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AP-CAI offers objective threshold for discharge after pancreatitis
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LAS VEGAS — A new scoring system presented during ACG 2016 predicted 30-day readmission after acute pancreatitis, with patients above a certain threshold tenfold more likely to be readmitted.
“Readmission within 30 days after a hospitalization for acute pancreatitis has been found to be a strong predictor of mortality at 1 year,” Michael Quezada, MD, from LAC+USC Medical Center, Los Angeles, said during his presentation. “The Acute Pancreatitis Clinical Activity Index (AP-CAI) is a recently developed metric designed to be a dynamic disease-specific clinical assessment tool in acute pancreatitis. ... While a multicenter study validating the tool as an objective measurement of disease is currently in progress, the purpose of this study was to validate AP-CAI as a means to identify threshold score for safe discharge from the inpatient setting.”
Quezada explained that the AP-CAI is calculated on 12-hour intervals, with peak and total measurements used for calculations. This index weighs organ failure, SIRS, abdominal pain, morphine equivalent dose and toleration of solid diet.
This study looked at patients admitted to the LAC+USC Medical Center with acute pancreatitis between March 2015 and March 2016. The AP-CAI score was only determined in the first admission and was calculated retrospectively.
Primary outcome was readmission to LAC+USC Medical Center for smoldering or worsening pancreatitis symptoms, management of pancreatitis complications or complications of therapy for pancreatitis within 30 days of initial hospitalization.
“Our data shows that patients are being discharged with active disease at our large urban center treating underserved patients,” Quezada said. “AP-CAI score greater than 50 at time of discharge is strongly associated with inpatient readmission and presentation to the ED within 30 days of discharge from and admission for acute pancreatitis after controlling for age, race, gender and disease severity.”
The cohort included 332 patients (56% male, 80% Hispanic, mean age 46 years). Etiology reported as gallstones (n = 149), alcohol (n = 84) or other (n = 99). Eighteen percent of patients had a history of admission for acute pancreatitis.
Of the patients with a discharge AP-CAI score greater than or equal to 50 (n = 114), 25 were readmitted and 13 presented to the ED. Of those with a discharge AP-CAI score less than 50 (n = 218), four were readmitted and three presented to the ED.
Of those readmitted within 30 days, 72% presented with smoldering or worsening pancreatitis symptoms, four presented with pancreatitis complications and four presented with complications of therapy. For those who came to the ED, all 16 had smoldering or worsening symptoms.
“We have demonstrated that the AP-CAI is an easily calculable and potentially clinically useful tool in determining appropriateness for discharging patients hospitalized for acute pancreatitis. In terms of future applications, the AP-CAI analysis could be useful clinically in determining appropriate time for certain interventions such as fluid resuscitation and reintroduction of normal diet,” Quezada said.
After univariate analysis, researchers showed patients with an AP-CAI score greater than 50 were nearly nine times as likely to be readmitted (OR = 8.9; 95% CI, 3.5-22.7). Those with previous acute pancreatitis admission were three times as likely to be readmitted (OR = 3.2; 95% CI, 1.4-7.1). After multivariate analysis, a score greater than 50 were 10 times more likely to be readmitted (OR = 10.3; 95% CI, 3.8-27.9) and previous admission maintained its likelihood of readmission (OR = 2.7; 95% CI, 1-7.6).
For presentation to the ED, only AP-CAI score greater than 50 was a predictor, nearly nine times more likely under univariate analysis (OR = 9.2; 95% CI, 2.6-33) and eight times as likely under multivariate analysis (OR = 8.1; 95% CI, 2.1-32).
Optimal cutoff in various populations still need to be determined, he said.
“What the AP-CAI offers is the ability to objectively measure state of illness in real time and to mark their score trajectory across their hospitalization. Perhaps some of the parameters are more reflective of underlying disease activity as opposed to previous scoring parameters,” Quezada said. – by Katrina Altersitz
Reference:
Quezada M, et al. Abstract #4. Presented at American College of Gastroenterology Annual Scientific Meeting. October 17-19, 2016; Las Vegas.
Disclosure: Quezada reports no relevant financial disclosures.