Predicting mortality with pneumonia severity scores: importance of model recalibration to local settings

Schuetz, Philipp; Koller, Michael; Christ‐Crain, Mirjam; Steyerberg, Ewout W.; Stolz, Daiana; Müller, Christian; Bucher, Heiner C.; Bingisser, Roland; Tamm, Michael; Müller, Beat

doi:10.1017/s0950268808000435

Cited by 67 publications

(57 citation statements)

References 25 publications

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“…The consensus favoring multidimensional assessment of COPD [1,2,[85][86][87], experience with blood biomarkers and risk scoring systems in other pulmonary disease settings [32,88,89], and literature focused on ProADM in COPD [42,90] appear to support three concepts in clinical application of ProADM (Supplemental Data, Panel 2). First, the use of this analyte in conjunction with a limited number of demographic and clinical, and possibly other laboratory, variables may be a practical and effective approach.…”

Section: Clinical Considerationsmentioning

confidence: 99%

“…Third, as should be the case with cutoffs for all multidimensional scoring system components [89], ProADM cutoffs should be calibrated to local conditions, e.g., EDs treating large numbers of COPD patients for acute dyspnea or pneumonic exacerbations probably need higher cutoffs than would outpatient clinics primarily seeing patients in the COPD stable state.…”

Section: Clinical Considerationsmentioning

confidence: 99%

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The prognostic blood biomarker proadrenomedullin for outcome prediction in patients with chronic obstructive pulmonary disease (COPD): a qualitative clinical review

Schuetz¹,

Marlowe²,

Müeller

2015

Clinical Chemistry and Laboratory Medicine (CCLM)

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Plasma proadrenomedullin (ProADM) is a blood biomarker that may aid in multidimensional risk assessment of patients with chronic obstructive pulmonary disease (COPD). Co-secreted 1:1 with adrenomedullin (ADM), ProADM is a less biologically active, more chemically stable surrogate for this pluripotent regulatory peptide, which due to biological and ex vivo physical characteristics is difficult to reliably directly quantify. Upregulated by hypoxia, inflammatory cytokines, bacterial products, and shear stress and expressed widely in pulmonary cells and ubiquitously throughout the body, ADM exerts or mediates vasodilatory, natriuretic, diuretic, antioxidative, anti-inflammatory, antimicrobial, and metabolic effects. Observational data from four separate studies totaling 1366 patients suggest that as a single factor, ProADM is a significant independent, and accurate, long-term allcause mortality predictor in COPD. This body of work also suggests that combined with different groups of demographic/clinical variables, ProADM provides significant incremental long-term mortality prediction power relative to the groups of variables alone. Additionally, the literature contains indications that ProADM may be a global cardiopulmonary stress marker, potentially supplying prognostic information when cardiopulmonary exercise testing results such as 6-min walk distance are unavailable due to time or other resource constraints or to a patient's advanced disease. Prospective, randomized, controlled interventional studies are needed to demonstrate whether ProADM use in risk-based guidance of site-of-care, monitoring, and treatment decisions improves clinical, qualityof-life, or pharmacoeconomic outcomes in patients with COPD.

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Section: Clinical Considerationsmentioning

confidence: 99%

Section: Clinical Considerationsmentioning

confidence: 99%

The prognostic blood biomarker proadrenomedullin for outcome prediction in patients with chronic obstructive pulmonary disease (COPD): a qualitative clinical review

Schuetz¹,

Marlowe²,

Müeller

2015

Clinical Chemistry and Laboratory Medicine (CCLM)

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“…The impact of a criterion might be different according to each institution's epidemiological profile. A criterion not impacting in low-mortality-rate institutions might be important for places where mortality is high (19). The overall 30-day mortality was 1.3% in the current study, whereas they were 14.7% in Phua's study (9), 9% in Lim's study (15) and 3.6% in Liapikou's study (16).…”

Section: Discussionmentioning

confidence: 49%

Weight of the CURB-65 Criteria for Community-Acquired Pneumonia in a Very Low-Mortality-Rate Setting

Guo

Zhong

et al. 2012

Intern. Med.

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Objective The CURB-65 score is a simple well validated tool for the assessment of severity in communityacquired pneumonia (CAP). The weight of each criterion in very low-mortality-rate settings is unclear. The purpose of this study was to determine the weight in such setting. Methods This study retrospectively reviewed 1,230 adult patients admitted for CAP from 2005 to 2009. Results The 30-day mortality rose sharply from 0%, 1.0%, 8.2% and 16.7%, respectively, for patients with CURB-65 scores of 0, 1, 2 and 3 to 100.0% for patients with the scores of 4 (x 2 = 219.494, p<0.001). Confusion had the strongest association with mortality (odds ratio, 22.148). The presence of low blood pressure was not associated with mortality. Confusion, urea >7 mmol·L -1 and age ! 65 yrs showed independent relationships with mortality (Odds ratio, 11.537, 5.988 and 10.462; respectively). Urea >7 mmol·L --1 was most strongly associated with the sequential organ failure assessment (SOFA) scores [rank correlation coefficient (rs), 0.352]. Confusion had the closest relationship with hospital length of stay (rs, 0.114). Age ! 65 yrs had the strongest association with costs (rs, 0.223). Conclusion The individual CURB-65 criteria were of unequal weight for predicting the 30-day mortality, SOFA scores, hospital length of stay and costs in a very low-mortality-rate setting, and a low blood pressure was not associated with mortality.

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“…8,[11][12][13][14][15][16][17][18][19][20][21][22][23] Table 1 summarises the characteristics of the included studies. Additional data were provided from three studies, 13,15,23 and clarification of included overlapping subjects obtained from two other studies.…”

Section: Description Of Included Studiesmentioning

confidence: 99%

“…11 In terms of comparative prognostic value when comparing CURB-65 with CRB-65, it appears that additional urea measurement does not substantially improve the predictive value of CURB-65. [12][13][14][15]17,20,23 This, along with the simplicity of CRB-65, indicates that it is emerging as potentially the most useful severity score for CAP.…”

Section: Comparison With Existing Literaturementioning

confidence: 99%

Validity of British Thoracic Society guidance (the CRB-65 rule) for predicting the severity of pneumonia in general practice: systematic review and meta-analysis

McNally¹,

Curtain²,

O'Brien³

et al. 2010

Br J Gen Pract

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The CRB-65 score is a clinical prediction rule that grades the severity of community-acquired pneumonia in terms of 30-day mortality. AimThe study sought to validate CRB-65 and assess its clinical value in community and hospital settings. Design of studySystematic review and meta-analysis of validation studies of CRB-65. Medline (1966 to June 2009), Embase (1988 to November 2008, British Nursing Index (BNI) and PsychINFO were searched, using a diagnostic accuracy search filter combined with subject-specific terms. The derived (index) rule was used as a predictive model and applied to all validation studies. Comparison was made between the observed and predicted number of deaths stratified by risk group (low, intermediate, and high) and setting of care (community or hospital). Pooled results are presented as risk ratios (RRs) in terms of over-prediction (RR>1) or under-prediction (RR<1) of 30-day mortality. Method ResultsFourteen validation studies totalling 397 875 patients are included. CRB-65 performs well in hospitalised patients, particularly in those classified as intermediate (RR 0.91, 95% confidence interval [CI] = 0.71 to 1.17) or high risk (RR 1.01, 95% CI = 0.87 to 1.16). In community settings, CRB-65 over-predicts the probability of 30-day mortality across all strata of predicted risk, low (RR 9.41, 95% CI = 1.75 to 50.66), intermediate (RR 4.84, 95% CI = 2.61 to 8.69), and high (RR 1.58, 95% CI = 0.59 to 4.19). ConclusionCRB-65 performs well in stratifying severity of pneumonia and resultant 30-day mortality in hospital settings. In community settings, CRB-65 appears to over-predict the probability of 30-day mortality across all strata of predicted risk. Caution is needed when applying CRB-65 to patients in general practice. Keywordsgeneral practice; meta-analysis; pneumonia; prognosis; severity of illness index. INTRODUCTIONCommunity-acquired pneumonia (CAP) has an annual incidence of 5-11 per 1000, accounting for 5-12% of all cases of adult lower respiratory tract infection managed by GPs.1 Appropriate management for patients with suspected CAP must be determined by GPs at initial presentation, particularly with regard to whether or not to manage a patient in the community or refer them to hospital.2 The proportion of adults with CAP who require hospital admission in the UK varies between 22% and 42%.1 This proportion varies in other countries, possibly due to differing structures of primary and secondary healthcare systems.

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Predicting mortality with pneumonia severity scores: importance of model recalibration to local settings

Cited by 67 publications

References 25 publications

The prognostic blood biomarker proadrenomedullin for outcome prediction in patients with chronic obstructive pulmonary disease (COPD): a qualitative clinical review

The prognostic blood biomarker proadrenomedullin for outcome prediction in patients with chronic obstructive pulmonary disease (COPD): a qualitative clinical review

Weight of the CURB-65 Criteria for Community-Acquired Pneumonia in a Very Low-Mortality-Rate Setting

Validity of British Thoracic Society guidance (the CRB-65 rule) for predicting the severity of pneumonia in general practice: systematic review and meta-analysis

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