Development of a clinical prediction rule to identify patients with plantar heel pain likely to benefit from biomechanical anti-pronation taping: A prospective cohort study

ObjectivesPatients who present in primary care with chronic functional somatic symptoms (FSS) have reduced quality of life and increased health care costs. Recognising these early is a challenge. The aim is to develop and internally validate a clinical prediction rule for repeated consultations with FSS.Design and settingRecords from the longitudinal population-based (‘Lifelines’) cohort study were linked to electronic health records from general practitioners (GPs).ParticipantsWe included patients consulting a GP with FSS within 1 year after baseline assessment in the Lifelines cohort.Outcome measuresThe outcome is repeated consultations with FSS, defined as ≥3 extra consultations for FSS within 1 year after the first consultation. Multivariable logistic regression, with bootstrapping for internal validation, was used to develop a risk prediction model from 14 literature-based predictors. Model discrimination, calibration and diagnostic accuracy were assessed.Results18 810 participants were identified by database linkage, of whom 2650 consulted a GP with FSS and 297 (11%) had ≥3 extra consultations. In the final multivariable model, older age, female sex, lack of healthy activity, presence of generalised anxiety disorder and higher number of GP consultations in the last year predicted repeated consultations. Discrimination after internal validation was 0.64 with a calibration slope of 0.95. The positive predictive value of patients with high scores on the model was 0.37 (0.29–0.47).ConclusionsSeveral theoretically suggested predisposing and precipitating predictors, including neuroticism and stressful life events, surprisingly failed to contribute to our final model. Moreover, this model mostly included general predictors of increased risk of repeated consultations among patients with FSS. The model discrimination and positive predictive values were insufficient and preclude clinical implementation.

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Risk factors, costs and complications of delayed hospital discharge from internal medicine wards at a Canadian academic medical centre: retrospective cohort study

BMC Health Services Research ◽

10.1186/s12913-019-4760-3 ◽

2019 ◽

Vol 19 (1) ◽

Cited By ~ 2

Author(s):

Anthony D. Bai ◽

Cathy Dai ◽

Siddhartha Srivastava ◽

Christopher A. Smith ◽

Sudeep S. Gill

Keyword(s):

Internal Medicine ◽

Risk Factors ◽

Cohort Study ◽

Retrospective Cohort ◽

Hospital Costs ◽

Prediction Rule ◽

Clinical Prediction Rule ◽

Clinical Prediction ◽

Delayed Discharge ◽

Patients At Risk

Abstract Background Hospitalized patients are designated alternate level of care (ALC) when they no longer require hospitalization but discharge is delayed while they await alternate disposition or living arrangements. We assessed hospital costs and complications for general internal medicine (GIM) inpatients who had delayed discharge. In addition, we developed a clinical prediction rule to identify patients at risk for delayed discharge. Methods We conducted a retrospective cohort study of consecutive GIM patients admitted between 1 January 2015 and 1 January 2016 at a large tertiary care hospital in Canada. We compared hospital costs and complications between ALC and non-ALC patients. We derived a clinical prediction rule for ALC designation using a logistic regression model and validated its diagnostic properties. Results Of 4311 GIM admissions, 255 (6%) patients were designated ALC. Compared to non-ALC patients, ALC patients had longer median length of stay (30.85 vs. 3.95 days p < 0.0001), higher median hospital costs ($22,459 vs. $5003 p < 0.0001) and more complications in hospital (25.5% vs. 5.3% p < 0.0001) especially nosocomial infections (14.1% vs. 1.9% p < 0.0001). Sensitivity analyses using propensity score and pair matching yielded similar results. In a derivation cohort, seven significant risk factors for ALC were identified including age > =80 years, female sex, dementia, diabetes with complications as well as referrals to physiotherapy, occupational therapy and speech language pathology. A clinical prediction rule that assigned each of these predictors 1 point had likelihood ratios for ALC designation of 0.07, 0.25, 0.66, 1.48, 6.07, 17.13 and 21.85 for patients with 0, 1, 2, 3, 4, 5, and 6 points respectively in the validation cohort. Conclusions Delayed discharge is associated with higher hospital costs and complication rates especially nosocomial infections. A clinical prediction rule can identify patients at risk for delayed discharge.

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Combination Of 4T’s Score and Rapid Gel Centrifugation Assay Excludes HIT In a Prospective Cohort Study

Blood ◽

10.1182/blood.v122.21.3535.3535 ◽

2013 ◽

Vol 122 (21) ◽

pp. 3535-3535 ◽

Cited By ~ 1

Author(s):

Lori Ann Linkins ◽

Shannon M. Bates ◽

Agnes Y.Y. Lee ◽

Theodore E. Warkentin

Keyword(s):

Cohort Study ◽

Prospective Cohort Study ◽

Prospective Cohort ◽

Research Funding ◽

Diagnostic Testing ◽

Prediction Rule ◽

Turnover Time ◽

Serotonin Release ◽

Diagnostic Strategy ◽

Bleeding Events

Abstract The diagnosis of heparin-Induced thrombocytopenia (HIT) is based on the presence of a compatible clinical picture combined with laboratory evidence of heparin-dependent, platelet-activating IgG antibodies. The 4T's Score is a clinical prediction rule that determines the likelihood that a patient has HIT before laboratory testing is performed. A rapid assay (H/PF4-PaGIA, Diamed, Switzerland) uses gel centrifugation to measure binding of antibodies to antigen-coated polystyrene beads (15 min turnover time). The purpose of this study is to evaluate the clinical utility of a diagnostic strategy which combines the 4T's Score with a H/PF4-PaGIA result to guide management of patients with suspected HIT while awaiting results of the serotonin-release assay (SRA). Methods Prospective cohort study of 538 consecutive adult patients with suspected HIT at 4 Canadian hospitals. Physicians completed a standardized 4T's Score sheet and the H/PF4-PaGIA was performed using fresh plasma in a central lab by technologists blinded to the 4T's Score (frozen plasma was used for 85 patients due to disruptions in worldwide availability of the assay.) The SRA and an in-house IgG anti-PF4/H enzyme-immunoassay (EIA) were performed on all patients by blinded technologists. Serologically-confirmed HIT (“HIT positive”) was defined as >50% serotonin release (mean) at three reaction conditions (0.1 U/mL heparin; 0.3 U/mL heparin; enoxaparin, 0.1 U/ml), as well as inhibition (<20% release or >50% inhibition) at 100 U/mL heparin and in the presence of Fc receptor-blocking monoclonal antibody, and a positive EIA. Thrombotic events, major bleeding events, and mortality were captured at day 30. Recommendations for management of patients while awaiting the SRA: patients with a Low 4T's Score (irrespective of H/PF4-PaGIA result) and patients with an Intermediate 4T's Score and negative H/PF4-PaGIA were to receive low-dose danaparoid or fondaparinux. Therapeutic-dose non-heparin anticoagulation was recommended for all patients with an Intermediate 4T's Score and positive H/PF4-PaGIA and for all patients with a High 4T's Score irrespective of H/PF4-PaGIA result. The primary outcome measure was the frequency of management failures defined as a patient with serologically-confirmed HIT who had one of the following combinations of diagnostic testing (a) Low 4T's Score and negative H/PF4-PaGIA; (b) Low 4T's Score and positive H/PF4-PaGIA or (c) Intermediate 4T's Score and negative H/PF4-PaGIA. Results 527 patients with mean age 66.5 yr (sd 15.4) were analyzed; 11 patients with missing diagnostic testing results were excluded. Clinical outcomes of the management of patients according to the diagnostic strategy will be reported separately. Results of diagnostic accuracy of the 4T's Score and H/PF4-PaGIA compared to the SRA are provided below. The prevalence of serologically-confirmed HIT in the study population was 6.5%. Two patients with indeterminate SRAs but IgG>1.0 were reported as HIT Positive. A negative H/PF4-PaGIA result reduced the probability of HIT based on the 4T's Score from 2.5% to 0.7% (95% CI: 0.1-2.6%) in the Low group, from 6.1% to 0% (95% CI: 0-2.7%) in the Intermediate group and from 35.7% to 0% (95% CI: 0-14.3%) in the High group. A positive H/PF4-PaGIA result increased the probability of HIT based on the 4T's Score to 15.4% (Low 4T's), 38.5% (intermediate 4T's) and 83.3% (High 4T's). The proportion of management failures was 1.5% (95% CI : 0.7%-3.0%). Of the 8 patients who were identified as management failures, 2 (Low 4T's) had a negative H/PF4-PaGIA. Out of 33 HIT Positive patients, 8 (24.2%) would have been missed based on a Low 4T's Score alone and 2 (6.1%) based on negative H/PF4-PaGIA alone. The combination of a Low or Intermediate 4T's Score and a negative H/PF4-PaGIA result had a negative predictive value for HIT of 99.5% (95% CI: 98.3-99.9). Conclusions The proportion of management failures was low (1.5%) and within acceptable limits (95% CI : 0.7%-3.0%). Combining the 4T's Score with the result of H/PF4-PaGIA excludes the diagnosis of HIT in the majority of patients with a Low or Intermediate probability for HIT and raises the likelihood of HIT in patients with a High probability. Disclosures: Linkins: BioRad DiaMed: PaGIA assays purchased at cost for study Other. Bates:BioRad Diamed: provided assays for study at cost Other. Lee:BioRad Diamed: provided assays for study at cost Other. Warkentin:GSK: Research Funding; WL Gore: Consultancy; Immucor GTI Diagnostics: Research Funding; Paringenix: Consultancy; Pfizer Canada: Honoraria; BioRad Diamed: provided assays for study at cost, provided assays for study at cost Other.

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