00851-07
Stupka JE, Mortensen EM, Anzueto A, Restrepo MI. Community-acquired pneumonia in elderly patients. Aging health. 2009;5(6):763-774. doi:10.2217/ahe.09.74
Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases. 2007;44(Supplement_2):S27-S72. doi:10.1086/511159
Wispelwey B, Schafer KR. Fluoroquinolones in the management of community-acquired pneumonia in primary care. Expert Rev Anti Infect Ther. 2010;8(11):1259-1271. doi:10.1586/eri.10.110

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Estimating the clinical and economic burden of community-acquired pneumonia (CAP) among adult patients in India using the CAP burden of illness questionnaire

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Abstract

Background

Methods

Results

Conclusion

Introduction

Methods

Statistical Analysis

Results

Sample Description

Findings from the Physician Survey

Findings from the CAP-Burden of Illness Questionnaire

Time to Symptom Resolution, Impact of CAP Symptoms on Daily Activities and Work Productivity

CAP Related Health Care Resource Utilization

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1