Predicting and Communicating Risk of Clinical Deterioration: An Observational Cohort Study of Internal Medicine Residents

Abstract Background Sepsis is associated with excessive release of catecholamines, which causes tachycardia and is correlated with poor clinical outcome. β-Blockers (BBs) may blunt this effect on heart rate (HR). The objective of this study is to assess whether long-term BB therapy is associated with better clinical outcomes in patients with sepsis admitted to internal medicine wards. Methods We performed a single-center, observational cohort study. We included adult patients who were hospitalized in medicine departments due to sepsis. A propensity score model for BB therapy was used to match patients. The primary outcome was the 30-day all-cause mortality rate. A multivariate analysis was performed to identify risk factors for an adverse outcome. Patients were stratified according to absolute tachycardia (HR ≥100/min) or relative tachycardia at presentation (tachycardia index above the third quartile, with tachycardia index defined as the ratio of HR to temperature). Results A total of 1186 patients fulfilled the inclusion criteria. In the propensity-matched cohort patients given BB treatment were younger (median age [interquartile range], 74 [62–82] vs 81 [68–87] years; P ≤ .001). BB treatment was associated with reduction in 30-day mortality rates for patients with absolute tachycardia (odds ratio, 0.406; 95% confidence interval, .177–.932). Final model with interaction variable of BB treatment with HR was associated with short-term survival (odds ratio, 0.38; 95% confidence interval, .148–.976). Selective BB therapy had a stronger protective effect than nonselective BB therapy. Conclusions Long-term BB therapy was associated with decreased mortality rate in patients hospitalized with sepsis in internal medicine wards exhibiting absolute and relative tachycardia.

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Systematic evaluation and external validation of 22 prognostic models among hospitalised adults with COVID-19: An observational cohort study

10.1101/2020.07.24.20149815 ◽

2020 ◽

Cited By ~ 6

Author(s):

Rishi K Gupta ◽

Michael Marks ◽

Thomas H. A. Samuels ◽

Akish Luintel ◽

Tommy Rampling ◽

...

Keyword(s):

Cohort Study ◽

Oxygen Saturation ◽

External Validation ◽

Observational Cohort Study ◽

Clinical Deterioration ◽

Prognostic Models ◽

Systematic Evaluation ◽

Care Hospital ◽

Net Benefit ◽

Observational Cohort

Background The number of proposed prognostic models for COVID-19, which aim to predict disease outcomes, is growing rapidly. It is not known whether any are suitable for widespread clinical implementation. We addressed this question by independent and systematic evaluation of their performance among hospitalised COVID-19 cases. Methods We conducted an observational cohort study to assess candidate prognostic models, identified through a living systematic review. We included consecutive adults admitted to a secondary care hospital with PCR-confirmed or clinically diagnosed community-acquired COVID-19 (1st February to 30th April 2020). We reconstructed candidate models as per their original descriptions and evaluated performance for their original intended outcomes (clinical deterioration or mortality) and time horizons. We assessed discrimination using the area under the receiver operating characteristic curve (AUROC), and calibration using calibration plots, slopes and calibration-in-the-large. We calculated net benefit compared to the default strategies of treating all and no patients, and against the most discriminating predictor in univariable analyses, based on a limited subset of a priori candidates. Results We tested 22 candidate prognostic models among a cohort of 411 participants, of whom 180 (43.8%) and 115 (28.0%) met the endpoints of clinical deterioration and mortality, respectively. The highest AUROCs were achieved by the NEWS2 score for prediction of deterioration over 24 hours (0.78; 95% CI 0.73-0.83), and a novel model for prediction of deterioration <14 days from admission (0.78; 0.74-0.82). Calibration appeared generally poor for models that used probability outcomes. In univariable analyses, admission oxygen saturation on room air was the strongest predictor of in-hospital deterioration (AUROC 0.76; 0.71-0.81), while age was the strongest predictor of in-hospital mortality (AUROC 0.76; 0.71-0.81). No prognostic model demonstrated consistently higher net benefit than using the most discriminating univariable predictors to stratify treatment, across a range of threshold probabilities. Conclusions Oxygen saturation on room air and patient age are strong predictors of deterioration and mortality among hospitalised adults with COVID-19, respectively. None of the prognostic models evaluated offer incremental value for patient stratification to these univariable predictors.

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Golf habits among physicians and surgeons: observational cohort study

BMJ ◽

10.1136/bmj.k4859 ◽

2018 ◽

pp. k4859 ◽

Cited By ~ 2

Author(s):

Gal Koplewitz ◽

Daniel M Blumenthal ◽

Nate Gross ◽

Tanner Hicks ◽

Anupam B Jena

Keyword(s):

Internal Medicine ◽

Infectious Disease ◽

Cohort Study ◽

Patient Outcomes ◽

Orthopedic Surgery ◽

Observational Cohort Study ◽

Female Physicians ◽

Male And Female ◽

The Us ◽

Observational Cohort

AbstractObjectivesTo examine patterns of golfing among physicians: the proportion who regularly play golf, differences in golf practices across specialties, the specialties with the best golfers, and differences in golf practices between male and female physicians.DesignObservational study.SettingComprehensive database of US physicians linked to the US Golfing Association amateur golfer database.Participants41 692 US physicians who actively logged their golf rounds in the US Golfing Association database as of 1 August 2018.Main outcome measuresProportion of physicians who play golf, golf performance (measured using golf handicap index), and golf frequency (number of games played in previous six months).ResultsAmong 1 029 088 physicians, 41 692 (4.1%) actively logged golf scores in the US Golfing Association amateur golfer database. Men accounted for 89.5% of physician golfers, and among male physicians overall, 5.5% (37 309/683 297) played golf compared with 1.3% (4383/345 489) among female physicians. Rates of golfing varied substantially across physician specialties. The highest proportions of physician golfers were in orthopedic surgery (8.8%), urology (8.1%), plastic surgery (7.5%), and otolaryngology (7.1%), whereas the lowest proportions were in internal medicine and infectious disease (<3.0%). Physicians in thoracic surgery, vascular surgery, and orthopedic surgery were the best golfers, with about 15% better golf performance than specialists in endocrinology, dermatology, and oncology.ConclusionsGolfing is common among US male physicians, particularly those in the surgical subspecialties. The association between golfing and patient outcomes, costs of care, and physician wellbeing remain unknown.

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Accuracy of telephone triage for predicting adverse outcome in suspected COVID-19: An observational cohort study

10.1101/2021.06.24.21259441 ◽

2021 ◽

Author(s):

Carl Marincowitz ◽

Tony Stone ◽

Peter Bath ◽

Richard Richard Campbell ◽

Janette Turner ◽

...

Keyword(s):

Cohort Study ◽

Clinical Assessment ◽

Adverse Outcome ◽

Self Care ◽

Observational Cohort Study ◽

Adverse Outcomes ◽

Clinical Deterioration ◽

Telephone Triage ◽

Observational Cohort ◽

First Contact

Objective: To assess accuracy of telephone triage in identifying patients who need emergency care amongst those with suspected COVID-19 infection and identify factors which affect triage accuracy. Design: Observational cohort study Setting: Community telephone triage in the Yorkshire and Humber, Bassetlaw, North Lincolnshire and North East Lincolnshire region. Participants: 40, 261 adults who contacted NHS 111 telephone triage services provided by Yorkshire Ambulance Service NHS Trust between the 18th March 2020 and 29th June 2020 with symptoms indicating possible COVID-19 infection were linked to Office for National Statistics death registration data, hospital and general practice electronic health care data collected by NHS Digital. Outcome: Accuracy of triage disposition (self-care/non-urgent clinical assessment versus ambulance dispatch/urgent clinical assessment) was assessed in terms of death or need for organ support at 30, 7 and 3 days from first contact with the telephone triage service. Results: Callers had a 3% (1, 200/40, 261) risk of adverse outcome. Telephone triage recommended self-care or non-urgent assessment for 60% (24, 335/40, 261), with a 1.3% (310/24, 335) risk of subsequent adverse outcome. Telephone triage had 74.2% sensitivity (95% CI: 71.6 to 76.6%) and 61.5% specificity (61% to 62%) for adverse outcomes at 30 days from first contact. Multivariable analysis suggested some co-morbidities (such as chronic respiratory disease) may be over-estimated as predictors of adverse outcome, while the association of diabetes with adverse outcome may be under-estimated. Repeat contact with the service appears to be an important under recognised predictor of adverse outcomes with both 2 contacts (OR 1.77 95% CI: 1.14 to 2.75) and 3 or more contacts (OR 4.02 95% CI: 1.68 to 9.65) associated with clinical deterioration when not provided with an ambulance or urgent clinical assessment. Conclusion: Patients advised to self-care or receive non-urgent clinical assessment had a small but non-negligible risk of serious clinical deterioration. The sensitivity and specificity of telephone triage was comparable to other tools used to triage patient acuity in emergency and urgent care. Repeat contact with telephone services needs recognition as an important predictor of subsequent adverse outcomes.

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