The early prediction of mortality in acute pancreatitis: a large population-based study

Abstract

Background: Identification of patients at risk for mortality early in the course of acute pancreatitis (AP) is an important step in improving outcome. Methods: Using Classification and Regression Tree (CART) analysis, a clinical scoring system was developed for prediction of in-hospital mortality in AP. The scoring system was derived on data collected from 17 992 cases of AP from 212 hospitals in [2000][2001]. The new scoring system was validated on data collected from 18 256 AP cases from 177 hospitals in [2004][2005]. The accuracy of the scoring system for prediction of mortality was measured by the area under the receiver operating characteristic curve (AUC). The performance of the new scoring system was further validated by comparing its predictive accuracy with that of Acute Physiology and Chronic Health Examination (APACHE) II. Results: CART analysis identified five variables for prediction of in-hospital mortality. One point is assigned for the presence of each of the following during the first 24 h: blood urea nitrogen (BUN) .25 mg/dl; impaired mental status; systemic inflammatory response syndrome (SIRS); age .60 years; or the presence of a pleural effusion (BISAP). Mortality ranged from .20% in the highest risk group to ,1% in the lowest risk group. In the validation cohort, the BISAP AUC was 0.82 (95% CI 0.79 to 0.84) versus APACHE II AUC of 0.83 (95% CI 0.80 to 0.85). Conclusions: A new mortality-based prognostic scoring system for use in AP has been derived and validated. The BISAP is a simple and accurate method for the early identification of patients at increased risk for in-hospital mortality.Acute pancreatitis (AP) is a disease with a substantial burden on the US healthcare system. Recent data indicate a rise in the absolute number as well as the rate of emergency room visits, hospital admissions and direct healthcare costs for AP in the USA (210 000 admissions in 2002; 4.6 of every 1000 hospitalisations from 1988 to 2003, annual direct costs in excess of US$2 billion). 1-3With an overall mortality rate of 2-5%, 3 4 a reliable method of risk stratification for AP is of significant clinical importance.Current methods of risk stratification in AP have important limitations. The Ranson 5 and modified Glasgow score 6 contain data not routinely collected at the time of hospitalisation. In addition, both require 48 h to complete, missing a potentially valuable early therapeutic window.5 7 The most commonly utilised prediction scoring system for clinical research studies in AP is the Acute Physiology and Chronic Health Examination (APACHE) II.8 9 However, the APACHE II was originally developed as an intensive care instrument and requires the collection of a large number of parameters, some of which may not be relevant to prognosis in AP. The purpose of this study was to develop a simple and accurate clinical scoring system for stratifying patents according to their risk of inhospital mortality. To develop a clinical tool useful early in the disease course, we examined data collected within th...

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