Drivers of geographic differences could include variations in coding practices between regions and vaccination recommendation adherence (15).Known changes in the epidemiology of pneumonia over the study period include the emergence of influenza A(H1N1)pdm09 virus, which caused 60.8 million cases of influenza and 12,469 deaths in 2009 2010 alone (3). We found that patients with influenza virus infections had the highest hospitalization rate during 2009. Many previous studies excluded influenza because it likely represents a separate clinical entity and the hospitalization rate can be difficult to interpret using calendar years (because early or late influenza seasons can skew yearly trends) (2,11).Our study was limited by its reliance on ICD 9 CM coding to identify cases, potentially allowing misclassification.

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