title: CURB-65 Performance Among Admitted and Discharged Emergency Department Patients With Community-acquired Pneumonia.
abstract: OBJECTIVE
  Pneumonia severity tools were primarily developed in cohorts of hospitalized patients, limiting their applicability to the emergency department (ED). We describe current community ED admission practices and examine the accuracy of the CURB-65 to predict 30-day mortality for patients, either discharged or admitted with community-acquired pneumonia (CAP).
  
  
  METHODS
  A retrospective, observational study of adult CAP encounters in 14 community EDs within an integrated healthcare system. We calculated CURB-65 scores for all encounters and described the use of hospitalization, stratified by each score (0-5). We then used each score as a cutoff to calculate sensitivity, specificity, positive predictive value, negative predictive value (NPV), positive likelihood ratios, and negative likelihood ratios for predicting 30-day mortality.
  
  
  RESULTS
  The sample included 21,183 ED encounters for CAP (7,952 discharged and 13,231 admitted). The C-statistic describing the accuracy of CURB-65 for predicting 30-day mortality in the full sample was 0.761 (95% confidence interval [CI], 0.747-0.774). The C-statistic was 0.864 (95% CI, 0.821-0.906) among patients discharged from the ED compared with 0.689 (95% CI, 0.672-0.705) among patients who were admitted. Among all ED encounters a CURB-65 threshold of ≥1 was 92.8% sensitive and 38.0% specific for predicting mortality, with a 99.9% NPV. Among all encounters, 62.5% were admitted, including 36.2% of those at lowest risk (CURB-65 = 0).
  
  
  CONCLUSIONS
  CURB-65 had very good accuracy for predicting 30-day mortality among patients discharged from the ED. This severity tool may help ED providers risk stratify patients to assist with disposition decisions and identify unwarranted variation in patient care.
authors.affiliation: Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA.|Department of Emergency Medicine, Los Angeles Medical Center, Kaiser Permanente Southern California, Los Angeles, CA.
authors.forename: Adam L
authors.initials: AL
authors.lastname: Sharp
authors.affiliation: Kaiser Foundation Health Plan, Pasadena, CA.
authors.forename: Jason P
authors.initials: JP
authors.lastname: Jones
authors.affiliation: Department of Emergency Medicine, Downey Medical Center, Kaiser Permanente Southern California, Downey, CA.
authors.forename: Ivan
authors.initials: I
authors.lastname: Wu
authors.affiliation: Department of Internal Medicine, Orange County Medical Centers, Kaiser Permanente Southern California, Anaheim, CA.
authors.forename: Dan
authors.initials: D
authors.lastname: Huynh
authors.affiliation: Department of Emergency Medicine and the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI.
authors.forename: Keith E
authors.initials: KE
authors.lastname: Kocher
authors.affiliation: Kaiser Foundation Health Plan, Pasadena, CA.
authors.forename: Nirav R
authors.initials: NR
authors.lastname: Shah
authors.affiliation: Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA.
authors.forename: Michael K
authors.initials: MK
authors.lastname: Gould
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017714:Community-Acquired Infections / Q000401:mortality*; D004636:Emergency Service, Hospital / Q000458:organization & administration* / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge; D011014:Pneumonia / Q000401:mortality*; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index