title: Adrenomedullin for Risk Stratification of Emergency Patients With Nonspecific Complaints: An Interventional Multicenter Pilot Study.
abstract: Patients with nonspecific complaints (NSC) presenting to the emergency department (ED) are at risk of life-threatening conditions. New stress biomarkers such as the midregional portion of adrenomedullin (MR-proADM) promise to support decision-making. This study tested the following hypotheses: biomarker-assisted disposition of patients with NSC will not increase mortality. Second, discharge from the ED will increase if clinical risk assessment is combined with low MR-proADM levels. Third, inappropriate disposition to a lower level of care will decrease, if clinical assessment is combined with high MR-proADM levels, and fourth that this algorithm is feasible in the ED setting. Prospective, multicenter, randomized, controlled interventional feasibility study with a 30-day follow-up, including patients with NSC. Patients were randomly assigned to either the standard group (decision-making solely based on clinical assessment) or the Novum group (biomarker-assisted). Regarding disposition, patients were assigned to 1 of 3 risk classes: high-risk (admission to hospital), intermediate risk (community geriatric hospital), and low-risk patients (discharge). In the Novum group, in addition to clinical risk assessment, the information of the MR-proADM level was used. Unless there were overruling criteria, patients were transferred or discharged according to the risk assessment. Primary endpoint was 30-day mortality. Secondary endpoints were comparisons of patient disposition and related mortality rates, ED, and hospital length of stay and readmission. The final study cohort consisted of 398 patients (210 in the Standard group and 188 in the Novum group). Overruling, that is, disposition not according to the result of the proposed algorithm occurred in 51 cases. Baseline characteristics between Standard and Novum groups were similar. The mortality rate in the Novum group was 4.3%, as compared to the Standard group mortality of 6.2%, which was not significantly different (intention-to treat analysis). This was confirmed by the perprotocol analysis as well as by sensitivity analysis. For the secondary endpoints, no significant differences were detected. Biomarker-assisted disposition is safe in patients with NSC. Discharge rates did not increase. Feasibility could only partly be shown due to an unexpectedly high overruling rate. Inappropriate disposition to lower levels of care did not change. ClinicalTrials. gov Identifier: NCT00920491.
authors.affiliation: From the Emergency Department, University Hospital, Basel (CHN, ASM, LG, JI-K, RB); Emergency Department, Kantonsspital Baselland, Liestal, Switzerland (NG); Research Department, Thermo Scientific Biomarkers, Hennigsdorf, Germany (SG, SH); and Emergency Department, Kantonsspital Olten, Olten, Switzerland (SE).
authors.forename: Christian Hans
authors.initials: CH
authors.lastname: Nickel
authors.forename: Anna Sarah
authors.initials: AS
authors.lastname: Messmer
authors.forename: Leyla
authors.initials: L
authors.lastname: Ghanim
authors.forename: Julia
authors.initials: J
authors.lastname: Ilsemann-Karakoumis
authors.forename: Sven
authors.initials: S
authors.lastname: Giersdorf
authors.forename: Sabine
authors.initials: S
authors.lastname: Hertel
authors.forename: Susanne
authors.initials: S
authors.lastname: Ernst
authors.forename: Nicolas
authors.initials: N
authors.lastname: Geigy
authors.forename: Roland
authors.initials: R
authors.lastname: Bingisser
mesh_terms: D053607:Adrenomedullin / Q000097:blood*; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D015415:Biomarkers; D003657:Decision Making; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D011446:Prospective Studies; D018570:Risk Assessment; D055986:Vital Signs
chemical_list: D015415:Biomarkers; D053607:Adrenomedullin