Prognostic and discriminative accuracy of the quick Sepsis-related Organ Failure Assessment compared with an early warning score: a Danish cohort study.

BACKGROUND: The clinical benefit of implementing the quick Sepsis-related Organ Failure Assessment (qSOFA) instead of early warning scores (EWS) to screen all hospitalised patients for critical illness has yet to be investigated in a large, multicentre study. METHODS: We conducted a cohort study including all hospitalised patients ≥18 years with EWS recorded at hospitals in the Central Denmark Region during the year 2016. The primary outcome was intensive care unit (ICU) admission and/or death within 2 days following an initial EWS. Prognostic accuracy was examined using sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV). Discriminative accuracy was examined by the area under the receiver operating characteristic curve (AUROC). RESULTS: Among 97 332 evaluated patients, 1714 (1.8%) experienced the primary outcome. The qSOFA ≥2 was less sensitive (11.7% (95% CI: 10.2% to 13.3%) vs 25.1% (95% CI: 23.1% to 27.3%)) and more specific (99.3% (95% CI: 99.2% to 99.3%) vs 97.5% (95% CI: 97.4% to 97.6%)) than EWS ≥5. The NPV was similar for the two scores (EWS ≥5, 98.6% (95% CI: 98.6% to 98.7%) and qSOFA ≥2, 98.4% (95% CI: 98.3% to 98.5%)), while the PPV was 15.1% (95% CI: 13.8% to 16.5%) for EWS ≥5 and 22.4% (95% CI: 19.7% to 25.3%) for qSOFA ≥2. The AUROC was 0.72 (95% CI: 0.70 to 0.73) for EWS and 0.66 (95% CI: 0.65 to 0.67) for qSOFA. CONCLUSION: The qSOFA was less sensitive (qSOFA ≥2 vs EWS ≥5) and discriminatively accurate than the EWS for predicting ICU admission and/or death within 2 days after an initial EWS. This study did not support replacing EWS with qSOFA in all hospitalised patients.

Unburdening dementia - a basic social process grounded theory based on a primary care physician survey from 25 countries.

OBJECTIVE: To explore dementia management from a primary care physician perspective. DESIGN: One-page seven-item multiple choice questionnaire; free text space for every item; final narrative question of a dementia case story. Inductive explorative grounded theory analysis. Derived results in cluster analyses. Appropriateness of dementia drugs assessed by tertiary care specialist. SETTING: Twenty-five European General Practice Research Network member countries. SUBJECTS: Four hundred and forty-five key informant primary care physician respondents of which 106 presented 155 case stories. MAIN OUTCOME MEASURES: Processes and typologies of dementia management. Proportion of case stories with drug treatment and treatment according to guidelines. RESULTS: Unburdening dementia - a basic social process - explained physicians' dementia management according to a grounded theory analysis using both qualitative and quantitative data. Unburdening starts with Recognizing the dementia burden by Burden Identification and Burden Assessment followed by Burden Relief. Drugs to relieve the dementia burden were reported for 130 of 155 patients; acetylcholinesterase inhibitors or memantine treatment in 89 of 155 patients - 60% appropriate according to guidelines and 40% outside of guidelines. More Central and Northern primary care physicians were allowed to prescribe, and more were engaged in dementia management than Eastern and Mediterranean physicians according to cluster analyses. Physicians typically identified and assessed the dementia burden and then tried to relieve it, commonly by drug prescriptions, but also by community health and home help services, mentioned in more than half of the case stories. CONCLUSIONS: Primary care physician dementia management was explained by an Unburdening process with the goal to relieve the dementia burden, mainly by drugs often prescribed outside of guideline indications. Implications: Unique data about dementia management by European primary care physicians to inform appropriate stakeholders. Key points Dementia as a syndrome of cognitive and functional decline and behavioural and psychological symptoms causes a tremendous burden on patients, their families, and society. •We found that a basic social process of Unburdening dementia explained dementia management according to case stories and survey comments from primary care physicians in 25 countries. •First, Burden Recognition by Identification and Assessment and then Burden Relief - often by drugs. •Prescribing physicians repeatedly broadened guideline indications for dementia drugs. The more physicians were allowed to prescribe dementia drugs, the more they were responsible for the dementia work-up. Our study provides unique data about dementia management in European primary care for the benefit of national and international stakeholders.

How comorbidities impact Early Warning Score as a predictor of 7-day mortality.

BACKGROUND: Early Warning Score systems are used to monitor patients at risk of deterioration. How comorbidities impact Early Warning Score's ability to predict short-term mortality in the emergency department is not fully elucidated. The aim of the study was to investigate how comorbidities impact Early Warning Score as predictor of 7-day mortality. METHODS: This is an observational cohort study of adult emergency department patients attending one of the five emergency departments in Central Region Denmark from 1 March 2015 to 31 May 2015. Charlson Comorbidity Index was used as a measure of comorbidities. Logistic regression was used to calculate the odds ratio for 7-day mortality. Patients were compared in three groups: Charlson Comorbidity Index: 0, 1-2, 3+. RESULTS: A total of 30 060 adult patients attended one of the five emergency departments. Nineteen thousand one hundred twenty-three patients were included. Charlson Comorbidity Index 3+ patients presenting with Early Warning Score 0, 1-2 or 3-4 had significantly higher odds ratio of 7-day mortality compared to Charlson Comorbidity Index 0 patients with equal Early Warning Score. For patients with Early Warning Score 5+, Charlson Comorbidity Index -status had no significant impact on 7-day mortality after adjusting for age. CONCLUSION: In patients presenting with lower acuity (Early Warning Score 0-4) Charlson Comorbidity Index has a significant impact on 7-day mortality regardless of Early Warning Score. Including Charlson Comorbidity Index status in Early Warning Score or adjusting for Charlson Comorbidity Index -status could increase the predictive value of Early Warning Score in predicting 7-day mortality.

Utilisation of primary care before a childhood cancer diagnosis: do socioeconomic factors matter?: A Danish nationwide population-based matched cohort study.

OBJECTIVES: Early diagnosis of childhood cancer is critical. Nevertheless, little is known about the potential role of inequality. This study aims to describe the use of primary care 2 years before a childhood cancer diagnosis and to investigate whether socioeconomic factors influence the use of consultations and diagnostic tests in primary care. DESIGN: A national population-based matched cohort study. SETTING AND PARTICIPANTS: This study uses observational data from four Danish nationwide registers. All children aged 0-15 diagnosed with cancer during 2008-2015 were included (n=1386). Each case was matched based on gender and age with 10 references (n=13 860). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was additional rates for consultations and for invoiced diagnostic tests for children with cancer according to parental socioeconomic factors. Furthermore, we estimated the association between socioeconomic factors and frequent use of consultations, defined as at least four consultations, and the odds of receiving a diagnostic test within 3 months of diagnosis. RESULTS: Children with cancer from families with high income had 1.46 (95% CI 1.23 to 1.69) additional consultations 3 months before diagnosis, whereas children from families with low income had 1.85 (95% CI 1.60 to 2.11) additional consultations. The highest odds of frequent use of consultations was observed among children from low-income families (OR: 1.94, 95% CI 1.24 to 3.03). A higher odds of receiving an invoiced diagnostic test was seen for children from families with mid-educational level (OR: 1.46, 95% CI 1.09 to 1.95). CONCLUSION: We found a socioeconomic gradient in the use of general practice before a childhood cancer diagnosis. This suggests that social inequalities exist in the pattern of healthcare utilisation in general practice.