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Validation of the NaURSE rule for predicting in-hospital mortality in nonagenarians
Validación externa de la regla NaURSE para predecir mortalidad intrahospitalaria en nonagenarios
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Pérez, I. Urreta, M. Elola, P. Aranegui" "autores" => array:4 [ 0 => array:4 [ "nombre" => "N." "apellidos" => "Pérez" "email" => array:1 [ 0 => "naiara.perezfernandez@osakidetza.net" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "I." "apellidos" => "Urreta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "M." "apellidos" => "Elola" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "P." "apellidos" => "Aranegui" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario Donostia, Donostia-San Sebastián, Guipúzcoa, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Epidemiología Clínica, Hospital Universitario Donostia, Donostia-San Sebastián, Guipúzcoa, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Validación externa de la regla NaURSE para predecir mortalidad intrahospitalaria en nonagenarios" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In recent years, the worldwide population has aged. It is estimated that the population older than 65 years will represent 20% of the overall European population by 2025.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> Between 1991 and 2001, the absolute number of individuals aged 90 years or more in Spain doubled.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> This aging of the population will logically lead to an increase in hospitalizations, diagnostic and therapeutic procedures and costs. In 2014, the results were published from the derivation and external validation cohort for a simple prediction rule for hospital mortality in nonagenarian patients. The rule is based on acute disease markers and includes 4 variables collected at admission (1 point per item): sodium (>145<span class="elsevierStyleHsp" style=""></span>mEq/L) and urea (>84<span class="elsevierStyleHsp" style=""></span>mg/dL) concentrations in blood, respiratory rate (>20<span class="elsevierStyleHsp" style=""></span>bpm) and shock index (heart rate/systolic blood pressure >1).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> These variables, applied to elderly patients, constitute the abbreviation NaURSE (<span class="elsevierStyleBold">Na</span><span class="elsevierStyleSup">+</span>, <span class="elsevierStyleBold">U</span>rea, <span class="elsevierStyleBold">R</span>espiratory rate, <span class="elsevierStyleBold">S</span>hock index, <span class="elsevierStyleBold">S</span>enility, <span class="elsevierStyleBold">E</span>lderly). The endpoint for this study was all-cause death during hospitalization. The rule had an area under the receiver operating characteristic (ROC) curve of 0.69 (95% confidence interval [CI] 0.63–0.76).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The aim of this study was to validate this rule in a Spanish nonagenarian population.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A retrospective, cross-sectional study was designed to extract all discharges of patients older than 90 years from the department of internal medicine for 2013 from the registry of University Hospital of Donostia (San Sebastian, Spain). The study analyzed 917 episodes from the 998 obtained, due to the loss of a number of the critical variables at admission. This resulted in a loss rate of 8%. The study cohort's mean age was 92.5 years (standard deviation, 2.7). The mortality rate was 13.6% and increased according to the risk levels predicted by the rule (0–4 points): 0 points – 15/211 (7.1%); 1 point – 57/492 (11.6%); 2 points – 32/172 (18.5%); 3 points – 17/37 (45.9%); and 4 points – 4/5 (80%). Statistically significant differences were found when comparing the patients who died with the survivors (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.005) in terms of age (93 vs. 92 years), frequency of dementia (60% vs. 30%), degree of dependence (Barthel index, 24 vs. 52) and respiratory disease as the reason for hospitalization (44% vs. 25%), respectively. The area under the ROC curve for the NaURSE rule was 0.65 (95% CI 0.56–0.70). The remaining results are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">There have been few studies to date that have analyzed the factors associated with hospital mortality during the 10th decade of life. A number of studies<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> have shown that classic prognostic factors such as age, comorbidity and dependence are not associated with mortality. In the case of acute disease markers (blood pressure, heart rate, etc.), the results have been mixed.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">5,6</span></a> Furthermore, a number of models have limited practical applicability due to their complexity.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> Reproducible predictors are therefore difficult to find, which is probably due to the significant heterogeneity in these patients’ physical, psychological and social situation. Specific patient subgroups therefore need to be identified to better define the prediction models.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In conclusion, the application of the NaURSE rule to a local population older than 90 years confirmed its modest capacity for predicting mortality in hospitalized patients. The rule's performance increases dramatically in patients with higher scores, which could help adjust the clinical decisions and therapeutic effort for patients with a higher probability of death in the immediate term. Even so, this rule should not substitute clinical judgment based on an individual assessment of each patient.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pérez N, Urreta I, Elola M, Aranegui P. Validación externa de la regla NaURSE para predecir mortalidad intrahospitalaria en nonagenarios. Rev Clín Esp. 2018;218:110–111.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: 95% CI, 95% confidence interval; LR+/LR−, positive and negative likelihood ratios; PPV/NPV, positive/negative predictive value.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NaURSE score \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sensitivity % (95% CI) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Specificity % (95% CI) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LR+ \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LR− \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PPV % (95% CI) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NPV % (95% CI) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Crude accuracy rate (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">>0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">88.0 (81.0–93.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24.7 (21.8–27.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.6 (13.0–18.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">92.9 (88.5–96.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">>1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42.4 (33.6–51.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79.7 (76.7–82.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24.8 (19.1–31.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">89.8 (87.3–91.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">>2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.8 (10.7–24.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">97.4 (96.0–98.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50.0 (34.2–65.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">88.1 (85.8–90.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">86.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">>3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.2 (0.9–8.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99.8 (99.3–100.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">80 (28.4–99.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">86.7 (84.4–88.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">86.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1678896.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Sensitivity, specificity, likelihood ratios, predictive values and crude accuracy rate for mortality of the NaURSE rule in the study population.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => 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