A simple risk score calculated at hospital discharge helps predict which patients with acute pancreatitis are likely to require readmission, Dr. Tom Lee Whitlock and his colleagues reported in the February issue of Clinical Gastroenterology and Hepatology.
"With this information, a clinician may decide to delay discharge of a patient at high risk for readmission, increase the level of outpatient care, or schedule earlier clinic follow-up," the investigators said (Clin. Gastroenterol. Hepatol. 2011 February [doi:10.1016/j.cgh.2010.08.017]).
Similarly, using this tool can reassure clinicians that they "can feel reasonably safe discharging" patients with low risk scores.
"Reducing the rates of early readmission in acute pancreatitis ultimately leads to improved overall care and may reduce overall health care costs," said Dr. Whitlock and his associates at Brigham and Women’s Hospital, Boston.
The investigators had recently reported results of another study in which the incidence of early readmission for patients hospitalized with acute pancreatitis was found to be 19%. They suspected that several risk factors observed in that study might be useful in predicting the need for early readmission, which could in turn improve clinical practice.
They then performed a retrospective cohort study of 248 adults admitted to their hospital between 2005 and 2007 with a wide spectrum of severity of acute pancreatitis, to determine which risk factors were predictive of readmission within 30 days of initial discharge. Patient factors that were considered included age, gender, race, insurance status, smoking status, body mass index, and alcohol intake.
Clinical factors that were considered included the presence or degree of hypoxia, leukocytosis, gastrointestinal symptoms, pain, pancreatic necrosis, fever, tachycardia, tachypnea, and hyper- or hypotension. The use of antibiotics, opiates, abdominal drains, and other invasive devices was assessed, as were the etiology of the pancreatitis and the patient’s length of hospital stay.
Five of these factors were found to significantly predict the need for readmission within 30 days of discharge: intolerance of a solid diet at discharge; GI symptoms of nausea, vomiting, or diarrhea at discharge; pancreatic necrosis; use of antibiotics at discharge; and pain at discharge.
Points were assigned to each of these five predictors, according to the degree to which they correlated with readmission. Based on the scoring system then devised, 39 patients (14%) were classified as being at high risk, with scores of 4 or more points. Two-thirds of the patients were classified as low risk, with scores of 0-1 points. And the remaining 47 patients (19%) were classified as moderate risk, with scores of 2-3 points.
A total of 68% of the high-risk group did require readmission, while only 6% of the low-risk group did.
The scoring system was then tested prospectively in a validation cohort of 198 patients hospitalized in 2008 and 2009.
Forty-seven patients (24%) were classified as high risk, and the rate of early readmission in this group was 68%, exactly the same as the rate found in the derivation cohort. A total of 112 patients (57%) was classified as low risk, and their rate of early readmission was only 5%.
The remaining 38 patients (20% of the entire group) were classified as moderate risk, and their rate of early readmission was 17%.
To help clinicians remember the five key risk factors, in order of importance, Dr. Whitlock and his colleagues proposed the pneumonic SNNAP, which stands for (GI) Symptoms, Nutrition, Necrosis, Antibiotics, and Pain. "This new scoring system may aid clinicians in their decisions regarding discharge planning for patients with acute pancreatitis," the researchers said.
The authors had no relevant conflicts of interest or disclosures.