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Prediction Models of Mortality in Acute Pancreatitis in Adults: A Systematic ReviewPrediction Models of Mortality in Acute Pancreatitis in Adults ONLINE FIRST

Meng-Yang Di, MD, PhD; Hao Liu, MD; Zu-Yao Yang, PhD; Peter A.L. Bonis, MD; Jin-Ling Tang, MD, PhD; and Joseph Lau, MD
[+] Article, Author, and Disclosure Information

This article was published at www.annals.org on 26 July 2016.


From Brown University School of Public Health, Providence, Rhode Island; The Chinese University of Hong Kong, Hong Kong, China; and Harvard Medical School and Tufts University School of Medicine, Boston, Massachusetts.

Acknowledgment: The authors thank Professors Christopher Schmid, Ethan Balk, and Thomas Trikalinos for their insights and suggestions on data interpretation.

Grant Support: Global Scholarship Programme for Research Excellence for 2014–2015, the Chinese University of Hong Kong.

Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-0650.

Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.

Reproducible Research Statement:Study protocol: See Supplement 2). Statistical code: See Methods. Data set: See Supplement 3.

Correspondig Author: Joseph Lau, MD, Brown University School of Public Health, Box G-S121-8, Providence, RI 02912; e-mail, joseph_lau@brown.edu, or Jin-Ling Tang, MD, PhD, 4/F, School of Public Health Building, Prince of Wales Hospital, Shatin, New Territories, Hong Kong; e-mail, jltang@cuhk.edu.hk.

Current Author Addresses: Drs. Di and Lau: Center for Evidence-Based Medicine, School of Public Health, Brown University, Box G-S121-8, Providence, RI 02912.

Dr. Liu: Biology and Biomedical Sciences, Leder Human Biology and Translational Medicine, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115.

Drs. Yang and Tang: Division of Epidemiology, The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China.

Dr. Bonis: Division of Gastroenterology, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02110.

Author Contributions: Conception and design: M.Y. Di, P.A.L. Bonis, J.L. Tang, J. Lau.

Analysis and interpretation of the data: M.Y. Di, Z.Y. Yang, P.A.L. Bonis, J.L. Tang, J. Lau.

Drafting of the article: M.Y. Di, P.A.L. Bonis, J. Lau.

Critical revision for important intellectual content: M.Y. Di, Z.Y. Yang, P.A.L. Bonis, J.L. Tang, J. Lau.

Final approval of the article: M.Y. Di, H. Liu, Z.Y. Yang, P.A.L. Bonis, J.L. Tang, J. Lau.

Statistical expertise: J.L. Tang, J. Lau.

Obtaining of funding: M.Y. Di, J.L. Tang.

Administrative, technical, or logistic support: J.L. Tang, J. Lau.

Collection and assembly of data: M.Y. Di, H. Liu, Z.Y. Yang.


Ann Intern Med. Published online 26 July 2016 doi:10.7326/M16-0650
© 2016 American College of Physicians
Text Size: A A A

Background: Acute pancreatitis (AP) varies in severity, prompting development of systems aimed at predicting prognosis to help guide therapy. Although several prediction approaches are available, their test characteristics and clinical utility are not completely understood.

Purpose: To evaluate the test characteristics (prognostic accuracy, incremental predictive value) and clinical utility (effect on patient outcomes) of severity scores for predicting mortality in AP.

Data Sources: Ovid MEDLINE and EMBASE (inception to 3 May 2016).

Study Selection: Longitudinal studies, in any language, that evaluated the prognostic value of at least 1 clinical severity score in AP.

Data Extraction: Dual data extraction and quality assessment.

Data Synthesis: Of 4039 citations screened, 94 unique studies evaluating 18 scores in 53 547 patients met the inclusion criteria. All studies provided data on prognostic accuracy, whereas 6 provided data on incremental predictive values. Most scores demonstrated low prognostic accuracy. The Acute Physiology and Chronic Health Evaluation (APACHE) II score and the Ranson criteria were studied most extensively. The median sensitivity and specificity of APACHE II at a threshold of 7 were 100% (range, 68% to 100%) and 63% (range, 21% to 96%), respectively, and those of the Ranson criteria at a threshold of 2 were 90% (range, 0% to 100%) and 67% (range, 14% to 97%), respectively. Estimates of sensitivity were based on relatively few patients. Evidence was limited regarding the incremental predictive value of the scoring systems or their effect on patient outcomes.

Limitation: Substantial clinical heterogeneity and inadequate methodological and reporting quality precluded a meta-analysis.

Conclusion: The test characteristics and clinical utility of AP severity scores remain uncertain. Additional studies with improved methodological rigor are needed, and the development of new scoring systems may be justified.

Primary Funding Source: Global Scholarship Programme for Research Excellence for 2014 to 2015, The Chinese University of Hong Kong.

Figures

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Figure.

Flow chart of study selection and reasons for exclusion.

* 95 studies in total, with 2 studies evaluating different scores using the same data set.

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Appendix Figure.

Distribution of mortality rate in studies of each clinical severity score.

Area of the dots or bubbles is proportional to the relative sample size of the 95 studies. APACHE = Acute Physiology and Chronic Health Evaluation; BISAP = Bedside Index of Severity in Acute Pancreatitis; EWS = Early Warning Score; JSS = Japanese Severity Score; LODS = Logistic Organ Dysfunction Score; MODS = Multiple Organ Dysfunction Score; MPM = Mortality Probability Model; POPS = Pancreatitis Outcome Prediction Score; SAPS = Simplified Acute Physiology Score; SIRS = Systemic Inflammatory Response Syndrome; SOFA = Sequential Organ Failure Assessment; SPS = Simple Prognostic Score.

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