Measured Factor Disease
- Low risk mortality
- Early discharge
- Escalation of care
- Discussion of goals of care
- Increased length of hospital stay
- Increased risk of inpatient mortality
- Increased risk of death
- Short time to death
Measured Factor Detail
The Dyspnoea, Eosinopenia, Consolidation, Acidaemia, and atrial Fibrillation (DECAF) score was derived in a large cohort of consecutive patients hospitalised with Acute exacerbations of COPD (AECOPD), is simple to apply at the bedside and predicts inhospital mortality using indices routinely available on admission. The score comprises five predictors, the strongest of which is stable state dyspnoea, as measured by the extended Medical Research Council Dyspnoea score.
Measured Factor Low Impact
- A score of 0 - 1, a low risk patient, may indicate early discharge.
- A score of 0 - 1 is associated with a low mortality risk.
Measured Factor High Impact
- A score of 3 - 6, a high risk patient, may indicate the need for escalated care or discussion of goals of care.
- A score of 3 - 6 may be associated with increased length of hospital stay.
- A score of 3 - 6 is associated with high risk of death and short time to death.
- Critical High: 300%
- Normal: 0 - 1
- Normal Adult Male: 0 - 1
- Normal Adult Female: 0 - 1
- Normal Geriatric Male: 0 - 1
- Normal Geriatric Female: 0 - 1
Result High Conditions
- High risk of mortality
- Short time to death
Key limitations of the test include the requirement of the Extended Medical Research Council Dyspnea (eMRCD) score, which may be difficult to obtain in patients with acute encephalopathy, dementia, or those who are incutubated. Also, while this test is validated for use at the time of admission in hospitals in the United Kingdom, it is not yet validated in United States emergency departments.
Study Validation 1
The study took place in the two hospitals within the derivation study (internal validation) and in four additional hospitals (external validation) between January 2012 and May 2014. Consecutive admissions were identified by screening admissions and searching coding records. Admission clinical data, including DECAF indices, and mortality were recorded. The prognostic value of DECAF and other scores were assessed by the area under the receiver operator characteristic (AUROC) curve. In the internal and external validation cohorts, 880 and 845 patients were recruited. Mean age was 73.1 (SD 10.3), 54.3% were female, and mean (SD) FEV1 45.5% (18.3) predicted. Overall mortality was 7.7%. The DECAF AUROC curve for inhospital mortality was 0.83 (95% CI 0.78 to 0.87) in the internal cohort and 0.82 (95% CI 0.77 to 0.87 in the external cohort, and was superior to other prognostic scores for inhospital or 30-day mortality.
Study Validation 2
Consecutive patients hospitalized with an exacerbation of COPD were recruited. Admission clinical data and inhospital death rates were recorded. Independent predictors of outcome were identified by logistic regression analysis and incorporated into a clinical prediction tool. 920 patients were recruited: mean (SD) age was 73.1 (10.0) years; 53.9% were female subjects; mean (SD) forced expiratory volume in one second was 43.6 (17.2)% predicted; and 96 patients (10.4%) died in hospital. The five strongest predictors of mortality (extended MRC Dyspnoea Score, eosinopenia, consolidation, acidaemia, and atrial fibrillation) were combined to form the Dyspnoea, Eosinopenia, Consolidation, Acidaemia and atrial Fibrillation (DECAF) score. The Score, which underwent internal bootstrap validation, showed excellent discrimination for mortality (area under the receiver operator characteristic curve = 0.86 (95% CI 0.82 to 0.89) and performed more strongly than other clinical prediction tools. In the subgroup of patients with coexistent pneumonia (n = 299), DECAF was a significantly stronger predictor of mortality than CURB-65.
Study Validation 3
A prospective, observational study was carried out in fifty patients of AECOPD admitted in A and E department. Dyspnea, Eosinopenia, Consolidation, Acidemia and atrial Fibrillation (DECAF) score and elevated blood urea nitrogen, altered mental status, pulse >109, age >65 (BAP-65) score were calculated. Forty-one patients were discharged and 9 (18%) died during treatment. Patients who were discharged and patients who died during hospital stay were compared. There was no significant difference in terms of sociodemographic variables, presence of comorbidities, and other markers of disease severity. A significant difference was found in blood counts, blood urea, serum creatinine, acidotic respiratory failure, and atrial fibrillation. A higher value of DECAF score and BAP-65 score was found more commonly in patients who died. Sensitivity for prediction of mortality for DECAF score and BAP-65 score was 100% and specificity was 34.1% and 63.4%, respectively. Sensitivity for prediction of need for invasive ventilation for DECAF score and BAP-65 score was 80% and 100%, respectively, and specificity was 80% and 60%, respectively.
Study Additional 1
Two hundred patients with primary diagnosis of AECOPD were included. They were subjected to thorough medical history taking, full clinical examination, plain chest X-ray, routine laboratory investigations, ECG, ABGs analysis, assessment of DECAF Score, Acute Physiology and Chronic Health Evaluation (APACHE II) score, COPD and Asthma Physiology Score (CAPS) and CURB-65 score. Inhospital mortality was recorded. Twenty-five (12.5%) patients died in hospital. The DECAF Score showed an excellent discrimination for inhospital mortality (AUROC = 0.83) and performed significantly better for the prediction of inhospital mortality than: APACHE II Score (AUROC = 0.68, DECAF vs APACHE II p = 0.03); and the COPD and Asthma Physiology Score (CAPS) (AUROC = 0.65, p = 0.01). Furthermore, DECAF was a significantly stronger predictor of inhospital mortality than CURB-65 for the subgroup of patients with radiological consolidation (AUROC = 0.87 vs 0.65, p = 0.02).
Study Additional 2
Patients admitted to respiratory wards with AECOPD between Dec 2014 to Feb 2015 were prospectively reviewed and DECAF score applied to each patient. Length of hospital stay (LOS) was then correlated with total DECAF scores and each predictive index. Out of 78 total admissions, 66 were reviewed as 12 patients died. 64% were male, mean age was 71.6 years and average LOS of 15.1 days. LOS highest in those with DECAF scores of 3-5 (16.7 days) and lowest in those with scores of 0-1 (12 days). LOS with an eMRC dyspnoea score of 5A/5B was 16.1 days, eosinopenia was 17.6 days and acidemia was 20.1 days. Also LOS increased with each DECAF score.
Study Additional 3
In a non-inferiority randomised controlled trial, 118 patients admitted with a low-risk ECOPD (DECAF 0 or 1) were recruited to HAH or usual care (UC). The primary outcome was health and social costs at 90 days. Mean 90-day costs were £1016 lower in HAH, but the one-sided 95% CI crossed the non-inferiority limit of £150 (CI - 2343 to 312). Savings were primarily due to reduced hospital bed days: HAH=1 (IQR 1-7), UC=5 (IQR 2-12) (P=0.001). Length of stay during the index admission in UC was only 3 days, which was 2 days shorter than expected. Based on quality-adjusted life years, the probability of HAH being cost-effective was 90%. There was one death within 90 days in each arm, readmission rates were similar and 90% of patients preferred HAH for subsequent ECOPD. HAH selected by low-risk DECAF score was safe, clinically effective, cost-effective, and preferred by most patients. Compared with earlier models, selection is simpler and approximately twice as many patients are eligible. The introduction of DECAF was associated with a fall in UC length of stay without adverse outcome, supporting use of DECAF to direct early discharge.