Community acquired pneumonia: variation in healthcare outcomes and the effectiveness of the pneumococcal vaccine

Lawrence, Hannah (2022) Community acquired pneumonia: variation in healthcare outcomes and the effectiveness of the pneumococcal vaccine. PhD thesis, University of Nottingham.

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Community acquired pneumonia (CAP) remains a leading cause of emergency hospital admission in the UK. Despite established vaccination programs and effective antimicrobial treatment, it continues to be associated with substantial morbidity, mortality and healthcare costs worldwide. Variation in healthcare is well established but, in relation to outcomes in adults hospitalised with CAP, is incompletely described. Firstly, this thesis describes reasons for mortality and readmission following hospitalisation with CAP in England. Secondly, it investigates variation in healthcare outcomes of adults hospitalised with CAP with reference to variation between institutions, socioeconomic groups and by time of presentation to hospital. Thirdly, it analyses the effectiveness of the 23-valent pneumococcal polysaccharide vaccine (PPV23) in preventing vaccine-type pneumococcal pneumonia in adults.


Three main data sources are used within this thesis. In brief, data are derived from: i) the British Thoracic Society national CAP audit database, ii) NHS digital’s Hospital Episode Statistics dataset, and iii) a longitudinal cohort study of adults hospitalised with CAP within the Greater Nottingham area.


This thesis reports that the most common reason for readmission within 30-days of index CAP admission was pneumonia. Inpatient mortality was high in this group; they were over twice as likely to die during readmission than those readmitted for other reasons. Greater social deprivation was associated with increased 30-day mortality in persons aged <65 years, but not in older adults. Regardless of age, increasing deprivation was associated with increasing risk of hospital readmission. There was no evidence of increased mortality for patients admitted at the weekend with CAP despite an older cohort with higher severity disease. Analysis of variation in BTS audit data found inter-Trust variation in 30-day mortality and readmission rates were low. Greater variation in length of stay and process of care measures were observed. However, no significant association between outlier status for mortality and variation in process of care measures was observed. In addition, a high proportion of the observed variation in all outcome measures examined could be attributed to chance. Lastly, in the setting of an established national childhood PCV13 vaccination programme, PPV23 vaccination in clinical at-risk patient groups and adults ≥65 years of age appears moderately effective against hospitalisation with PPV23 serotype pneumococcal pneumonia.


This thesis describes a significant ongoing burden of adverse outcomes associated with admission to hospital in the UK with CAP and has clear implications in the context of the recent global COVID-19 pandemic. Areas for further study identified by this thesis include: i) the role of revaccination against pneumococcal disease in adults, ii) the short-term health effects of pneumonia following discharge from hospital, and iii) the development of a platform to identify Trusts with outlying healthcare outcomes using the methodology described in this thesis.

Item Type: Thesis (University of Nottingham only) (PhD)
Supervisors: Lim, Wei Shen
McKeever, Tricia
Keywords: Community acquired pneumonia; Hospitalisation; Mortality; 23-valent pneumococcal polysaccharide vaccine
Subjects: W Medicine and related subjects (NLM Classification) > WC Communicable diseases
Faculties/Schools: UK Campuses > Faculty of Medicine and Health Sciences > School of Medicine
Item ID: 68744
Depositing User: Lawrence, Hannah
Date Deposited: 31 Jul 2022 04:41
Last Modified: 31 Jul 2022 04:41

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