Advertisement
Browse Subject Areas
?

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here.

  • Loading metrics

Type 2 diabetes and postoperative pneumonia: An observational, population-based study using the Spanish Hospital Discharge Database, 2001-2015

  • Ana López-de-Andrés,

    Roles Conceptualization, Investigation, Methodology, Writing – original draft, Writing – review & editing

    Affiliation Preventive Medicine and Public Health Teaching and Research Unit. Health Sciences Faculty, Rey Juan Carlos University, Alcorcón, Madrid, Spain

  • Napoleon Perez-Farinos ,

    Roles Investigation, Methodology, Supervision, Writing – review & editing

    jnpf.uma@gmail.com

    Affiliation Public Health and Psychiatry Department, Faculty of Medicine, Universidad de Malaga, Malaga, Spain

  • Javier de Miguel-Díez,

    Roles Methodology, Supervision, Writing – review & editing

    Affiliation Respiratory Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid (UCM), Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain

  • Valentín Hernández-Barrera,

    Roles Formal analysis, Methodology, Writing – review & editing

    Affiliation Preventive Medicine and Public Health Teaching and Research Unit. Health Sciences Faculty, Rey Juan Carlos University, Alcorcón, Madrid, Spain

  • Isabel Jiménez-Trujillo,

    Roles Methodology, Supervision, Writing – review & editing

    Affiliation Preventive Medicine and Public Health Teaching and Research Unit. Health Sciences Faculty, Rey Juan Carlos University, Alcorcón, Madrid, Spain

  • Manuel Méndez-Bailón,

    Roles Methodology, Supervision, Writing – review & editing

    Affiliation Internal Medicine Department, Hospital Universitario Clínico San Carlos, Madrid, Spain

  • José M. de Miguel-Yanes,

    Roles Conceptualization, Methodology, Supervision, Writing – original draft

    Affiliation Internal Medicine Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain

  • Rodrigo Jiménez-García

    Roles Conceptualization, Funding acquisition, Methodology, Supervision, Writing – review & editing

    Affiliation Preventive Medicine and Public Health Teaching and Research Unit. Health Sciences Faculty, Rey Juan Carlos University, Alcorcón, Madrid, Spain

Type 2 diabetes and postoperative pneumonia: An observational, population-based study using the Spanish Hospital Discharge Database, 2001-2015

  • Ana López-de-Andrés, 
  • Napoleon Perez-Farinos, 
  • Javier de Miguel-Díez, 
  • Valentín Hernández-Barrera, 
  • Isabel Jiménez-Trujillo, 
  • Manuel Méndez-Bailón, 
  • José M. de Miguel-Yanes, 
  • Rodrigo Jiménez-García
PLOS
x

Abstract

Purpose

We analyzed temporal trends, demographic and clinical characteristics and hospital mortality rates of postoperative pneumonia among type 2 diabetes mellitus (T2DM) patients in Spain from 2001 to 2015. We also compared the incidence, comorbidities and mortality between patients with and without T2DM suffering from postoperative pneumonia. Finally, we analyzed the factors involved in the prediction of in-hospital mortality among patients suffering postoperative pneumonia.

Methods

We used the Spanish National Hospital Discharge Database for the period 2001–2015. We analyzed patients aged 40 years or over who had been hospitalized for a surgical procedure and suffered pneumonia or ventilator-associated pneumonia during their hospital admission. We compared patients with and without T2DM. The main outcome measures were the type of surgical procedure, the presence of a comorbidity, the type of isolated pathogens, admission to the emergency room (ER) and in-hospital mortality (IHM).

Results

We selected 117,665 hospitalized patients who suffered postoperative pneumonia (16.9% with T2DM). After multivariable adjustment, T2DM patients had a 21% higher incidence of postoperative pneumonia than nondiabetic patients (IRR 1.21, 95% CI 1.03–1.42). The IHM was approximately 31% in both groups. Predictors of IHM included age, the presence of comorbidities, treatment with a pleural drainage tube, dialysis, blood transfusion, mechanical ventilation and admission to the ER. From 2001 to 2015, the IHM decreased significantly in both populations. Suffering from T2DM was not a predictor of IHM (OR 0.99, 95% CI 0.96–1.03) in our investigation.

Conclusions

T2DM patients have a higher incidence of postoperative pneumonia than those without this disease. The IHM decreased from 2001 to 2015, regardless of T2DM status. T2DM did not predict a higher IHM after suffering from postoperative pneumonia.

Introduction

Hospital-acquired pneumonia (HAP) represents approximately 15% of all infections acquired during hospitalizations [1]. Over the last two decades, research has focused mainly on ventilator-associated pneumonia (VAP), and as a consequence, the incidence of this complication has decreased and patient outcomes have improved [25]. In Spain, a recent investigation showed that the incidence rates of VAP improved significantly from 41.7 cases/100,000 inhabitants in 2010 to 40.55 cases/100,000 inhabitants in 2014 [6]. However, VAP is not the only form of HAP; a recent report with data from the US National Inpatient Sample dataset found that nonventilator HAP was associated with mortality, a greater length of hospital stay and an increase in the cost of care [7].

Kazaure HS et al. analyzed complications for all surgical procedures, finding that postoperative pneumonia is very frequent, representing the third most common complication and resulting in increased morbidity and mortality of postsurgical patients [8].

Diabetes is a risk factor that contributes to the development of postoperative pneumonia for several surgical specialties [9]. In general, surgery, cardiothoracic surgery, orthopedic surgery and spine surgery, diabetes was associated with an approximately 2-fold higher risk of postoperative pneumonia [1013]. Poor glycemic control and a longer duration of diabetes were associated with increased susceptibility to hospital-acquired infections [14].

In this study, we analyzed temporal trends, demographic and clinical characteristics and hospital mortality of postoperative pneumonia among type 2 diabetes mellitus (T2DM) patients in Spain from 2001 to 2015. We also compared the incidence, comorbidities and mortality between patients with and without T2DM suffering postoperative pneumonia. Finally, we tested which factors predicted in-hospital mortality among patients suffering postoperative pneumonia.

Materials and methods

The Spanish National Hospital Discharge Database was used to conduct this observational retrospective investigation. The Spanish National Hospital Discharge Database (CMBD, Conjunto Mínimo Básico Datos) was implemented in Spain in 1987. According to the Spanish legislation, all hospitals must submit information of every single patient hospitalized for at least one night in a hospital ward to the Ministry of Health. The variables included were dates of admission and discharge, age, sex, hospitalization services, type of admission (emergency room/scheduled), hospital size and discharge status (discharged home, discharged and transferred to other facilities, dead, not stated or not reported). Medical diagnoses (up to 14) and procedures (up to 20) conducted during hospitalization were obtained from the discharge report. The first or primary diagnosis was the disease that was considered responsible for the hospital admission of the patient after investigation [15]. The International Classification of Diseases-Ninth Revision, Clinical Modification (ICD-9-MC) was used for coding in the CMBD.

We analyzed all registries included in the CMBD from 2001 to 2015. For study purpose, only subjects aged ≥40 years who had an ICD-9-MC code for pneumonia (507.xx, 480.xx-488.xx) or VAP (997.31) in any of their secondary diagnosis fields were included. Following the recommendations of Guevara et al., if a patient’s primary diagnosis was bacteremia (790.7), sepsis (0.38, 995.92, 995.91), meningitis (322.xx). empyema (510.9, 510.0) or pneumonia (997.31, 507.xx, 480.xx-488.xx), they were excluded as these patients may suffer from community-acquired pneumonia [16].

Patients who presented codes 250.x0 or 250.x2 in any of the diagnosis positions were considered T2DM sufferers. Those with codes 250.x1 or 250.x3 were considered type 1 diabetes mellitus sufferers and excluded. The remaining patients were considered nondiabetic subjects.

The presence of comorbidities was measured using the Charlson comorbidity index (CCI) [17].

We categorized the surgical procedures conducted during hospitalization using the following ICD-9-CM codes in any of the 20 procedure fields: i) codes 01–05 (surgeries involving the nervous system); ii) codes 30–34 (surgeries involving the respiratory system); iii) codes 35–39 (surgeries involving the cardiovascular system); iv) codes 42–54 (surgeries involving the digestive system); v) codes 55–75 (surgeries involving the urinary system/male and female genital organs/obstetrical procedures); and iv) codes 76–89 (surgeries involving the musculoskeletal system/integumentary system).

Other procedures also identified included dialysis (codes 39.95, 54.98), transfusion (codes 99.00, 99.01–99.08), thoracentesis (code 34.91), invasive mechanical ventilation (codes 96.7, 96.70–72), pleural drainage tube (codes 34.0, 34.01–34.09), noninvasive mechanical ventilation (code 93.90) and respiratory culture (codes 90.4x).

The pneumonia pathogens analyzed in our study have been described by de Miguel-Díez J et al. [6].

Finally, for each patient, hospital admission (emergency room or programmed admission) and patient death during hospitalization (IHM) were analyzed.

Statistical analysis

To assess time trends, three periods were considered: 2001 to 2005, 2006 to 2010 and 2011 to 2015.

To assess the temporal trends, we estimated incidence rates by dividing those patients who suffered postoperative pneumonia by the total number of those undergoing a surgical procedure. These incidences were calculated according to the presence or absence of T2DM and are expressed per 100,000 patients based on surgical procedure. Poisson regression models adjusted by “year of admission” (three periods included as continuous variables) and “rate of hospital admissions adjusted by age and sex” were constructed to assess time trends.

In the model including the total population, “T2DM” was also included as a covariate. In this last model, we included the interaction “year*T2DM”. The interaction was not significant. As we included the rate of hospital admissions adjusted by sex and age, we did not include more interactions.

Descriptive statistics included proportions (categorical variables) and means with standard deviations (continuous variables). Comparisons of proportions were performed using the χ2 test and ANOVA or Student’s t-test for means.

Logistic regression models were constructed to assess changes over time in the categorical variables and to identify predictors of IHM.

The construct of the multivariable logistic regression models for IHM followed the steps recommended by El-Amrani-Joutey et al. [18].

Statistical analyses were performed with Stata 10.1 (Stata, College Station, Texas, USA). Statistical significance was set at p<0.05 (2-tailed).

Ethical aspects

In this investigation, data were provided to the authors anonymized so it was impossible to identify patients. According to Spanish legislation, given the characteristics of the database and as the Spanish Ministry of Health considered the study ethically acceptable, it was not necessary to obtain the approval of an ethics committee.

Patient and public involvement

For this investigation, we used a publicly accessible, anonymous and mandatory dataset, so patients’ priorities, experience, and preferences were not considered in the development of the research question and outcome measures. Furthermore, patients were not involved in the design or recruitment of this study. Finally, as we do not have personal data, we cannot disseminate the results of the study to participants.

Results

We analyzed data from 117,665 hospitalizations of patients ≥40 years who suffered postoperative pneumonia in Spain from 2001 to 2015. T2DM was a diagnosis codified in 16.9% of patients (n = 20,003).

The incidence, comorbidities and type of surgical procedures conducted among patients who suffered postoperative pneumonia according to the presence of T2DM are shown in Table 1.

thumbnail
Table 1. Sociodemographic and clinical characteristics of hospitalized patients who suffered from postsurgical pneumonia in Spain from 2001 to 2015 according to diabetes status.

https://doi.org/10.1371/journal.pone.0211230.t001

The overall incidence of postoperative pneumonia per 100,000 surgeries was significantly higher in T2DM patients than in non-T2DM patients (397.35 vs. 310.40 cases; p<0.001); these differences were also significant in all time periods analyzed. The incidence of postoperative pneumonia rose significantly from 393.67 cases per 100,000 surgeries in patients with T2DM in 2001–05 to 419.28 cases per 100,000 surgeries in 2011–15 (p<0.001). However, in patients without diabetes, the incidence of postoperative pneumonia decreased significantly, as shown in Table 1 (p<0.001).

According to the adjusted Poisson regression analysis, patients with T2DM had a 21% higher incidence of postoperative pneumonia than those without diabetes (IRR, 1.21 95% CI 1.03–1.42).

Postoperative pneumonia was identified more frequently among men than women in both populations studied (65.66% and 67.54% for T2DM and nondiabetic patients, respectively p<0.001). The percentage of males affected increased significantly (p<0.001) in patients with T2DM; however, it decreased in those without diabetes (p<0.001). The mean age was significantly higher in those with T2DM (73.01±10.85 years vs. 69.15±13.5 years; p<0.001), and they also had a higher mean CCI index (1.32±0.98 vs 1.13±0.92; p<0.001). The mean age and CCI increased significantly over time among T2DM patients.

In patients with T2DM, the most frequent surgical procedures were surgeries of the musculoskeletal system/integumentary system (20.37%), followed by surgeries involving the cardiovascular system (19.06%) and the digestive system (18.01%). T2DM patients included in our investigation had undergone significantly more frequent obstetrical surgeries of the female reproductive organs and surgeries of the male urinary system, cardiovascular system, musculoskeletal system and integumentary system than nondiabetic patients (Table 1).

Diagnostic and therapeutic procedures, isolated pathogens and in-hospital outcomes for patients who suffered postsurgical pneumonia according to diabetes status are shown in Table 2.

thumbnail
Table 2. Procedures, hospital outcomes and isolated pathogens of hospitalized patients who suffered from postsurgical pneumonia in Spain from 2010 to 2015 according to diabetes status.

https://doi.org/10.1371/journal.pone.0211230.t002

Mechanical ventilation (28.82%) and transfusion (21.02%) were the procedures most frequently performed among T2DM patients. However, thoracentesis, dialysis (p<0.001), mechanical ventilation (p<0.001), transfusion (p<0.001), and pleural drainage tubes (p<0.001) were more frequently codified among nondiabetic patients.

Invasive mechanical ventilation was used in a smaller proportion of patients over time, whereas transfusion and noninvasive mechanical ventilation were more frequently used over time (both p<0.001).

Among patients with T2DM, the most commonly identified pathogens were Streptococcus pneumoniae (5.86%), Pseudomonas (3.34%) and Staphylococcus aureus (3.29%). The prevalence of the pathogens analyzed (except Streptococcus pneumoniae) was higher in patients without diabetes than in those with T2DM (p<0.001). For both groups of patients, the prevalence of all pathogens decreased from 2001 to 2015 (p<0.001).

Respiratory cultures were more frequently performed in those without T2DM (3.85%) than in those with the disease (3.15%) (p = 0.002).

The proportion of patients admitted through the emergency room was higher in patients with T2DM (76.73% vs 73.35%, p<0.001).

Over the fifteen years, IHM was approximately 31% in both groups. However, crude IHM decreased over time from 35.98% to 26.59% in patients with T2DM (p<0.001), and from 34.79% to 27.59% in those without diabetes (p<0.001).

Table 3 and Table 4 show the characteristics of the hospitalizations during which patients with and without T2DM developed postsurgical pneumonia according to hospital survival.

thumbnail
Table 3. Sociodemographic and clinical characteristics of hospitalized patients with and without diabetes who suffered from postsurgical pneumonia according to hospitalization survival in Spain, 2001–2015.

https://doi.org/10.1371/journal.pone.0211230.t003

thumbnail
Table 4. Procedures, hospital outcomes and isolated pathogens of hospitalized patients with and without diabetes who suffered from postsurgical pneumonia according to hospitalization survival in Spain, 2001–2015.

https://doi.org/10.1371/journal.pone.0211230.t004

In both groups, IHM was higher in the older age groups, those with more coexisting conditions, those who underwent any diagnostic or therapeutic procedure (except thoracocentesis) and those who had any pathogen isolated (except Streptococcus pneumoniae or Haemophilus influenzae).

When we compare the IHM between T2DM patients with those without T2DM according to the type of surgical procedure, we find higher figures for diabetic patients who underwent surgical procedures involving the respiratory system, nervous system and musculoskeletal/integumentary system. IHM was also higher among those who were treated with noninvasive mechanical ventilation and dialysis. However, IHM was higher among non-T2DM patients than T2DM patients in older patients (>75 years), those with higher CCI, those who had surgeries involving the cardiovascular system and those who were treated with mechanical ventilation.

Table 5 presents the results of the multivariable analysis to identify predictors of IHM after postsurgical pneumonia for patients with and without T2DM.

thumbnail
Table 5. Factors independently associated with in-hospital mortality among hospitalized diabetic and nondiabetic patients who suffered from postsurgical pneumonia according to hospitalization survival in Spain, 2001–2015.

https://doi.org/10.1371/journal.pone.0211230.t005

Being older, suffering more comorbid conditions according to the CCI, emergency room admission and undergoing therapeutic procedures such as dialysis, pleural drainage tube usage, any type of mechanical ventilation and blood transfusion were predictors of higher IHM in both populations. However, T2DM patients who had thoracentesis had a lower risk of IHM (OR 0.90, 95% CI 0.82–0.98).

Isolation of Haemophilus influenza or Streptococcus pneumoniae predicted a lower IHM in patients with T2DM. On the other hand, isolation of Aspergillosis (for both groups) or Pseudomonas (for those with T2DM) increased the risk of dying.

Temporal trend analysis, using multivariable adjustment, showed a significant reduction in IHM from 2001 to 2015 in T2DM (OR 0.79 95% CI 0.77–0.80) and nondiabetic patients (OR 0.76 95% CI 0.73–0.81).

Finally, we found that in our studied population, T2DM was not associated with IHM after postsurgical pneumonia (OR 0.99, 95% CI 0.96–1.03).

Discussion

In Spain using data from the national hospital discharge database, we found higher incidence rates of hospitalization with postoperative pneumonia in patients suffering T2DM than in patients without this condition. Therefore, T2DM is a risk factor for developing postoperative pneumonia. Similar to other authors, we found that a higher prevalence of postoperative pneumonia in patients with T2DM occurred in the setting of orthopedic and spine surgery, cardiothoracic surgery and general surgery [9]. In a retrospective cohort study including patients undergoing total joint arthroplasty, the presence of diabetes was found to be a predictor for postoperative pneumonia (RR 1.2, 95% CI 0.9–1.5 for noninsulin-dependent diabetes vs no diabetes) [19]. A previous study using the American College of Surgery National Surgical Quality Improvement Program database, which controlled for demographics and other comorbidities, demonstrated that patients with diabetes undergoing lumbar fusion surgeries were at greater risk for postoperative complications, longer hospitalization times, and more readmissions [13]. This increased risk might be associated with immunosuppression caused by diabetes [20]. In the US, an observational study of 16,084 patients who underwent coronary artery bypass grafting identified seventeen preoperative risk factors associated with postoperative pneumonia, including diabetes as a comorbid disease (OR 1.26; p = 0.02) [21]. After the hepatectomy procedure, diabetes was associated with an approximately 2-fold increased risk of postoperative pneumonia. The authors concluded that diabetic patients had several mechanisms that could increase their risk of infection, including increased altered immune cell function, bacterial proliferation and changes in vascular permeability and endothelial cells [10,11]. In 2016, Miki et al. reported that after gastrectomy for gastric cancer treatment, diabetes increased the risk of postoperative pneumonia by 2.46-fold [22]. A suggested explanation is that poor glycemic control or a longer duration of diabetes could increase susceptibility to postoperative pneumonia [23].

In our investigation, we detected a significant increase in the incidence of postsurgical pneumonia in T2DM patients. We think that three possible reasons could explain this increase. First, according to several studies, Spanish T2DM patients are undergoing more complex surgeries, all of which have a high risk of postsurgical complications (coronary artery bypass graft, surgical aortic valve replacement, solid organ transplants, bariatric surgery, revision of total hip and knee arthroplasty) more frequently over time. Furthermore, the rates of these surgeries are increasing over time among T2DM patients and are higher than those among nondiabetic patients [2428]. Second, as described in this and previous investigations, the mean age and the prevalence of concomitant conditions among T2DM patients have increased in recent decades [2429]. Third, as suggested by Trinh et al., pneumonia is becoming better recognized in postoperative patients, resulting in an increase in the incidence [30].

T2DM was not a predictor of IHM after postoperative pneumonia. Umpierrez et al. found that incident hyperglycemia was a better predictor of IHM than a prior history of diabetes, concluding that hyperglycemia and not diabetes itself increased the risk of death [31]. Serio et al. (2013) investigated the postoperative risk of morbidity and mortality in diabetic patients versus nondiabetic patients who underwent general or vascular surgery and found that the presence of diabetes was not predictive of mortality; however, vascular surgery itself was predictive of mortality [32]. Perhaps the fact that subjects suffering diabetes were more likely to be admitted to the hospital for less severe illnesses might explain this association. Unfortunately, the CMBD does not include information on the severity of T2DM, and this variable could affect IHM after postoperative pneumonia. Furthermore, the presence of other T2DM complications, such as kidney disease, heart attack, stroke or peripheral vascular disease, has been demonstrated to increase the risk of mortality after postoperative pneumonia [9,19,21,22]. In our investigation, among T2DM patients, IHM was associated with a higher number of conditions included in the CCI (kidney disease, heart attack, stroke and peripheral vascular disease) and with undergoing dialysis during hospitalization, confirming the negative effect of T2DM chronic complications in the IHM after postoperative pneumonia.The IHM was higher in T2DM patients than non-T2DM patients who had undergone surgical procedures involving the respiratory system, nervous system, and musculoskeletal/integumentary system and those who required noninvasive mechanical ventilation or dialysis. The site or type of surgery could have more importance in the probability of developing pulmonary complications or adverse outcomes than the pulmonary condition of the patients prior to the intervention [33].

The results of Studer et al. [34] align with our findings, as they identified higher age and intraoperative red cell transfusion as predictors of IHM after postoperative pneumonia.

The negative effect of blood transfusion causing transient immunosuppression has been found in other studies. [35] Other predictors of higher postoperative mortality described by other authors include poor underlying medical conditions, prolonged mechanical ventilation, pleural effusion and emergency surgery compared with elective surgery [3640].

We described a positive decline in IHM in addition to diabetes status. In a recent study, Chughtai et al. analyzed trends in the incidence of postoperative pneumonia from 2009 to 2013 in different surgical services and found reductions in all of them. Appropriate patient selection and optimization of preoperative management might have contributed to improved outcomes. [9]

The most relevant findings from our investigation for clinicians and researchers in the management of patients with pneumonia and diabetes is that the risk of suffering from postoperative pneumonia increases if patients also have T2DM; therefore, preventive measures must be strictly performed in these patients. Furthermore, among T2DM patients, those who were older, had more comorbid conditions or were admitted through the ER had a higher IHM; thus, rapid diagnosis and aggressive therapeutic procedures and treatments must be considered for those with these risk factors.

Further investigations should include mortality rates after hospital discharge and an analysis of the effect of diabetes treatments and controls (glycosylated hemoglobin) on the incidence and outcomes of postoperative pneumonia among T2DM patients.

There are several limitations of our investigation that must be considered.

We selected patients aged 40 years or older because, according to Spanish studies, the prevalence of T2DM is very low under this age (<1%) [41, 42]. Furthermore, even if the validity of diabetes as a discharge diagnosis had been demonstrated in previous investigations, the possibility of miscoding T1DM as T2DM is higher in younger groups [43, 44]

As occurs with any administrative database, changes in coding practices over time and coding errors may affect the validity of our results.

Previous investigations have found that the decision to admit a patient and the indication for surgery is affected by factors such as the age, dependency, comorbid conditions, mental health and severity of acute illness [45,46]. Spanish T2DM patients are older and have more comorbidities and disabilities than nondiabetic subjects and therefore may have fewer indications for surgery, so T2DM patients could be underrepresented in the study sample [47].

Another limitation is the lack of data regarding glycosylated hemoglobin measurements or blood glucose levels prior to or during hospitalization. Furthermore, other known risk factors for postoperative complications, such as antimicrobial treatments, number of days on ventilator support, and illness or disease severity are not collected in the CMBD[48].

In conclusion, T2DM patients have a higher incidence of postoperative pneumonia than those without this disease. The IHM dropped from 2001 to 2015, regardless of T2DM status, and diabetes did not predict a higher IHM after suffering postoperative pneumonia.

References

  1. 1. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R; CDC; Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing health-care–associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep 2004;53:1–36.
  2. 2. Melsen WG, Rovers MM, Koeman M, Bonten MJ. Estimating the attributable mortality of ventilator-associated pneumonia from randomized prevention studies. Crit Care Med 2011;39:2736–2742. pmid:21765351
  3. 3. Ding S, Kilickaya O, Senkal S, Gajic O, Hubmayr RD, Li G. Temporal trends of ventilator-associated pneumonia incidence and the effect of implementing health-care bundles in a suburban community. Chest 2013;144:1461–1468. pmid:23907411
  4. 4. Righi E, Aggazzotti G, Ferrari E, Giovanardi C, Busani S, Rinaldi L, et al. Trends in ventilator-associated pneumonia: impact of a ventilator care bundle in an Italian tertiary care hospital intensive care unit. Am J Infect Control 2014;42:1312–1316. pmid:25444306
  5. 5. Khan R, Al-Dorzi HM, Al-Attas K, Ahmed FW, Marini AM, Mundekkadan S, et al. The impact of implementing multifaceted interventions on the prevention of ventilator-associated pneumonia. Am J Infect Control 2016; 44: 320–326. pmid:26940595
  6. 6. de Miguel-Díez J, López-de-Andrés A, Hernández-Barrera V, Jiménez-Trujillo I, Méndez-Bailón M, Miguel-Yanes JM, et al. Decreasing incidence and mortality among hospitalized patients suffering a ventilator-associated pneumonia: Analysis of the Spanish national hospital discharge database from 2010 to 2014. Medicine (Baltimore) 2017;96:e7625.
  7. 7. Giuliano KK, Baker D, Quinn B. The epidemiology of nonventilator hospital-acquired pneumonia in the United States. Am J Infect Control. 2017 Oct 16. pmid:29050905
  8. 8. Kazaure HS, Martin M, Yoon JK, Wren SM. Long-term results of a postoperative pneumonia prevention program for the inpatient surgical ward. JAMA Surg 2014;149:914–918. pmid:25054486
  9. 9. Chughtai M, Gwam CU, Mohamed N, Khlopas A, Newman JM, Khan R, et al. The Epidemiology and Risk Factors for Postoperative Pneumonia. J Clin Med Res 2017;9:466–475. pmid:28496546
  10. 10. Pessaux P, van den Broek MA, Wu T, Olde Damink SW, Piardi T, Dejong CH, et al. Identification and validation of risk factors for postoperative infectious complications following hepatectomy. J Gastrointest Surg 2013;17:1907–1916. pmid:23661000
  11. 11. Nobili C, Marzano E, Oussoultzoglou E, Rosso E, Addeo P, Bachellier P, et al. Multivariate analysis of risk factors for pulmonary complications after hepatic resection. Ann Surg 2012;255:540–550. pmid:22330041
  12. 12. Allou N, Allyn J, Snauwaert A, Welsch C, Lucet JC, Kortbaoui R, et al. Postoperative pneumonia following cardiac surgery in non-ventilated patients versus mechanically ventilated patients: is there any difference? Crit Care 2015;19:116. pmid:25881186
  13. 13. Bohl DD, Mayo BC, Massel DH, Iantorno SE, Ahn J, Basques BA, et al. Incidence and Risk Factors for Pneumonia After Posterior Lumbar Fusion Procedures: An ACS-NSQIP Study. Spine (Phila Pa 1976) 2016;41:1058–1063.
  14. 14. Rady MY, Johnson DJ, Patel BM, Larson JS, Helmers RA. Influence of individual characteristics on outcome of glycemic control in intensive care unit patients with or without diabetes mellitus. Mayo Clin Proc 2005;80:1558–1567. pmid:16342648
  15. 15. Instituto Nacional de Gestión Sanitaria, Ministerio de Sanidad, Servicios Sociales e Igualdad. Conjunto Mínimo Básico de Datos, Hospitales del INSALUD. Available from http://www.ingesa.msssi.gob.es/estadEstudios/documPublica/CMBD-2001.htm. Accessed 16 October 2017.
  16. 16. Guevara RE, Butler JC, Marston BJ, Plouffe JF, File TM Jr, Breiman RF. Accuracy of ICD 9 CM Codes in Detecting CAP for Incidence and Vaccine Efficacy Studies. Am J Epi 1999; 149: 282–289.
  17. 17. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373–383. pmid:3558716
  18. 18. El-Amrani-Joutey M, Jiménez-García R, Linares-García-Valdecasas R, Palomar-Gallego MA, Jiménez-Trujillo I, López-de-Andrés A, et al. Infection by Epstein-Barr virus in Fes (Morocco). Prevalence and predictors of positivity in nasopharyngeal cancer. J Infect Public Health. 2018;11:807–811. pmid:29871843
  19. 19. Bohl DD, Saltzman BM, Sershon RA, Darrith B, Okroj KT, Della Valle CJ. Incidence, Risk Factors, and Clinical Implications of Pneumonia Following Total Hip and Knee Arthroplasty. J Arthroplasty 2017;32:1991–1995.e1. pmid:28161137
  20. 20. Golinvaux NS, Varthi AG, Bohl DD, Basques BA, Grauer JN. Complication rates following elective lumbar fusion in patients with diabetes: insulin dependence makes the difference. Spine (Phila Pa 1976) 2014;39:1809–1816.
  21. 21. Strobel RJ, Liang Q, Zhang M, Wu X, Rogers MA, Theurer PF, et al. A Preoperative Risk Model for Postoperative Pneumonia After Coronary Artery Bypass Grafting. Ann Thorac Surg 2016;102:1213–1219. pmid:27261082
  22. 22. Miki Y, Makuuchi R, Tokunaga M, Tanizawa Y, Bando E, Kawamura T, et al. Risk factors for postoperative pneumonia after gastrectomy for gastric cancer. Surg Today 2016;46:552–526. pmid:26077287
  23. 23. Kornum JB, Thomsen RW, Riis A, Lervang HH, Schønheyder HC, Sørensen HT. Diabetes, glycemic control, and risk of hospitalization with pneumonia: a population-based case-control study. Diabetes Care 2008;31:1541–1545. pmid:18487479
  24. 24. Lopez-de-Andrés A, Perez-Farinos N, de Miguel-Díez J, Hernández-Barrera V, Méndez-Bailón M, de Miguel-Yanes JM, et al. Impact of type 2 diabetes mellitus in the utilization and in-hospital outcomes of surgical aortic valve replacement in Spain (2001–2015). Cardiovasc Diabetol. 2018;17:135. pmid:30326902
  25. 25. de Miguel-Yanes JM, Jiménez-García R, de Miguel-Díez J, Hernández-Barrera V, Méndez-Bailón M, Muñoz-Rivas N, et al. In-hospital outcomes for solid organ transplants according to type 2 diabetes status: an observational, 15-year study in Spain. Int J Clin Pract. 2018:e13283. pmid:30317700
  26. 26. López-de-Andrés A, Hernández-Barrera V, Martínez-Huedo MA, Villanueva-Martinez M, Jiménez-Trujillo I, Jiménez-García R. Type 2 diabetes and in-hospital complications after revision of total hip and knee arthroplasty. PLoS One. 2017 Aug 24;12:e0183796. pmid:28837689
  27. 27. Lopez-de-Andres A, Jimenez-García R, Hernandez-Barrera V, Perez-Farinos N, de Miguel-Yanes JM, Mendez-Bailon M, et al. National trends in utilization and outcomes of coronary revascularization procedures among people with and without type 2 diabetes in Spain (2001–2011). Cardiovasc Diabetol. 2014;13:3. pmid:24383412
  28. 28. Lopez-de-Andres A, Jiménez-García R, Hernández-Barrera V, Gil-de-Miguel A, Jiménez-Trujillo MI, Carrasco-Garrido P. Trends in utilization and outcomes of bariatric surgery in obese people with and without type 2 diabetes in Spain (2001–2010). Diabetes Res Clin Pract. 2013;99:300–6. pmid:23305900
  29. 29. Jiménez-Trujillo I, Jiménez-García R, de Miguel-Díez J, de Miguel-Yanes JM, Hernández-Barrera V, Méndez-Bailón M, et al. Incidence, characteristic and outcomes of ventilator-associated pneumonia among type 2 diabetes patients: An observational population-based study in Spain. Eur J Intern Med 2017;40:72–78. pmid:28139447
  30. 30. Trinh VQ, Ravi P, Abd-El-Barr AE, Jhaveri JK, Gervais MK, Meyer CP, et al. Pneumonia after Major Cancer Surgery: Temporal Trends and Patterns of Care. Can Respir J. 2016;2016:6019416. pmid:27445554
  31. 31. Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab 2002;87:978–982. pmid:11889147
  32. 32. Serio S, Clements JM, Grauf D, Merchant AM. Outcomes of diabetic and nondiabetic patients undergoing general and vascular surgery. ISRN Surg 2013;2013:963930. pmid:24455308
  33. 33. Yang CK, Teng A, Lee DY, Rose K. Pulmonary complications after major abdominal surgery: National Surgical Quality Improvement Program analysis. J Surg Res 2015; 198:441–449. pmid:25930169
  34. 34. Studer P, Raber G, Ott D, Candinas D, Schnuriger B. Risk factors for fatal outcome in surgical patients with postoperative aspiration pneumonia. Int J Surg 2016; 27:21–25. pmid:26804349
  35. 35. Crawford TC, Magruder JT, Fraser C, Suarez-Pierre A, Alejo D, Bobbitt J, et al. Less Is More: Results of a Statewide Analysis of the Impact of Blood Transfusion on Coronary Artery Bypass Grafting Outcomes. Ann Thorac Surg. 2017 Oct 24. pmid:29074154
  36. 36. Sheikh HQ, Hossain FS, Aqil A, Akinbamijo B, Mushtaq V, Kapoor H. A comprehensive analysis of the causes and predictors of 30-day mortality following hip fracture surgery. Clin Orthop Surg 2017; 9:10–18. pmid:28261422
  37. 37. Aydin C, Otan E, Akbulut S, Karakas S, Kayaalp C, Karagul S, et al. Postoperative pulmonary complications after liver transplantation: assessment of risk factors for mortality. Transplant Proc 2015; 47:1488–1494. pmid:26093749
  38. 38. Gianchandani Moorjani R, Marchena-Gomez J, Casimiro-Perez J, Roque-Castellano C, Ramirez-Felipe J. Morbidity- and mortality-related prognostic factors of nontraumatic splenectomies. Asian J Surg 2014; 37:73–79. pmid:24210540
  39. 39. Ozhathil DK, Li Y, Smith JK, Witkowski E, Coyne ER, Alavi K, et al. Colectomy performance improvement within NSQIP 2005–2008. J Surg Res 2011;171:e9–13. pmid:21872886
  40. 40. Gajdos C, Hawn MT, Kile D, Robinson TN, Henderson WG. Risk of major nonemergent inpatient general surgical procedures in patients on long-term dialysis. JAMA Surg 2013; 148:137–143. pmid:23560284
  41. 41. Soriguer F, Goday A, Bosch-Comas A, Bordiú E, Calle-Pascual A, Carmena R, et al. Prevalence of diabetes mellitus and impaired glucose regulation in Spain: the Di@bet.es Study. Diabetologia 2012;55:88–93. pmid:21987347
  42. 42. Cambra K, Galbete A, Forga L, Lecea O, Ariz MJ, Moreno-Iribas C, et al. Sex and age differences in the achievement of control targets in patients with type 2 diabetes: results from a population-based study in a South European region. BMC Fam Pract. 2016;17:144. pmid:27729015
  43. 43. Khokhar B, Jette N, Metcalfe A, Cunningham CT, Quan H, Kaplan GG, et al. Systematic review of validated case definitions for diabetes in ICD-9-coded and ICD-10-coded data in adult populations. BMJ Open 2016;6:e009952. pmid:27496226
  44. 44. Jiang J, Southern D, Beck CA, James M, Lu M, Quan H. Validity of Canadian discharge abstract data for hypertension and diabetes from 2002 to 2013. CMAJ Open. 2016;4:E646–E653 pmid:28018877
  45. 45. Pintado MC, Villa P, González-García N, Luján J, Molina R, Trascasa M,et al. Characteristics and outcomes of elderly patients refused to ICU. Scientific World Journal. 2013;2013:590837. pmid:24453879
  46. 46. Iapichino G, Corbella D, Minelli C, Mills GH, Artigas A, Edbooke DL, et al. Reasons for refusal of admission to intensive care and impact on mortality. Intensive Care Med 2010;36:1772–1779. pmid:20533023
  47. 47. Martinez-Huedo MA, Lopez de Andres A, Hernandez-Barrera V, Palacios-Ceña D, Carrasco-Garrido P, Hernandez DM, et al. Trends in the prevalence of physical and functional disability among Spanish elderly suffering from diabetes (2000–2007). Diabetes Res Clin Pract 2011;94:e30–3. pmid:21831470
  48. 48. Ribera A, Marsal JR, Ferreira-González I, Cascant P, Pons JM, Mitjavila F,et al. Predicting in-hospital mortality with coronary bypass surgery using hospital discharge data: comparison with a prospective observational study. Rev Esp Cardiol 2008;61:843–852. pmid:18684367