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Prediction Model for 30-day Outcomes Among Emergency Department Patients with Lower Gastrointestinal Bleeding.

ABSTRACT: INTRODUCTION:There are currently no robust tools available for risk stratification of emergency department (ED) patients with lower gastrointestinal bleed (LGIB). Our aim was to identify risk factors and develop a preliminary model to predict 30-day serious adverse events among ED LGIB patients. METHODS:We conducted a health records review including adult ED patients with acute LGIB. We used a composite outcome of 30-day all-cause death, recurrent LGIB, need for intervention to control the bleeding, and severe adverse events resulting in intensive care unit admission. One researcher collected data for variables and a second researcher independently collected 10% of the variables for inter-observer reliability. We used backward multivariable logistic regression analysis and SELECTION=SCORE option to create a preliminary risk-stratification tool. We assessed the diagnostic accuracy of the final model. RESULTS:Of 372 patients, 48 experienced an adverse outcome. We found that age ?75 years, hemoglobin ?100 g/L, international normalized ratio ?2.0, ongoing bleed in the ED, and a medical history of colorectal polyps were statistically significant predictors in the multivariable regression analysis. The area under the curve (AUC) for the model was 0.83 (95% confidence interval, 0.77-0.89). We developed a scoring system based on the logistic regression model and found a sensitivity 0.96 (0.90-1.00) and specificity 0.53 (0.48-0.59) for a cut-off score of 1. CONCLUSION:This model showed good ability to differentiate patients with and without serious outcomes as evidenced by the high AUC and sensitivity. The results of this study could be used in the prospective derivation of a clinical decision tool.

SUBMITTER: Ramaekers R

PROVIDER: S-EPMC7081856 | biostudies-literature | 2020 Feb

REPOSITORIES: biostudies-literature

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Prediction Model for 30-day Outcomes Among Emergency Department Patients with Lower Gastrointestinal Bleeding.

Ramaekers Rosa R Perry Jeffrey J Leafloor Cameron C Thiruganasambandamoorthy Venkatesh V

The western journal of emergency medicine 20200224 2

<h4>Introduction</h4>There are currently no robust tools available for risk stratification of emergency department (ED) patients with lower gastrointestinal bleed (LGIB). Our aim was to identify risk factors and develop a preliminary model to predict 30-day serious adverse events among ED LGIB patients.<h4>Methods</h4>We conducted a health records review including adult ED patients with acute LGIB. We used a composite outcome of 30-day all-cause death, recurrent LGIB, need for intervention to co ...[more]

PMID: 32191192

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Project description:BackgroundHypertension (HTN) is common in discharged emergency department (ED) patients, yet the short-term outcomes of treating HTN at ED discharge are unclear. This study aimed to investigate whether emergency physician (EP) prescription of oral antihypertensive therapy at ED discharge for hypertensive patients is associated with a decreased 30-day risk of the severe adverse events (AEs), death, and revisits to the ED.MethodsWe conducted an observational cohort study assessing the 30-day outcomes of discharged ED patients with HTN, comparing outcomes based on whether antihypertensive therapy was prescribed. All discharged adult ED patients from an eight-hospital system with a diagnosis of HTN from January 2016 to February 2020 were screened, and consisted of a mix of suburban and urban patients with broad ethnic and socioeconomic backgrounds. Patients were categorized into the treatment group if they received a prescription for antihypertensive medication at ED discharge. The primary outcome was severe composite AEs from HTN (aortic catastrophe, heart failure, myocardial infarction, hemorrhagic and ischemic stroke, or hypertensive encephalopathy) within 30 days of ED discharge. The secondary outcomes were death or ED revisit over the same period.ResultsThe study sample consisted of 93,512 ED visits; 57.5% were female, and mean age was 59.3 years. 4.7% of patients were prescribed antihypertensive treatment at ED discharge. Within 30 days, 0.7% of patients experienced an AE, 0.1% died, and 15.2% had an ED revisit. The treatment group had significantly lower odds of AE (adjusted odds ratio [aOR]: 0.224, 95%CI 0.106-0.416, p < 0.001), and ED revisits (aOR: 0.610, 95%CI 0.547-0.678, p < 0.001), adjusting for age, race, degree of HTN, ED treatment for elevated HTN, Elixhauser comorbidity index, and heart failure history. There was no difference in odds of death 30 days after discharge.Conclusion and relevancePrescription antihypertensive therapy for discharged ED patients is associated with a 30-day decrease in severe adverse events and ED revisit rate.

Project description:ObjectivesPublished literature on national emergency department (ED) revisit rates among older adults with dementia is sparse, despite anecdotal evidence of higher ED utilization. Thus we evaluated the odds ratio (OR) of 30-day ED revisits among older adults with dementia using a nationally representative sample.DesignWe assessed the frequency of claims associated with a 30-day ED revisit among Medicare beneficiaries with and without a dementia diagnosis before or at index ED visit. We used a logistic regression model controlling for dementia, age, sex, race, region, Medicaid status, transfer to a skilled nursing facility after ED, primary care physician use 12 months before index, and comorbidity.SettingA nationally representative sample of claims data for Medicare beneficiaries aged 65 and older who maintained continuous fee-for-service enrollment during 2015 and 2016. Only outpatient claims associated with an ED visit between January 2016 and November 2016 were included as a qualifying index encounter.ParticipantsWe identified 240 249 patients without dementia and 54 622 patients for whom a dementia code was recorded in the year before the index encounter in 2016.ResultsOur results indicate a significant difference in unadjusted 30-day ED revisit rates among those with an ED dementia diagnoses (22.0%) compared with those without (13.9%). Our adjusted results indicated that dementia is a significant predictor of 30-day ED revisits (P < .0001). Those with a dementia diagnosis at or before the index ED visit were more likely to have experienced an ED revisit within 30 days (OR = 1.27; 95% confidence interval = 1.24-1.31).ConclusionDementia diagnoses were a significant predictor of 30-day ED revisits. Further research should assess potential reasons why dementia is associated with markedly higher revisit rates, as well as opportunities to manage and transition dementia patients from the ED back to the community more effectively. J Am Geriatr Soc 67:2254-2259, 2019.

Project description:BackgroundUrgency triage in the emergency department (ED) is important for early identification of potentially lethal conditions and extensive resource utilization. However, in older patients, urgency triage systems could be improved by taking geriatric vulnerability into account. We investigated the association of geriatric vulnerability screening in addition to triage urgency levels with 30-day mortality in older ED patients.DesignSecondary analysis of the observational multicenter Acutely Presenting Older Patient (APOP) study.SettingEDs within four Dutch hospitals.ParticipantsConsecutive patients, aged 70 years or older, who were prospectively included.MeasurementsPatients were triaged using the Manchester Triage System (MTS). In addition, the APOP screener was used as a geriatric screening tool. The primary outcome was 30-day mortality. Comparison was made between mortality within the geriatric high- and low-risk screened patients in every urgency triage category. We calculated the difference in explained variance of mortality by adding the geriatric screener (APOP) to triage urgency (MTS) by calculating Nagelkerke R2 .ResultsWe included 2,608 patients with a median age of 79 (interquartile range = 74-84) years, of whom 521 (20.0%) patients were categorized as high risk according to geriatric screening. Patients were triaged on urgency as standard (27.2%), urgent (58.5%), and very urgent (14.3%). In total, 132 (5.1%) patients were deceased within a period of 30 days. Within every urgency triage category, 30-day mortality was threefold higher in geriatric high-risk compared to low-risk patients (overall = 11.7% vs 3.4%; P < .001). The explained variance of 30-day mortality with triage urgency was 1.0% and increased to 6.3% by adding the geriatric screener.ConclusionCombining triage urgency with geriatric screening has the potential to improve triage, which may help clinicians to deliver early appropriate care to older ED patients. J Am Geriatr Soc 68:1755-1762, 2020.

Project description:BackgroundUpper gastrointestinal bleeding is a common presentation in emergency departments and carries significant morbidity worldwide. It is paramount that treating physicians have access to tools that can effectively evaluate the patient risk, allowing quick and effective treatments to ultimately improve their prognosis. This study aims to establish a mortality risk assessment model for patients with acute upper gastrointestinal bleeding at an emergency department.MethodsA total of 991 patients presenting with acute upper gastrointestinal bleeding between July 2016 and June 2019 were enrolled in this retrospective single-center cohort study. Patient demographics, parameters assessed at admission, laboratory test, and clinical interventions were extracted. We used the least absolute shrinkage and selection operator regression to identify predictors for establishing a nomogram for death in the emergency department or within 24 h after leaving the emergency department and a corresponding nomogram. The area under the curve of the model was calculated. A bootstrap resampling method was used to internal validation, and decision curve analysis was applied for evaluate the clinical utility of the model. We also compared our predictive model with other prognostic models, such as AIMS65, Glasgow-Blatchford bleeding score, modified Glasgow-Blatchford bleeding score, and Pre-Endoscopic Rockall Score.ResultsAmong 991 patients, 41 (4.14%) died in the emergency department or within 24 h after leaving the emergency department. Five non-zero coefficient variables (transfusion of plasma, D-dimer, albumin, potassium, age) were filtered by the least absolute shrinkage and selection operator regression analysis and used to establish a predictive model. The area under the curve for the model was 0.847 (95% confidence interval [0.794-0.900]), which is higher than that of previous models for mortality of patients with acute upper gastrointestinal bleeding. The decision curve analysis indicated the clinical usefulness of the model.ConclusionsThe nomogram based on transfusion of plasma, D-dimer, albumin, potassium, and age effectively assessed the prognosis of patients with acute upper gastrointestinal bleeding presenting at the emergency department.

Project description:ImportanceTrauma of hospitalization refers to the depersonalizing and stressful experience of a hospital admission and is hypothesized to increase the risk of readmission after discharge.ObjectivesTo characterize the trauma of hospitalization by measuring patient-reported disturbances in sleep, mobility, nutrition, and mood among medical inpatients, and to examine the association between these disturbances and the risk of unplanned return to hospital after discharge.Design, setting, and participantsThis prospective cohort study enrolled participants between September 1, 2016, and September 1, 2017, at 2 academic hospitals in Toronto, Canada. Participants were adults admitted to the internal medicine ward for more than 48 hours. Participants were interviewed before discharge using a standardized questionnaire to assess sleep, mobility, nutrition, and mood. Responses for each domain were dichotomized as disturbance or no disturbance. Disturbance in 3 or 4 domains (the upper tertile) was considered high trauma of hospitalization, and disturbance in 0 to 2 domains (the lower 2 tertiles) was considered low trauma.Main outcome and measuresThe primary outcome was readmission or emergency department visit within 30 days of discharge. The association between trauma of hospitalization and the primary outcome was examined using logistic regression, adjusted for age; sex; length of stay; Charlson Comorbidity Index Score; Laboratory-Based Acute Physiology Score; and baseline disturbances in sleep, mobility, nutrition, and mood.ResultsA total of 207 patients participated, of whom 82 (39.6%) were women and 125 (60.4%) were men, with a mean (SD) age of 60.3 (16.8) years. Among the 207 participants, 75 (36.2%) reported sleep disturbance, 162 (78.3%) reported mobility disturbance, 114 (55.1%) reported nutrition disturbance, and 48 (23.2%) reported mood disturbance. Nearly all participants (192 [92.8%]) described a disturbance in at least 1 domain, and 61 participants (29.5%) had high trauma exposure. A statistically significant 15.8% greater absolute risk of readmission or emergency department visit was found in participants with high trauma (37.7%; 95% CI, 25.9%-51.1%) compared with those with low trauma (21.9%; 95% CI, 15.7%-29.7%), which remained statistically significant after adjusting for baseline characteristics (adjusted odds ratio, 2.52; 95% CI, 1.24-5.17; P = .01) and propensity score matching (odds ratio, 2.47; 95% CI, 1.11-5.73; P = .03).Conclusions and relevanceDisturbances in sleep, mobility, nutrition, and mood were common in medical inpatients; such trauma of hospitalization may be associated with a greater risk of 30-day readmission or emergency department visit after hospital discharge.

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Prediction Model for 30-day Outcomes Among Emergency Department Patients with Lower Gastrointestinal Bleeding.

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Prediction Model for 30-day Outcomes Among Emergency Department Patients with Lower Gastrointestinal Bleeding.

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