A tool to support the clinical decision based on risk of death in hospital admissions

AbstractRisk prediction scores are important tools to support clinical decision-making for patients with coronavirus disease (COVID-19). The objective of this paper was to validate the 4C mortality score, originally developed in the United Kingdom, for a Canadian population, and to examine its performance over time. We conducted an external validation study within a registry of COVID-19 positive hospital admissions in the Kitchener-Waterloo and Hamilton regions of southern Ontario between March 4, 2020 and June 13, 2021. We examined the validity of the 4C score to prognosticate in-hospital mortality using the area under the receiver operating characteristic curve (AUC) with 95% confidence intervals calculated via bootstrapping. The study included 959 individuals, of whom 224 (23.4%) died in-hospital. Median age was 72 years and 524 individuals (55%) were male. The AUC of the 4C score was 0.77, 95% confidence interval 0.79–0.87. Overall mortality rates across the pre-defined risk groups were 0% (Low), 8.0% (Intermediate), 27.2% (High), and 54.2% (Very High). Wave 1, 2 and 3 values of the AUC were 0.81 (0.76, 0.86), 0.74 (0.69, 0.80), and 0.76 (0.69, 0.83) respectively. The 4C score is a valid tool to prognosticate mortality from COVID-19 in Canadian hospitals and can be used to prioritize care and resources for patients at greatest risk of death.

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Development and Implementation of a clinical pathway to reduce inappropriate admissions among patients with Community acquired pneumonia in a private health system in Brazil: An observational cohort study and a promising tool for efficiency improvement.

10.21203/rs.2.14338/v1 ◽

2019 ◽

Author(s):

Rodrigo Moreira ◽

Hugo T. F. Mendonça ◽

Ayla M. Farias ◽

Henry Sznejder ◽

Eddy Lang ◽

...

Keyword(s):

Clinical Pathway ◽

Hospital Admissions ◽

Clinical Decision ◽

Community Acquired Pneumonia ◽

Low Risk ◽

Logistic Regression Models ◽

Risk Of Death ◽

Promising Tool ◽

Inappropriate Admissions ◽

Prolonged Hospital

Abstract Background: Patients with community-acquired pneumonia (CAP) at low risk of death by CURB-65 scoring system are usually unnecessarily treated as inpatients generating additional economic and clinical burden. We aimed to implement an evidence based clinical pathway to reduce hospital admissions of low risk CAP and investigate factors related to mortality and readmissions within 30 days.Methods: From November 2015 to August 2017 a clinical pathway was implemented at twenty hospitals. We included patients aged >18 years, with a diagnosis of CAP by the attendant physician. The main outcome was the monthly proportion of low risk CURB-65 admission after implementation of the clinical pathway. Logistic regression models were performed to assess variables associated with mortality and readmission in the admitted population within 30 days.Results: We included 10909 participants with suspected CAP. The proportion of low risk CAP admitted decreased from 22.1% to 12.8% in the period. Among participants with low risk, there has been no perceptible increase in deaths (0.80%) or readmissions (6.92%). Regression analysis identified that CURB-65 variables, presence of pleural effusion (OR= 1.74; 95%IC=1.08-2.8; p=0.02) and leucopenia (OR= 2.47; 95%IC=1.11-5.48;p=0.02) were independently associated with 30-day mortality whereas a prolonged hospital stay (OR= 2.09; 95%=1.14-3.83;p=0.01) were associated with 30-day readmission in the low risk population.Conclusion: The implementations of a clinical pathway diminished the proportion of low risk CAP admissions with no apparent increase of clinical outcomes within 30 days. Nonetheless, additional factors influences the clinical decision about site of care management in low risk CAP.

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Functional Decline in Emergency Department Patients with Dyspnea; a Register-Based Cohort

International Journal for Quality in Health Care ◽

10.1093/intqhc/mzab047 ◽

2021 ◽

Author(s):

Karoline Stentoft Rybjerg Larsen ◽

Marianne Lisby ◽

Hans Kirkegaard ◽

Annemette Krintel Petersen

Keyword(s):

Emergency Department ◽

Electronic Patient Record ◽

Hospital Admissions ◽

Functional Decline ◽

Patient Characteristics ◽

Risk Of Death ◽

Record Data ◽

Emergency Department Patients ◽

One Year ◽

Historic Cohort

Abstract Background Functional decline is associated with frequent hospital admissions and elevated risk of death. Presumably patients acutely admitted to hospital with dyspnea have a high risk of functional decline. The aim of this study was to describe patient characteristics, hospital trajectory, and use of physiotherapy services of dyspneic patients in an emergency department. Furthermore, to compare readmission and death among patients with and without a functional decline, and to identify predictors of functional decline. Methods Historic cohort study of patients admitted to a Danish Emergency Department using prospectively collected electronic patient record data from a Business Intelligence Registry of the Central Denmark Region. The study included adult patients that due to dyspnea in 2015 were treated at the emergency department (ED). The main outcome measures were readmission, death, and functional decline. Results In total 2,048 dyspneic emergency treatments were registered. Within 30 days after discharge 20% was readmitted and 3.9% had died. Patients with functional decline had a higher rate of 30-day readmission (31.2% vs. 19.1%, p<0.001) and mortality (9.3% vs. 3.6%, p=0.009) as well as mortality within one year (36.1% vs. 13.4%, p<0.001). Predictors of functional decline were age ≥60 years and hospital stay ≥6 days. Conclusion Patients suffering from acute dyspnea are seen at the ED at all hours. In total one in five patients were readmitted and 3.9% died within 30 days. Patients with a functional decline at discharge seems to be particularly vulnerable.

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Comparison of Cancer Patients to Non-Cancer Patients among COVID-19 Inpatients at a National Level

Cancers ◽

10.3390/cancers13061436 ◽

2021 ◽

Vol 13 (6) ◽

pp. 1436

Author(s):

Alain Bernard ◽

Jonathan Cottenet ◽

Philippe Bonniaud ◽

Lionel Piroth ◽

Patrick Arveux ◽

...

Keyword(s):

Colorectal Cancer ◽

Cancer Patients ◽

Mortality Risk ◽

Hospital Admissions ◽

National Level ◽

Administrative Database ◽

Hospital Death ◽

Solid Cancer ◽

Hematological Cancer ◽

Risk Of Death

(1) Background: Several smaller studies have shown that COVID-19 patients with cancer are at a significantly higher risk of death. Our objective was to compare patients hospitalized for COVID-19 with cancer to those without cancer using national data and to study the effect of cancer on the risk of hospital death and intensive care unit (ICU) admission. (2) Methods: All patients hospitalized in France for COVID-19 in March–April 2020 were included from the French national administrative database, which contains discharge summaries for all hospital admissions in France. Cancer patients were identified within this population. The effect of cancer was estimated with logistic regression, adjusting for age, sex and comorbidities. (3) Results: Among the 89,530 COVID-19 patients, we identified 6201 cancer patients (6.9%). These patients were older and were more likely to be men and to have complications (acute respiratory and kidney failure, venous thrombosis, atrial fibrillation) than those without cancer. In patients with hematological cancer, admission to ICU was significantly more frequent (24.8%) than patients without cancer (16.4%) (p < 0.01). Solid cancer patients without metastasis had a significantly higher mortality risk than patients without cancer (aOR = 1.4 [1.3–1.5]), and the difference was even more marked for metastatic solid cancer patients (aOR = 3.6 [3.2–4.0]). Compared to patients with colorectal cancer, patients with lung cancer, digestive cancer (excluding colorectal cancer) and hematological cancer had a higher mortality risk (aOR = 2.0 [1.6–2.6], 1.6 [1.3–2.1] and 1.4 [1.1–1.8], respectively). (4) Conclusions: This study shows that, in France, patients with COVID-19 and cancer have a two-fold risk of death when compared to COVID-19 patients without cancer. We suggest the need to reorganize facilities to prevent the contamination of patients being treated for cancer, similar to what is already being done in some countries.

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THUR 122 Parkinson’s kinetigraph improves movement disorder service provision

Journal of Neurology Neurosurgery & Psychiatry ◽

10.1136/jnnp-2018-abn.49 ◽

2018 ◽

Vol 89 (10) ◽

pp. A13.3-A13

Author(s):

Kobylecki Christopher ◽

Partington-Smith Lucy ◽

Silverdale Monty

Keyword(s):

Movement Disorder ◽

Service Provision ◽

Clinical Decision Making ◽

Hospital Admissions ◽

Clinical Decision ◽

Objective Evaluation ◽

Advanced Therapies ◽

Subsequent Effect ◽

Outpatient Appointments ◽

Deep Brain

IntroductionObjective evaluation of symptoms of Parkinson’s disease (PD) can be challenging. There is increasing interest in technological solutions to assess, monitor and manage people with PD.ObjectiveTo evaluate the effect of the Parkinson’s Kinetigraph (PKG) on management of patients with PD in a large tertiary movement disorder service.MethodsWe retrospectively reviewed the notes of 47 patients with PD (22 female, 25 male) who underwent PKG recording over a six month period. The indications and PKG findings, and the subsequent effect on clinical decision making and service provision were recorded.ResultsManagement was significantly altered in 25 patients (53%), while in 13 patients (28%) PKG confirmed the use of advanced therapies such as deep brain stimulation. Significant effects were seen with regard to service provision. Outpatient appointments could be deferred with advice following PKG in 15 (32%), advanced therapies assessment was improved in 16 (34%), while inpatient admission was avoided in six patients (13%).ConclusionThe use of PKG has enhanced service provision in our movement disorder service. In particular, it enhances our assessment of patients considered for high-cost advanced therapies, allows more efficient use of clinic appointments, and has the potential to reduce hospital admissions.

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Antimicrobial stewardship in rural nursing homes: Impact of interprofessional education and clinical decision tool implementation on urinary tract infection treatment in a cluster randomized trial

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2019.9 ◽

2019 ◽

Vol 40 (4) ◽

pp. 432-437 ◽

Cited By ~ 1

Author(s):

Darren K. Pasay ◽

Micheal S. Guirguis ◽

Rhonda C. Shkrobot ◽

Jeremy P. Slobodan ◽

Adrian S. Wagg ◽

...

Keyword(s):

Urinary Tract ◽

Nursing Homes ◽

Antimicrobial Stewardship ◽

Hospital Admissions ◽

Urine Culture ◽

Intervention Group ◽

Clinical Decision ◽

Rural Nursing ◽

Antimicrobial Prescribing ◽

Cluster Randomized

AbstractObjectives:To measure the impact of an antimicrobial stewardship initiative on the rate of urine culture testing and antimicrobial prescribing for urinary tract infections (UTIs) between control and intervention sites. Secondary objectives included evaluation of potential harms of the intervention and identifying characteristics of the population prescribed antimicrobials for UTI.Design:Cluster randomized controlled trial.Setting:Nursing homes in rural Alberta, Canada.Participants:The study included 42 nursing homes ranging from 8 to 112 beds.Methods/interventions:Intervention sites received on-site staff education, physician academic detailing, and integrated clinical decision-making tools. Control sites provided standard care. Data were collected for 6 months prior to and 12 months after the intervention.Results:Resident age (83.0 vs 83.8 years) and sex distribution (female, 62.5% vs 64.5%) were similar between the groups. Statistically significant decreases in the rate of urine culture testing (−2.1 tests per 1,000 resident days [RD]; 95% confidence interval [CI], −2.5 to −1.7;P< .001) and antimicrobial prescribing for UTIs (−0.7 prescriptions per 1,000 RD; 95% CI, −1.0 to −0.4;P< .001) were observed in the intervention group. There was no difference in hospital admissions (0.00 admissions per 1,000 RD; 95% CI, −0.4 to 0.3;P= .76), and the mortality rate decreased by 0.2 per 1,000 RD in the intervention group (95% CI, −0.5 to −0.1;P= .002). Chart reviews indicated that UTI symptoms were charted in 16% of cases and that urine culture testing occurred in 64.5% of cases.Conclusion:A multimodal antimicrobial stewardship intervention in rural nursing homes significantly decreased the rate of urine culture testing and antimicrobial prescriptions for UTI, with no increase in hospital admissions or mortality.

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Mortality in eating disorders

Psychological Medicine ◽

10.1017/s0033291700009879 ◽

1988 ◽

Vol 18 (4) ◽

pp. 947-951 ◽

Cited By ~ 110

Author(s):

G. C. Patton

Keyword(s):

Eating Disorders ◽

Anorexia Nervosa ◽

Hospital Admissions ◽

Fold Increase ◽

Reference Population ◽

Mortality Rates ◽

Initial Assessment ◽

Tertiary Referral Centre ◽

Risk Of Death ◽

Crude Mortality

SynopsisCrude mortality rates and mortality rates standardized against a British reference population have been calculated for a group of 460 consecutive patients with eating disorders seen between 1971 and 1981 in a tertiary referral centre for eating disorders. Crude mortality rates were 3·3% and 3·1% in the anorexia nervosa and bulimia nervosa groups respectively. Standardized rates demonstrated a six-fold increase in mortality in the anorexia nervosa group. The most common cause of death in this group was found to be suicide, with the risk of death remaining high for at least eight years after initial assessment. Specific associations of increased mortality were: being in the lowest weight group at the time of presentation, and having recurrent hospital admissions for eating problems.

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Data-driven transformation to an oncology patient-centered medical home.

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.34_suppl.285 ◽

2012 ◽

Vol 30 (34_suppl) ◽

pp. 285-285 ◽

Cited By ~ 3

Author(s):

John David Sprandio ◽

Brian Flounders ◽

Maureen R. Lowry ◽

Susan Higman Tofani

Keyword(s):

Medical Home ◽

Hospital Admissions ◽

Care Delivery ◽

Point Of Care ◽

Performance Status ◽

Clinical Decision ◽

Patient Centered Medical Home ◽

Patient Centered ◽

Oncology Patient ◽

Nccn Guidelines

285 Background: Consultants in Medical Oncology and Hematology (CMOH) implemented an EMR in 2003. It fell short in the compilation and presentation of meaningful data upon which to base clinical decisions. CMOH created a new workflow and effectively integrated the EMR with a practice-developed clinical decision support software (CDSS) called Iris. Methods: A project team outlined the data sources required in making a clinical decision and reviewed staff workflow. Within six months, they developed a system for displaying data from internal and external sources into a single scrollable screen for use by the physician at the point of care. Results: Iris promotes a rapid-learning cycle that results in 1) improved adherence to NCCN guidelines; 2) enhanced access and continuity of symptom management; 3) enhanced communication, tracking, and coordination of care; 4) reduction in ER utilization/hospital admissions; 5) a performance status driven approach to end of life care; 6) a systematic measurement of physician performance. This approach enabled CMOH to meet the NCQA’s criteria for level III Patient-Centered Medical Home in 2010. Conclusions: Implementation of EMRs alone does not improve health care delivery. Rather, it is the merger of clinical operations workflow and technology infrastructure delivering consumable data to providers that drives quality improvements and enhancements to the value of cancer care. [Table: see text]

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Patterns of palliative radiation near the end of life: A single-institution retrospective analysis.

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.15_suppl.9636 ◽

2013 ◽

Vol 31 (15_suppl) ◽

pp. 9636-9636 ◽

Cited By ~ 2

Author(s):

Sara R. Alcorn ◽

Thomas J. Smith ◽

Todd R. McNutt ◽

M. Jennifer Cheng ◽

Sydney Morss Dy ◽

...

Keyword(s):

End Of Life ◽

Retrospective Analysis ◽

Clinical Decision Making ◽

Clinical Decision ◽

Johns Hopkins Hospital ◽

National Guidelines ◽

Single Fraction ◽

Palliative Intent ◽

Risk Of Death ◽

Significant Difference

9636 Background: The care of patients who receive radiation therapy (RT) at the end of life (EOL) is under scrutiny to ensure effectiveness and value, with many patients not completing RT (Gripp, 2010; Toole, 2012). This retrospective analysis seeks to describe patterns of utilization of palliative RT, including rates of completion of RT offered at the EOL and the use of single fraction RT for bone metastases. Methods: Electronic medical records were used to create a database of 3,383 RT plans for brain, bone, lung, and other metastatic sites in patients treated at Johns Hopkins Hospital from 9/1/2007-7/15/2012. RT plans without palliative intent were excluded. T-tests and logistic regression compared patient and treatment characteristics between patients who died > 1 month versus ≤ 1 month after their last RT fraction. Results: A total of 983 patients were treated to 1,524 sites, with an average of 1.7 RT sites (SD 1.3) per patient. Of these, 872 (89%) patients had complete records and were included in analysis. At the time of analysis, 85% had died. The mean age of 62.1 years (SD 3.4) did not differ statistically based on time from RT to death. Death ≤ 1 month after RT was documented in 215 (24.7%) patients. Compared to patients living > 1 month after RT, patients receiving RT within the last month of life were more likely to be lung (17% versus 9%), less likely to be brain (34% versus 44%), and equally likely to be bone (45% versus 43%) sites. Patients who died ≤ 1 month after completing RT spent on average 5 days (16.6%) of the last month of life receiving RT, with no significant difference by disease site. Conclusions: Most patients receiving palliative RT finish therapy, with 25% dying ≤ 1 month after RT. Single fraction bone RT was relatively uncommon, with no significant difference in the rates of single fraction RT based on time from RT to death. These data provide a framework to match treatment patterns with national guidelines. Additionally, they provide context to model risk of death shortly after RT, which can aid in clinical decision-making. [Table: see text]

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CD3+ tumor-infiltrating lymphocytes (TILs) as prognostic in patients (pts) with stage II colon cancer (CC) not treated with adjuvant chemotherapy (ADJ).

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.4_suppl.167 ◽

2020 ◽

Vol 38 (4_suppl) ◽

pp. 167-167

Author(s):

Edoardo Francini ◽

Fang-Shu Ou ◽

Stefano Lazzi ◽

Roberto Petrioli ◽

Andrea Giovanni Multari ◽

...

Keyword(s):

Clinical Decision Making ◽

Multivariable Analysis ◽

Tumor Infiltrating Lymphocytes ◽

Clinical Decision ◽

Stage Ii ◽

Prognostic Impact ◽

Curative Surgery ◽

Cox Models ◽

Risk Of Death ◽

The Impact

167 Background: Previous studies have reported high TILs are a favorable prognostic factor in stage II CC. However, whether the impact of TILs on overall survival (OS) differs among pts who did or did not receive ADJ is still to be determined. We assessed the prognostic value of CD3+ TILs in pts with stage II CC according to whether they received ADJ or not (no-ADJ). Methods: Pts treated with curative surgery for stage II CC (2002-2013) were identified through the Santa Maria alle Scotte Hospital database. CD3+ TILs at the invasive front, center of tumor, and stroma, were determined by immunohistochemistry and manually quantified as the rate of TILs/total tissue areas. High TILs (H-TILs) was defined as > 20%. Pts were classified as high or low TILs (L-TILs) and ADJ or no-ADJ. Cox models were used to assess OS with hazard ratio estimates (95% CI). Results: Of the 678 pts included (356 deaths), 137 (20%) received ADJ while 541 (80%) did not. ADJ comprised fluoropyrimidine +/- oxaliplatin. Median follow-up was 8.5 years. The distributions of the 4 groups were: 16% (L-TIL/ADJ), 64% (L-TIL/no-ADJ), 5% (H-TIL/ADJ), 15% (H-TIL/no-ADJ). Compared to H-TILs/no-ADJ, ADJ pts had a significantly longer OS (P < .0001) regardless of the TILS rate while L-TILs/no ADJ had significantly shorter OS and higher risk of death (HR = 1.41; 95% CI, 1.06-1.88; P < .0001) [See table]. On multivariable analysis, adjusting for perforation, obstruction, T-stage, grade, < 12 lymph nodes resected, lymphovascular and perineural invasion, the adverse prognostic impact of L-TILs (vs H-TILs) in no-ADJ pts was confirmed (HR = 1.36; 95% CI 1.02, 1.82; P = .0373). Conclusions: Low CD3+ TILs rate was independently associated with shorter OS in stage II CC pts who did not receive ADJ, but was not prognostic among pts who had ADJ. These data suggest a potentially different impact of TILs in chemo-treated vs -untreated stage II CC which could affect clinical decision making. [Table: see text]

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