Predictors for mortality due to acute exacerbation of COPD in primary care: Derivation of a clinical prediction rule in a multicentre cohort study.

BACKGROUND: In primary care (PC), 80% of the acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are treated. However, no predictive model has been derived or validated for use in PC to help general practitioners make decisions about these patients. OBJECTIVES: To derive a clinical prediction rule for mortality from any cause 30 days after the last PC visit. METHODS: Between December 2013 and November 2014, we performed a cohort study with people aged 40 and over who were treated for AECOPD in 148 health centres in Spain. We recorded demographic variables, past medical history, signs, and symptoms of the patients and derived a logistic regression model. RESULTS: In the analysis, 1,696 cases of AECOPD were included and 17 patients (1%) died during follow-up. A clinical prediction rule was derived based on the exacerbations suffered in the last 12 months, age, and heart rate, displaying an area under the receiver operating characteristic curve of 0.792 (95% confidence interval, 0.692-0.891) and good calibration. CONCLUSION: This rule stratifies patients into three categories of risk and suggests to the physician a different action for each category: managing low-risk patients in PC, referring high-risk patients to hospitals and taking other criteria into account for decision-making in patients with moderate risk. These findings suggest that it is possible to accurately estimate the risk of death due to AECOPD without complex devices. Future studies on external validation and impact assessment are needed before this prediction rule may be used in clinical practice.

Clinical outcomes in medical outliers admitted to hospital with heart failure.

BACKGROUND: Due to the lack of beds in medical wards, many patients are placed in other departments' wards (usually in surgical wards). These patients are called "medical outliers". This is a common problem in countries with public national health services. We determined whether location influences progress and prognosis of patients. METHODS: This was a retrospective cohort study in a public university hospital in Madrid, Spain. 243 patients discharged from the Department of Internal Medicine during 2006 with the same diagnosis-related group (DRG) (congestive heart failure and cardiac arrhythmia with major complications or comorbidity) were studied. Patients admitted to departments other than the Internal Medicine department or Intensive Care Unit were excluded. "Medical outlier" was defined as a patient admitted to a ward different from the Internal Medicine ward. Medical outliers transferred to the Internal Medicine ward were not excluded. RESULTS: 109 (45%) patients were medical outliers. They had a longer stay in hospital (mean difference 2.6 days, 95% confidence interval 0.6-4.7) but with no statistically significant differences in mortality, readmission, or intra-hospital morbidity. These patterns persisted after control for confounding in multivariate analysis. CONCLUSION: Patients admitted to the Department of Internal Medicine with heart failure had a longer stay if they initially start in other departments' wards. Significant differences were not seen in this group of patients with respect to mortality, readmission, or intra-hospital morbidity.