title: Revisiting the effect of referral bias on the clinical spectrum of infective endocarditis in adults.
abstract: Referral bias occurs because of the clustering of patients at tertiary care centers. This may result in the distortion of observed clinical manifestations of rare diseases. This analysis evaluates the effect of referral bias on the epidemiology of infective endocarditis (IE) in the International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS). This is a prospective multicenter cohort study comparing transferred and non-transferred patients with IE. Factors independently associated with transfer status were evaluated using multivariable logistic regression. A total of 2,760 patients were included in the analysis, of which 1,164 (42.2%) were transferred from other medical centers. Transferred patients more often underwent surgery for IE (odds ratio [OR] = 2.5; 95% confidence interval [CI] 1.9-3.2). They were also more likely to have complications such as stroke (OR = 1.5; 95% CI 1.3-1.9), heart failure (OR = 1.4; 95% CI 1.1-1.6), and new valvular regurgitation (OR = 1.3; 95% CI 1.1-1.6). The in-hospital mortality rates were similar in both groups. Patients with IE who require surgery and suffer complications are referred to tertiary hospitals more frequently than patients with an uncomplicated course. Hospital transfer has no obvious effect on the in-hospital mortality. Referral bias should be taken into consideration when describing the clinical spectrum of IE.
authors.affiliation: American University of Beirut Medical Center, Beirut, Lebanon. zk10@aub.edu.lb
authors.forename: Z A
authors.initials: ZA
authors.lastname: Kanafani
authors.forename: S S
authors.initials: SS
authors.lastname: Kanj
authors.forename: C H
authors.initials: CH
authors.lastname: Cabell
authors.forename: E
authors.initials: E
authors.lastname: Cecchi
authors.forename: A
authors.initials: A
authors.lastname: de Oliveira Ramos
authors.forename: T
authors.initials: T
authors.lastname: Lejko-Zupanc
authors.forename: P A
authors.initials: PA
authors.lastname: Pappas
authors.forename: H
authors.initials: H
authors.lastname: Giamerellou
authors.forename: D
authors.initials: D
authors.lastname: Gordon
authors.forename: C
authors.initials: C
authors.lastname: Michelet
authors.forename: P
authors.initials: P
authors.lastname: Muñoz
authors.forename: O
authors.initials: O
authors.lastname: Pachirat
authors.forename: G
authors.initials: G
authors.lastname: Peterson
authors.forename: R-S
authors.initials: RS
authors.lastname: Tan
authors.forename: P
authors.initials: P
authors.lastname: Tattevin
authors.forename: V
authors.initials: V
authors.lastname: Thomas
authors.forename: A
authors.initials: A
authors.lastname: Wang
authors.forename: F
authors.initials: F
authors.lastname: Wiesbauer
authors.forename: D J
authors.initials: DJ
authors.lastname: Sexton
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D004696:Endocarditis / Q000175:diagnosis* / Q000453:epidemiology* / Q000401:mortality / Q000473:pathology; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012017:Referral and Consultation / Q000706:statistics & numerical data*