Mortality

Development and Validation of a Comorbidity Index to Predict In-hospital Mortality Risk for Stevens-Johnson Syndrome

Original Articles, Volume 24, Issue 2, Pages 61 – 108 (2025)

Background: Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a spectrum of high-mortality severe drug reactions. This study aimed to develop an in-hospital mortality risk calculator for SJS based on comorbidities for early risk prediction.
Methods: SJS/TEN patients were identified in National/Nationwide Inpatient Sample between Q4 2015-2020. Weight for each comorbidity was determined from a multivariable logistic regression to develop SJS Index.
Results: SJS Index had good discrimination power (c-statistic=0.704) and was well-calibrated (Brier score=0.049). SJS index had significantly better discriminative power than Elixhauser Comorbidity Index (p-value=0.001). SJS Index has good applicability in SJS-TEN and TEN. After adjusting for demographics, SJS Index had improved performance in all groups.
Conclusions: SJS Index effectively discriminates and predicts in-hospital mortality in SJS/TEN.

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Adjunctive Atorvastatin for Sepsis in the Acute Medical Unit: A Randomized Controlled Trial

Original Articles, Volume 24, Issue 1, Pages 1 – 60 (2025)

Background: Sepsis, a devastating syndrome of organ dysfunction triggered by a dysregulated host response to infection, remains a leading cause of global mortality. Statins, renowned for lipid-lowering, also exhibit potent anti-inflammatory and endothelial-stabilizing properties, offering a theoretical advantage in the septic milieu. This study investigated whether adjunctive atorvastatin could improve survival and modulate key sepsis-related outcomes.
Methods: In this open-label, randomized controlled trial conducted in the acute medical unit of a tertiary academic center, adult patients with sepsis(defined as suspected infection plus a SOFA score increment of ≥2) were allocated to receive either standard sepsis management plus daily oral atorvastatin 20mg or standard management alone for up to 28 days. The primary endpoint was 28-day all-cause mortality. Secondary endpoints included requirements for organ support, duration of hospitalization, and kinetic changes in C-reactive protein(CRP), procalcitonin(PCT), and lactate. Analysis adhered to intention-to-treat principles.
Results: Sixty-eight patients were randomized(36 atorvastatin, 32 control). While 28-day mortality trended lower in the atorvastatin arm(36% vs. 56% in controls; Risk Difference -20%, 95% CI -45% to 5%), this difference did not achieve statistical significance(p=0.10). Similarly, no significant benefits were observed in organ support needs or hospital stay. Critically, atorvastatin administration led to a significant and more pronounced reduction in both procalcitonin(median change -8 vs 0 ng/ml, p=0.005) and lactate levels(median change -0.95 vs -0.62 mmol/l, p=0.048) by day 7.
Conclusion: While adjunctive atorvastatin did not demonstrably reduce 28-day mortality in this sepsis cohort, its significant impact on attenuating procalcitonin and lactate levels suggests a beneficial modulation of underlying inflammatory and metabolic derangements.

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In-hospital mortality of 121,262 emergency patients according to their National Early Warning Score, alertness and eight physiologic categories on admission to hospital

Original Articles, Volume 24, Issue 1, Pages 1 – 60 (2025)

Aim: To determine the in-hospital mortality of eight physiological categories based on shock index, pulse pressure and ROX index, and to compare each category according to admission level of consciousness and National Early Warning Score.
Method: A non-interventional observational study of 122,262, unselected, adult emergency admissions between 2014 and 2022.
Results: In-hospital mortality increases according to physiological category and whether the admission NEWS was<3 or ≥3. For NEWS ≥3, patients were more likely to die when not alert. Irrespective of total NEWS, patients with a low ROX index <22 are more likely to die. Conclusion: Patients with the same NEWS value can have different physiological derangements. Level of consciousness also provides greater insight than NEWS alone regarding the risk of in-patient mortality.

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Incidence, predictors and outcomes associated with acute pulmonary embolism in patients hospitalized with pneumonia: Insights from the National Inpatient Sample

Original Articles, Volume 23, Issue 4, Pages 169– 208 (2024)

Background: The prevalence of acute pulmonary embolism (PE) among patients hospitalized with pneumonia and its association with adverse outcomes remain uncertain.Methods: Data from the US National Inpatient Sample between 2016 to 2020 was used to determine the proportion of patients with chief diagnosis of pneumonia that had concomitant PE and to examine the relationship between...

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Evaluating dynamic patterns in mortality before and after reconfiguration of the Danish emergency healthcare system

Original Articles, Volume 23, Issue 1, Pages 1 – 52 (2024)

Background: This study explored changes in short-term mortality during a national reconfiguration of emergency care starting in 2007.
Methods: Unplanned hospital contacts at emergency departments across Denmark from 2007 to 2016. The reconfiguration was a natural experiment, resulting in individual timelines for each hospital. The outcome was in-hospital and 30-day mortality.
Results: Individual patient-level data included 9,745,603 unplanned hospital contacts from 2007 to 2016 at 20 hospitals with emergency departments. We observed a sharp downwards shift in in-hospital mortality and 30-day mortality in three hospitals in relation to the reconfiguration.
Conclusion: This nationwide study identified three hospitals where the reconfiguration was closely associated with reduced in-hospital and 30-day mortality. In contrast, no major effects were identified for the remaining hospitals.

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The COVID-19 pandemic has not affected the mortality for patients admitted with pneumonia in Denmark

Correspondence, Volume 22, Issue 1, Pages 1 – 56 (2023)

During the COVID-19 pandemic, several hospital systems observed a reduction in patients with respiratory complaints. Using the Danish national registers, we conducted an observational study on disease severity and 30-day all-cause mortality for acutely admitted pneumonia patients before (3/19-3/20) and during (3/20-2/21) the pandemic. We calculated mortality rate ratios and Cox regression analyses. We identified 54,405 patients and during the pandemic, patients were older, more likely to be male, had more co-morbidity and a lower albumin on admission. Crude mortality was higher during the pandemic (8.4 vs. 6.9%). Adjusted hazard ratio for 30-day all-cause mortality was 1.07 (95%CI 1.01-1.14). We showed a small but significant, increase in mortality risk for patients admitted to hospital during the COVID-19 pandemic in Denmark.

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A whole healthcare system mortality review of the second wave COVID-19 pandemic response, were lessons learned?

Original Articles, Volume 22, Issue 1, Pages 1 – 56 (2023)

We previously reported a study of features of emergency healthcare response to COVID-19 that could be modified to mitigate against future excess deaths. Here we determined what themes persisted in later waves.
This was an expert panel review of all components of care delivered to COVID-19 patients who died (primary and secondary care, community services, NHS 111 and 999, COVID oximetry at home, virtual wards).
174 deaths were included. 5% were deemed >50% avoidable, 75% included avoidability themes.
Contact with primary care remains mostly via telephone, creating diagnostic risk. Patient decision to avoid healthcare contact was common.
Recommendations include: better utilisation of home monitoring in future pandemics; improved avoidance of nosocomial spread; patients be encouraged to seek medical advice earlier.

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Impact of Pleural Effusion on Clinical Outcomes in Patients with Pulmonary Embolism: Insights from the National Inpatient Sample

Original Articles, Volume 22, Issue 1, Pages 1 – 56 (2023)

Background: The incidence of hospital admissions for pulmonary embolism (PE) and associated pleural effusion, and the impact of these effusions on outcomes on a national level is unknown.
Methods: Data from the National Inpatient Sample between 2016 to 2019 was used to conduct a retrospective nationwide cohort study of hospital admissions for PE with and without pleural effusion. Multiple logistic regressions and linear regression analyses were used to determine the independent impact of effusions on in-hospital mortality, length of stay, and cost.
Results: There were 937,744 hospital admissions with PE included in our analysis (median age 64 [interquartile range 50-76] years; 52.5% females). The in-hospital mortality rate overall was 3.7% which was 5.5% for patients with pleural effusion and 3.6% for patients without pleural effusion (p<0.001). The median length of stay was longer in the group with pleural effusion (6 [3-12] days vs 4 [2-6] days, p<0.001) and the median healthcare cost was higher among patients with pleural effusion (13,689 [7,279-30,915] vs 8,855 [5,472-16,531], p<0.001). The factors most associated with pleural effusion were atrial fibrillation (OR 1.89 95%CI 1.78-2.00, p<0.001) and arterial thrombosis (OR 1.48 95%CI 1.19-1.84, p<0.001). Pleural effusion was associated with increased odds of mortality in patients with PE (OR 1.30 95%CI 1.18-1.45, p<0.001). Pleural effusion was associated with increased length of stay (Coefficient 4.15 95%CI 3.99 to 4.32, p<0.001), and healthcare costs (Coefficient 12,164; 95%CI:11,639 to 12,688, p<0.001)). Conclusion: Concomitant pleural effusion is not uncommon among PE patients which is more common in patients with atrial fibrillation and previous arterial thrombosis. Pleural effusions in patients with PE are associated with higher in-hospital mortality, length of stay and cost.

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Applying a COVID Virtual Ward model, assessing patient outcomes and staff workload

Original Articles, Volume 20, Issue 4, Pages 249 – 308 (2021)

A COVID virtual ward (CVW) is recommended by NHS England, but ‘usual care’ outcomes have not been reported.
A retrospective study of all adults with COVID-19 attending Queen Elizabeth Hospital Birmingham between 01/06/2020-31/01/2021, assessed against CVW criteria and followed for 28 days.
Of 2301 COVID-19 patients, 571(25%) would have met CVW criteria. Of these, 325(57%) were discharged after review and 246(43%) admitted. Of admitted patients who met CVW criteria, 81% required hospital-supported therapies; 11% died. Of the 325 discharged, 13% re-presented, 9% with COVID-related symptoms, 2% required intensive care admission, and one died (0.3%).
In this comparison, discharging patients without a CVW did not lead to more re-presentations, re-admissions, ITU escalations or deaths compared to published outcomes for hospitals with a CVW.

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Elevated level of urea is a good predictor for 30-day all-cause mortality in acutely admitted medical patients

Original Articles, Volume 20, Issue 3, Pages 157-248 (2021)

Objective: To assess the correlation between urea and mortality in acutely ill medical patients admitted to hospital.
Methods: We included consecutively admitted adult patients from the medical admission unit at a regional Danish hospital. Data on mortality was extracted. The association with 30-day mortality was described using cubic splines, and discriminatory power, crude association and adjusted analyses were performed.
Results: We included 5,894 patients, with a 30-day mortality of 5.6%. We found a dose-response relation between urea and 30-day mortality with an increase from 2.7% to 19.5% (p<0.001). Conclusion: Elevated urea is strongly associated with 30-day all-cause mortality in acutely admitted medical patients with acceptable discrimination and good calibration.

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