Trajectories of survival in patients with nonspecific complaints

Malinovska, Alexandra; Nickel, Christian H.; Bingisser, Roland

doi:10.1016/j.ejim.2018.06.020

Cited by 14 publications

(11 citation statements)

References 8 publications

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“…The rationale to focus on these patients is the lack of a standardized work-up, the high use of resources, and the risk of adverse outcomes [5][6][7][8]. All publications originating from the prospective multicenter Basel Nonspecific Complaints (BANC) cohorts used the above definition of NSCs [9][10][11][12], but other studies have used varying criteria to define NSCs [13]. There is an inherent difference regarding inclusion criteria between the studies considered by the present systematic review, e.g., some of the included studies were retrospective, and one study [14] has used a post-hoc classification of nonspecific complaints [15].…”

Section: Dear Editormentioning

confidence: 99%

How should nonspecific complaints be defined? Comment to: “nonspecific complaints (NSCs) in the emergency department”

Bingisser

Nickel

2020

Scand J Trauma Resusc Emerg Med

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Section: Dear Editormentioning

confidence: 99%

How should nonspecific complaints be defined? Comment to: “nonspecific complaints (NSCs) in the emergency department”

Bingisser

Nickel

2020

Scand J Trauma Resusc Emerg Med

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“…A patients' clinical condition as well as their emergency physicians' rating thereof may not be causally related to the outcomes under study such as 1-year mortality. Nevertheless, if the disease severity rating can predict relevant outcomes, it could serve as a red flag for these patients, i.e., it could draw attention to patients who are likely to follow negative health and survival trajectories [15]. Reliable prognoses are an essential component of the practice of emergency medicine.…”

Section: Discussionmentioning

confidence: 99%

“…Another study showed how the likelihood of death within the next 12 months is related to male gender, older age, admission to a medical specialty and social deprivation [18]. We have previously studied trajectories of illness in nonspecific complaints [15] and developed a framework containing five categories (functional, therapy-induced, deterioration of chronic condition, acute new condition, and acute event in a chronic condition). We found that each category has a distinct trajectory, as expressed by survival curves, thereby assisting prognostication.…”

Section: Discussionmentioning

confidence: 99%

Emergency department patients with weakness or fatigue: Can physicians predict their outcomes at the front door? A prospective observational study

et al. 2020

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Background Generalized weakness and fatigue are underexplored symptoms in emergency medicine. Triage tools often underestimate patients presenting to the emergency department (ED) with these nonspecific symptoms (Nemec et al., 2010). At the same time, physicians’ disease severity rating (DSR) on a scale from 0 (not sick at all) to 10 (extremely sick) predicts key outcomes in ED patients (Beglinger et al., 2015; Rohacek et al., 2015). Our goals were (1) to characterize ED patients with weakness and/or fatigue (W|F); to explore (2) to what extent physicians’ DSR at triage can predict five key outcomes in ED patients with W|F; (3) how well DSR performs relative to two commonly used benchmark methods, the Emergency Severity Index (ESI) and the Charlson Comorbidity Index (CCI); (4) to what extent DSR provides predictive information beyond ESI, CCI, or their linear combination, i.e., whether ESI and CCI should be used alone or in combination with DSR; and (5) to what extent ESI, CCI, or their linear combination provide predictive information beyond DSR alone, i.e., whether DSR should be used alone or in combination with ESI and / or CCI. Methods Prospective observational study between 2013–2015 (analysis in 2018–2020, study team blinded to hypothesis) conducted at a single center. We study an all-comer cohort of 3,960 patients (48% female patients, median age = 51 years, 94% completed 1-year follow-up). We looked at two primary outcomes (acute morbidity (Bingisser et al., 2017; Weigel et al., 2017) and all-cause 1- year mortality) and three secondary outcomes (in-hospital mortality, hospitalization and transfer to ICU). We assessed the predictive power (i.e., resolution, measured as the Area under the ROC Curve, AUC) of the scores and, using logistic regression, their linear combinations. Findings Compared to patients without W|F (n = 3,227), patients with W|F (n = 733) showed higher prevalences for all five outcomes, reported more symptoms across both genders, and received higher DSRs (median = 4; interquartile range (IQR) = 3–6 vs. median = 3; IQR = 2–5). DSR predicted all five outcomes well above chance (i.e., AUCs > ~0.70), similarly well for both patients with and without W|F, and as good as or better than ESI and CCI in patients with and without W|F (except for 1-year mortality where CCI performs better). For acute morbidity, hospitalization, and transfer to ICU there is clear evidence that adding DSR to ESI and/or CCI improves predictions for both patient groups; for 1-year mortality and in-hospital mortality this holds for most, but not all comparisons. Adding ESI and/or CCI to DSR generally did not improve performance or even decreased it. Conclusions The use of physicians’ disease severity rating has never been investigated in patients with generalized weakness and fatigue. We show that physicians’ prediction of acute morbidity, mortality, hospitalization, and transfer to ICU through their DSR is also accurate in these patients. Across all patients, DSR is less predictive of acute morbidity for female than male patients, however. Future research should investigate how emergency physicians judge their patients’ clinical state at triage and how this can be improved and used in simple decision aids.

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“…shown to be of prognostic significance, both in terms of diagnostic uncertainty [44] and survival [42,45]. Furthermore, older patients with atypical symptoms [46], homecare impossible [47], nonspecific complaints [48], unexplained symptoms [49], general disability [39], no cardinal symptom [40], (acute) frailty [50], or falls [51] represent a particularly vulnerable population, usually carrying a worse prognosis than all other emergency patients [52].…”

Section: Advances Due To Symptom-oriented Research At Triagementioning

confidence: 99%

“…This may in part be explained by the fact that no protocols exist for nonspecific complaints, but also by the wide range of underlying disease in nonspecific presentation, which favours the probability of a mismatch [89]. Therefore, in a nonspecific presentation, other concepts were developed for risk stratification, such as the frameworks of "acute morbidity" [74] or "acuity" [45,48]. Both can support risk stratification in a phase in which diagnoses are still unclear.…”

Section: Advances Due To Symptom-oriented Research At Work-upmentioning

confidence: 99%

The last decade of symptom-oriented research in emergency medicine: triage, work-up, and disposition

Bingisser

Nickel

2019

Swiss Med Wkly

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As a result of the ever-increasing use of imaging and clinical chemistry, symptom-oriented research has lost ground in many areas of clinical medicine. In emergency medicine, the importance of symptom-oriented research is obvious, as the three major tasks (triage, work-up and disposition) are still under-investigated. Scientific progress is closely linked to the analysis of readily available information, such as the patients' symptoms.A decade ago, there were more questions than answers. Therefore, we describe the state of the evidence and the importance of symptoms for decisions at triage, during work-up and for disposition. Recent advances in each field focusing on symptoms as predictors of outcome and/or diagnosis are shown. Finally, future directions of research regarding novel triage tools, efficient work-up and evidence-based disposition are discussed. Symptom-oriented research has been a driver for medical progress for centuries, and re-focusing on patient-centred clinical research will strengthen this field in the future in order to support smarter medicine.

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Trajectories of survival in patients with nonspecific complaints

Cited by 14 publications

References 8 publications

How should nonspecific complaints be defined? Comment to: “nonspecific complaints (NSCs) in the emergency department”

How should nonspecific complaints be defined? Comment to: “nonspecific complaints (NSCs) in the emergency department”

Emergency department patients with weakness or fatigue: Can physicians predict their outcomes at the front door? A prospective observational study

The last decade of symptom-oriented research in emergency medicine: triage, work-up, and disposition

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