Assessing the severity of acute pancreatitis (ASAP) in Switzerland: A nationwide survey on severity assessment in daily clinical practice

Pancreatology xxx (2017) 1e8

Contents lists available at ScienceDirect

Pancreatology journal homepage: www.elsevier.com/locate/pan

Assessing the severity of acute pancreatitis (ASAP) in Switzerland: A nationwide survey on severity assessment in daily clinical practice Sebastian Manuel Staubli*, Daniel Oertli, Christian Andreas Nebiker Department of General and Visceral Surgery, University Hospital Basel, Switzerland

a r t i c l e i n f o

a b s t r a c t

Article history: Received 30 August 2016 Received in revised form 21 January 2017 Accepted 6 February 2017 Available online xxx

Background/Objectives: We aim to assess which tools for severity stratification in acute pancreatitis are used in today's daily clinical practice and to what extent the new Atlanta classification is being implemented by the medical community in Switzerland. Methods: The heads of surgical, medical and emergency departments of Swiss hospitals (n ¼ 83) that directly treat patients with acute pancreatitis were given access to an online survey and asked to forward the questionnaire to their team. The questionnaire consisted of 16 items, including questions about the specialty background of the participants, the allocation of patients with AP, severity assessment, patient management, the role of imaging procedures, and future perspectives. Results: A total of 233 participants from 63 hospitals responded (response rate, 74%). A vast majority of participants [198 (87%)] does assess severity. The most frequently used tools are the Ranson [108 (87%)] and APACHE II scores [28 (23%)]. A majority of the participants were not satisfied with the currently available tools to assess severity [130 (59%)]. A minority [15 (12%)] use the revised Atlanta classification to assess the degree of severity in AP. Conclusions: The Ranson score remains the dominant risk stratification tool in clinical practice in Switzerland, followed by the APACHE II score. Other modern instruments, such as the Atlanta 2012 classification, have not yet earned broad recognition and have not reached daily practice. Further efforts must be made to expand physicians' awareness of their existence and significance. © 2017 IAP and EPC. Published by Elsevier B.V. All rights reserved.

Keywords: Acute pancreatitis Atlanta classification Biomarkers Severity Scoring

1. Introduction Acute pancreatitis (AP) is an inflammatory disease mainly caused by gallstones or excessive alcohol consumption. Recent epidemiological studies have shown rising incidence rates, possibly linked to increased obesity and improved detection [1]. In contrast, case fatality has declined, and the population mortality rates are stable. Thus, AP is an important health-care issue. Its course and severity are highly variable, and early risk stratification is the central pillar of the adequate management of patients suffering from AP. Whereas mild acute pancreatitis (MAP) has low mortality rates of about 3% [2], severe acute pancreatitis (SAP) with multiorgan failure (MOF) and infected necrosis have mortality rates up to 40% or higher [3]. These different groups of patients with AP must be managed differently.

* Corresponding author. Department for General and Visceral Surgery, Spitalstrasse 21, University Hospital Basel, 4031 Basel, Switzerland. E-mail address: [email protected] (S.M. Staubli).

Over the time, the definition of severity in AP has changed repeatedly. With the introduction of the new Atlanta classification in 2012, more attention was attached to organ failure (OF). With the addition of a temporal dimension to OF, an intermediary grade of severity (moderate) was created [4]. The objectives of the current revision of the Atlanta classification are mainly to incorporate modern concepts of the disease, improve the clinical assessment of severity, enable standardized data reporting, and facilitate communication among treating physicians and institutions. It is expected to become the dominant classification system in the near future [5]. A wide range of tools, such as scoring systems, biomarkers, imaging, or combinations thereof, now exist for the analysis and prediction of the severity of AP. They vary widely in reliability, and each of them has its own drawbacks, such as a time span of 48 h for completion (i.e. Ranson, Imrie-Glasgow), labor-intensiveness (APACHE II, JSS, POP), insufficient accuracy (all of them), absent validation (Panc 3) or low provider acceptance (HAPS) [5,6]. Predicting severity in acute pancreatitis is a highly dynamic

http://dx.doi.org/10.1016/j.pan.2017.02.006 1424-3903/© 2017 IAP and EPC. Published by Elsevier B.V. All rights reserved.

Please cite this article in press as: Staubli SM, et al., Assessing the severity of acute pancreatitis (ASAP) in Switzerland: A nationwide survey on severity assessment in daily clinical practice, Pancreatology (2017), http://dx.doi.org/10.1016/j.pan.2017.02.006

2

S.M. Staubli et al. / Pancreatology xxx (2017) 1e8

research field and new insights are published regularly. The extent to which new concepts and scoring systems have permeated daily clinical practice is unknown. We assume that many modern clinical scores and biomarkers are not in regular use and might even be unknown to many physicians. Furthermore, even though the revised Atlanta classification is widely accepted by the specialist community, its actual current role in daily clinical practice is unclear. The aim of this nationwide survey is to investigate the status quo in Swiss hospitals with regard to the assessment and prediction of the severity of AP. 2. Methods 2.1. Survey and general study design The survey was based on online, self-administered questionnaires addressed to the chiefs of the departments of surgery, internal medicine and emergency medicine in public and private hospitals in Switzerland where patients with acute pancreatitis are treated (n ¼ 85 hospitals). If an institution consisted of multiple sites, all sites were contacted. A reminder was sent to all hospitals one month after the first e-mail. All data were acquired from April to July 2016. A list of all hospitals in Switzerland was provided by the Swiss Hospital association (H Plus). This list was checked against the official online hospital database of the Swiss Federal Office of Public Health (BAG) of Switzerland to ensure completeness. All hospitals on the list were contacted and asked if they treat patients with acute pancreatitis. Only hospitals directly involved in treatment of patients with acute pancreatitis were included in this study. Two institutions declined to participate (one level 3 and one level 4 hospital) and were thus excluded. The final list included 83 hospitals: 5 university hospitals (“level 1”) and 35 “level 2,” 18 “level 3,” 19 “level 4,” and 6 “level 5” institutions. Level 2 hospitals are central hospitals, mostly cantonal hospitals in Switzerland. Levels 3e5 are primary care institutions, with level 3 having the most and level 5 the fewest patients treated per year. The e-mail addresses of the department chiefs were found on their hospital websites or, if this was not possible, by a telephone or e-mail inquiry to the hospital or department. The survey was accessible online at www.acutepancreatitis.ch. The department chiefs were given a 3- to 5-digit key code for their department and asked to transmit the questionnaire to their staff (senior physicians and consultants). The password was only known to the investigators, so that answers could be matched with centers. The anonymity of the participating caregivers and data safety were ensured. The Ethics Committee of Northwest and Central Switzerland (Ethikkommission Nordwest-und Zentralschweiz, EKNZ) determined that there was no need to obtain informed consent. The online questionnaire was available in German (translated version in Table 1). The 16 items on the questionnaire included

questions on professional background (1 question), patient allocation (1 question), assessment of severity of AP (10 questions), patient management (2 questions), imaging (1 question), and future perspectives (1 question). Question 1, 2, 3, 5, 10, 13, and 16 were single-answer questions. For questions 4, 6, 7, 8, 9, 14, and 15, multiple answers could be given. Question 11 was based on a rating scale ranging from 1 (not reliable) to 5 (very reliable). The sum of ratings of all participants was divided by the number of participants to yield a mean value. Question 12 was designed as a ranking question (1 ¼ highest, 5 ¼ lowest). The final score was calculated similarly to that of question 11, although the significance of the point system was inverted (i.e., rank 1 corresponded to the best rating in Question 12). 2.2. Data collection and statistical analysis Data collection was performed via SurveyMonkey®, Palo Alto, CA, USA. An independent statistician reviewed the data and confirmed their descriptive nature. Descriptive analyses were conducted with Microsoft Excel 2016™. Continuous variables were expressed as the mean ± standard deviation (SD), unless otherwise specified. 3. Results 3.1. Inclusion, participation, and responder characteristics A total of 85 hospitals that treat patients with AP were identified (5 university hospitals (level 1), 35 central hospitals (level 2), 19 large primary care hospitals (level 3), 20 medium-sized primary care hospitals (level 4), and 6 primary care hospitals (level 5). Two hospitals declined to participate (Fig. 1). The survey was sent to 83 hospitals in Switzerland. A total of 233 participants from 63 different institutions responded (response rate, 74%). The participants were surgeons [96 (41.4%)], internists [76 (32.8%)], and emergency doctors [38 (16.4%)]. A minority of participants were working in other specialties: gastroenterologists [11 (4.8%)], intensive care specialists [4 (1.7%)], geriatricians [3 (1.28%)], family doctors [2 (0.85%)], anesthesiologists [1 (0.43%)], and not unspecified [1 (0.43%)]. 3.2. Patient allocation Participants mainly allocate patients with AP to internal medicine [84 (36%)] and to the surgical department [76 (33%)]. Triaging patients by etiology is also widely practiced, allocating those with biliary pancreatitis to the surgical department and those with alcoholic pancreatitis to internal medicine [57 (25%)]. A minority of responders did not consciously allocate patients to any particular department [9 (4%)]. Some responded, that patients were allocated by the referring physician [2 (<1%)]. Interdisciplinary treatment [1

Table 1 Selected literature on the use of pancreatitis-related scores and parameters. Author (Year)

Country Severity assessment (in order of relevance)

Comment

Andersson (2012) [7] Rebours (2011) [8] Lankisch (2005) [9] Aly (2002) [10]

Sweden

In brackets: absolute numbers (chairmen)

France

APACHE II (10), Ranson-score (5), Glasgow/Imrie-Score (4), SOFA-Score (2), Balthazar-Score (2), Marshall-Score (0) CT Balthazar Score (76%), CRP (60%)

Germany CRP (100%), Ranson-Score (38%), APACHE II (32%), Glasgow/Imrie-Score (4%) UK

Glasgow/Imrie-Score, CRP (HPB specialists), Ranson-Score (Non-HPB specialists)

Please cite this article in press as: Staubli SM, et al., Assessing the severity of acute pancreatitis (ASAP) in Switzerland: A nationwide survey on severity assessment in daily clinical practice, Pancreatology (2017), http://dx.doi.org/10.1016/j.pan.2017.02.006

S.M. Staubli et al. / Pancreatology xxx (2017) 1e8

3

Fig. 1. The most relevant findings of our study for the reader in a hurry. a: fundamental cornerstones of the study, b: participants of the study by specialty, c: participating hospitals in Switzerland.

(<0.5%)], acute geriatric services [1 (<0.5%)]. One participant referred the patient depending on ”who's on call” [1 (<0.5%)]. Subgroup analysis showed that internists and surgeons mainly triage patients to their own department (68% and 57%, respectively) independently of the etiology. In our collective, surgeons triaged patients by etiology in 27% of all cases, and internists in 13%. Emergency medicine specialists weighted the etiology of AP differently: 44% said that etiology was the most important factor in triage, while they referred their patients with AP equally to surgeons and internists (24% each).

3.3. Severity assessment Most of the responders assess severity [198 (87%)]. They mainly do so on admission [158 (80%)], or at a later phase of the hospitalization [126 (64%)] (multiple answers to this question were permitted). Some participants assess severity at different timepoints [8 (4%)]: 5 at 48 h, 1 depending on the clinical course, 1 continuously during the hospitalization, and 1 uses a CT-based score if a CT scan is obtained. Fewer responders assess severity only once during the hospitalization [66 (34%)] in comparison to those who assess severity repeatedly [126 (66%)]. Repeated assessment of severity is done if the patient shows clinical worsening [72 (55%)] and at regularly defined time points [69 (53%)]. Multiple answers to this question were permitted.

3.4. Means of analyzing severity Scoring systems are the most frequently used tools for the assessment of severity [119 (92%)], followed by laboratory parameters [104 (81%)], the clinical impression [102 (79%)], and imaging procedures [73 (57%)], respectively. The reliability of scoring systems, laboratory parameters, the clinical impression, and imaging procedures are similarly rated (mean of 3.62, 3.88, 3.73 and 3.71, respectively) on a scale from 1 (very unreliable) to 5 (very reliable). 3.4.1. Scores to predict the severity of AP The Ranson score [108 (87%)] is the most commonly used score, followed by the APACHE II score [28 (23%)] and the CT severity index [23 (19%)]. Other scores, such as the SIRS score [17 (14%)], BISAP [6 (5%)], and Glasgow-Imrie score [6 (5%)], are used less often. The PANC-3 [2 (1.6%)], SOFA score [1 (<1%)], CAB score [1 (<1%)], and Harmless acute pancreatitis score [1 (<1%)] are the least often mentioned (Fig. 1). All other scores or rating systems not mentioned in this section were not used by our collective. 3.4.2. Atlanta classification and determinant based classification The vast majority does not use any severity classification systems [105 (84.7%)]. The revised Atlanta classification [15 (12.1%)] and the determinant-based classification [4 (3.2%)] are only used by a relatively small number of participants. The original Atlanta classification is not used in our collective.

Please cite this article in press as: Staubli SM, et al., Assessing the severity of acute pancreatitis (ASAP) in Switzerland: A nationwide survey on severity assessment in daily clinical practice, Pancreatology (2017), http://dx.doi.org/10.1016/j.pan.2017.02.006

4

S.M. Staubli et al. / Pancreatology xxx (2017) 1e8

Table 2 Current recommendations and guidelines for assessing the severity of AP. Association

Recommendation

Evidence-grade (According to guideline)

Year Ref

American Gastroenterological Association (AGA)

APACHE II, CRP as adjunct (>150 mg/l at 48 h) Atlanta 1992 SIRS score (at admission and at 48 h) 3-dimensional approach (host risk factors, scoring, and response to initial therapy) Atlanta 2012 No recommendation for a single scoring system Atlanta 2012 JSS (>8), APACHE II (>13), CRP (no cut-off defined) Atlanta criteria not mentioned APACHE II (>8), CRP as adjunct (>150 mg/l at 48 h) Atlanta 1992 quoted but not mentioned in the guidelines

N/A

2007 [11]

IAP/APA (International Association of Pancreatology, Australian and American Pancreatic Associations

American College of Gastroenterology Japanese Society of Hepato-Biliary Pancreatic Surgery

Italian Association for the Study of the Pancreas

Evidence Grade 2 B (¼ weak recommendation) 2013 [12] and moderate quality of evidence) Weak agreement Strong recommendation, moderate quality of evidence Grade A (good evidence)

2013 [13] 2015 [14]

Recommendation A (high quality of evidence)

2010 [15]

3.4.3. Serum parameters To assess severity, C-reactive protein is the most widely used single laboratory parameter [113 (90%)], followed by leukocyte count [81 (65%)], calcium [80 (64%)], hematocrit [56 (45%)], lipase [35 (28%)], amylase [28 (22%)], and procalcitonin [27 (22%)]. Other serum parameters mentioned were serum creatinine, LDH, glucose, urea and transaminases [17 (14%)].

3.6.2. Development of new scoring systems Some participants [89 (41%)] are satisfied with the current tools for the assessment of severity in acute pancreatitis and see no need for new instruments to assess and predict severity in AP. Nearly a third of participants [58 (27%)] expressed the need for new scoring systems, the remaining pollees [72 (33%)] are undecided whether new tools are necessary at this point.

3.4.4. Imaging analysis CT scans to assess severity are employed by a greater number of participants [81 (63%)] in comparison to those who do not [29 (23%)]. The free-text option was frequently used in this question [19 (15%)], and most responders wrote down several options: CT scan in case of clinical worsening [14 (6%)], if secondary complications are suspected [4 (3.2%)], if SAP is suspected [3 (2.4%)], and at a different time point during the hospitalization [3 (2.4%)].

3.7. Comparison of university hospitals with non-university institutions

3.5. The clinical relevance of severity assessment 3.5.1. Triage and intensive care In this question, the participants were asked to rate various criteria influencing their decision whether to transfer patients with AP to intensive care (1 ¼ most important factor, 5 ¼ least important factor). Poor general condition of the patient (1.89 ± 1.27) was rated the highest, followed by SIRS -criteria or sepsis (2.30 ± 1.26), scores that indicates severe pancreatitis (3.42 ± 1.13), laboratory parameters (3.59 ± 1.05), and pain (3.74 ± 1.23). 3.5.2. Consequences of severe AP Only one health care provider stated that identifying SAP has no therapeutic consequence, for the other participants, there is: transfer these patients to an intensive care unit [165 (86%)], regulate their fluid balance strictly [164 (85%)], and reduce or stop their oral food intake [81 (42%)]. Nasojejunal feeding or total parenteral nutrition is initiated [70 (36%)], and antibiotics are administered [26 (14%)]. Other participants used the free text option [22 (11%)]. The most frequent answers were close monitoring of the patient, performing a CT scan, evaluation of ERCP in case of suspected biliary obstruction, and consideration of antibiotic therapy. 3.6. General questions 3.6.1. Outpatient treatment In this collective, nearly a quarter of the responders stated that they treated selected patients with acute pancreatitis in an outpatient setting [47 (24%)]. The rest keeps all patients with AP in the hospital [147 (76%)].

We identified key-questions (3, 4, 5, 6, 8, 9, 10 and 13, respectively) to perform a subgroup analysis regarding the answers of participants from university hospitals and all other institutions. Most questions were answered comparably in both groups. The most noteworthy differences were seen in question 6 (“when do you repeat assessment?”): In university hospitals repeated assessment is slightly more often conducted in case of clinical worsening [15 (68%)] in comparison to other hospitals [57 (53%)]. Also, in university hospitals outpatient treatment is more often practiced [10 (45%)] than in the other institutions [37 (30%)]. In both university and non-university institutions, the Ranson and APACHE II scores are the most widely used scores (Ranson 90% university hospitals vs. 65% non-university hospitals and APACHE II 38% vs 17%, respectively). The revised Atlanta classification is similiarly used in both types of institutions (14% vs. 12%, respectively). Due to the descriptive nature of our data, no statistical comparison was conducted. The results are summarized in Table 2. 3.8. Comparison of different specialities The answers to the questions mentioned in chapter 4.7 were also analyzed to compare the different specialties (surgery, internal medicine, emergency medicine, gastroenterology and all other specialties). Most questions were answered comparably. The biggest differences could be detected in question 6 (“when do you perform repeated severity evaluation?”). Most surgeons [29 (59%)] and gastroenterologists [5 (56%)] repeat severity assessment in case of clinical worsening. Internists [27 (52%)] and emergency specialists [15 (62%)] predominantly choose to repeat assessment regularly. Another question that showed a non-uniform answering pattern was question 10 (“do you use CT imaging for severity assessment?”): A majority of surgeons [41 (72%)], internists [28 (68%)] and emergency medicine specialists [14 (64%)] answered by saying “yes”. On the other hand, gastroenterologists mostly answered by saying “no” [6 (75%)]. Another difference was noted in terms of the Atlanta classification, which is only used by fewer

Please cite this article in press as: Staubli SM, et al., Assessing the severity of acute pancreatitis (ASAP) in Switzerland: A nationwide survey on severity assessment in daily clinical practice, Pancreatology (2017), http://dx.doi.org/10.1016/j.pan.2017.02.006

S.M. Staubli et al. / Pancreatology xxx (2017) 1e8

5

Table 3 Questions and answers. Question

Answer options

1. What is your medical specialty?

Surgery Internal medicine Emergency services Anesthesiology Intensive care medicine Gastroenterology Other 2. In case of inpatient treatment: How do you Mainly to surgery allocate your patients? Mainly to internal medicine Depending on etioloy No conscious attribution Other 3. Do you assess the severity of AP in your Yes institution? No 4. When do you perform severity assessment? At admission

5. Do you perform repeated severity evaluation? 6. When do you repeat severity assessment?

7. How do you assess severity in AP?

8. Which scores or classification systems do you use?

9. Which serum parameters do you use for severity assessment?

10. Do you use CT imaging for severity assessment?

At a later time point Other Yes No At regularly defined timepoints In case of clinical deterioration Clinical impression Scoring

Response Comments count (%) 96 (41.4%) Other answers: geriatrics (3), family practice (2), unspecified (1) 76 (32.8%) 38 (16.4%) 1 (0.4%) 4 (1.7%) 11 (4.8%) 6 (2.6%) 76 (32.9%) Other answers: depending on who's on call (1), acute geriatric unit (1), depending on the 84 (36.4%) referring colleague (2), interdisciplinary abdominal center (1) 57 (24.7%) 9 (3.9%) 5 (2.2%) 198 (86.5%) 31 (13.5%) 158 1, 2 (80.2%) Other answers: depending on the course of the disease (1), continuous re-evaluation (1), at 126 (64%) 48 h (5). 8 (4.1%) 126 2 (65.6%) 66 (34.4%) 69 (53.1%) 1, 3

72 (55.4%)

102 1, 3 (79.1%) 119 (92.3%) Laboratory 104 parameters (80.6%) Imaging 73 (56.6%) Ranson's Criteria 108 1, 3 (87.1%) Other answers: CAB (1), PANC-3 (2), CRP (3), SOFA (1), not specified (1) APACHE II 28 (22.6%) Atlanta 1992 0 (0.0%) classification Atlanta 2012 15 (12.1%) classification 4 (3.2%) Determinantbased classification Glasgow-(Imrie)- 6 (4.8%) Score BISAP 6 (4.8%) Balthazar-Score 23 (18.5%) (CT sev. Index) SIRS-Score 17 (13.7%) Harmless acute 1 (0.8%) pancreatitis Score Other 8 (6.5%) Leukocyte count 81 (64.8%) 1, 3 C-reactive 113 Other answers: pancreatic amylase (2), creatinine (4), urea (11), glucose (7), lactate (7), protein (CRP) (90.4%) arterial blood-gas analysis (4), ASAT (5), platelet count (1) Hematocrit 56 (44.8%) Procalcitonin 27 (21.6%) (PCT) Calcium 80 (64%) Amylase 28 (22.4%) Lipase 35 (28%) Other 17 (13.6%) Yes 81 (62.8%) 3 No 29 (22.5%) Other answers (free-text, multiple answers allowed): in case of clinical deterioration (14), if Other 19 (14.7%) secondary complications are suspected (4), if SAP is suspected (3), different timepoint (3) (continued on next page)

Please cite this article in press as: Staubli SM, et al., Assessing the severity of acute pancreatitis (ASAP) in Switzerland: A nationwide survey on severity assessment in daily clinical practice, Pancreatology (2017), http://dx.doi.org/10.1016/j.pan.2017.02.006

6

S.M. Staubli et al. / Pancreatology xxx (2017) 1e8

Table 3 (continued ) Question

Answer options

Response Comments count (%)

11. How much do you rely on the following criteria to assess severity in AP?

Clinical evaluation Preferred score Laboratory parameters Imaging Poor general condition Scores

129 (3.73) 3 In brackets: rating average, 1 ¼ very unreliable, 5 ¼ very reliable) 125 (3.62) 128 (3.88)

12. Which criteria influence your decisionmaking regarding transfers to intensive care?

SIRS/Sepsis Laboratory parameters Pain 13. Do you treat AP-patients in an out-patient Yes setting? No 14. How does identifying SAP affect your strategy of treatment?

15. Timepoint of CT imaging

16. Are new tools for severity assessment needed?

ICU transfer Antibiotic therapy Strict fluid management Nasojejunal feeding/TPN Reduce/stop oral food intake None Other At a defined time point In case of deterioration Rising inflammatory parameters Preferably never Suspected severe AP Other Yes No Undecided

127 (3.71) 164 (1.89) [4.11] 172 (3.42) [2.58] 183 (2.30) [3.70] 181 (3.59) [2.41] 187 (3.74) [2.26] 47 (24.2%) 147 (75.8%) 165 (85.5%) 26 (13.5%)

2 In brackets: Rating average, 1 ¼ most important, 5 ¼ least important In square brackets: weighting

2

1, 2 Other answers: close monitoring (6), evaluation of antibiotic therapy (5), CT imaging (3), evaluation of CT-guided puncture (1), improved analgesic therapy (2), consideration of ERCP (2), oral volume replacement (1), not specified (2)

164 (85%) 70 (36.3%) 81 (42%) 1 (0.5%) 22 (11.4%) 36 (16.4%) 1 Other answers: After 72 h (11), at 48 h (4), suspected complication (9), at admittance (8), 152 after 7 days if no improvement (2), depending on course (8), unclear situation or etiology (69.4%) (2), before discharge (1), n/s (3) 98 (44.8%)

2 (0.9%) 113 (51.6%) 43 (19.6%) 58 (26.5%) 89 (40.6%) 72 (32.9%)

1: Multiple answers allowed. 2: Only asked if answered “yes” to Q3. 3: Only asked if answered “yes” to Q5.

internists in our collective [2 (4%)] in comparison to surgeons [7 (16%)] or emergency specialist [3 (14%)]. The gastroenterologists formed the subgroup with the most extensive use of the revised Atlanta classification [2 (33%)]. No statistical comparison was performed as described in section 4.7. The results are summarized in Table 3. 4. Discussion In acute pancreatitis (AP), new ways to assess and predict severity of AP have been continuously published. There is uncertainty over the extent to which advancements in this field are translated into daily clinical practice. The few studies that have appeared on clinicians' adherence to current guidelines have revealed significant gaps between the guidelines' recommendations and the real-life management of AP. It is unclear which scores are used to assess and predict severity in clinical practice. In a Swedish study by Anderson et al. (2012), the APACHE II score was the most frequently used scoring system, but only department chairmen took part in this survey, and the overall number of

participants was low [7]. A German study by Lankisch et al., in 2005 had a similar study design and showed that the Ranson score was more frequently used than the APACHE II score [9] (Table 4). The goal of our study was to find out which scores are used in daily clinical practice. We therefore involved not only chairmen, but also senior physicians and consultants. The risk of on-responder bias exists in every survey, yet with an inclusion rate of nearly three quarters we are convinced that this risk is low. The existing guidelines for the management of AP vary in their recommendations on which scoring system or laboratory parameter to use for predicting the severity of pancreatitis. To assess severity, the Atlanta classification and the value of CRP after 48 h of disease onset is uniformly accepted by the different associations [11e15]. This is in line with our results: over 90% of clinicians in this survey stated that they use CRP for severity assessment. Scores are the most widely used tools in our collective to assess and predict the severity of AP, and they are routinely used for this purpose. To our surprise, the Ranson score was by far the most frequently used score. Although it has been shown in the literature that the Ranson score performs comparably to other scores, it has

Please cite this article in press as: Staubli SM, et al., Assessing the severity of acute pancreatitis (ASAP) in Switzerland: A nationwide survey on severity assessment in daily clinical practice, Pancreatology (2017), http://dx.doi.org/10.1016/j.pan.2017.02.006

S.M. Staubli et al. / Pancreatology xxx (2017) 1e8

7

Table 4 Comparison of university hospitals and other hospitals. Question

University hospitals

Other hospitalsa

Do you assess severity of AP in your institution? (Q 3)

Yes (32, 86%) No (5, 13.5%) Admission (26, 81%) Later timepoint (15, 47%) Regularly (10, 45%) Clinical worsening (15, 68%) Ranson (19, 90%) APACHE II (8, 38%) Atlanta 2012 (3, 14%) Determinant based (1, 5%) BISAP (1, 5%) Balthazar-Score (4, 19%) SIRS (3, 14%)

Yes (166, 86%) No (26, 13.5%) Admission (134, 81%) Later timepoint (114, 69%) Regularly (59, 55%) Clinical worsening (57, 53%) Ranson (67, 65%) APACHE II (17, 17%) Atlanta 2012 (13, 12%) Determinant based (3, 3%) BISAP (4, 4%) Balthazar (13, 13%) SIRS (11, 11%) HAPS (1, 1%) Glasgow/Imrie (1, 1%) PANC-3 (1, 1%) SOFA (1, 1%) CAB (1, 1%) Yes (37, 30%) No (125, 70%)

When do you perform severity evaluation? (Q 4) When do you perform repeated severity evaluation? (Q 6) Which scores or classification systems do you use? (Q 8)

Do you treat Patients with AP in an outpatient setting? (Q 13) a

Yes (10, 45%) No (22, 55%)

Cantonal hospitals and primary care hospitals.

Table 5 Comparison between different specialities. Question

Surgeons

Internists

Emergency

When do you perform repeated severity evaluation? (Q 6)

Regularly (20, 41%) Clinical worsening (29, 59%)

Regularly (27, 52%) Clinical worsening (25, 48%)

Regularly (15, 62%) Regularly (4, 44%) Regularly (3, 43%) Clinical worsening (9, 38%) Clinical worsening (5, 56%) Clinical worsening (4, 57%) Ranson (18, 82%) Ranson (5, 83%) Ranson (4, 67%) APACHE II (4, 18%) APACHE II (3, 50%) Atlanta 2012 (1, 17%) Atlanta 2012 (3, 14%) Atlanta 2012 (2, 33%) BISAP (1, 17%) Determinant based Determinant based Balthazar (3, 50%) classification (1, 5%) classification (1, 17%) BISAP (1, 5%) Glasgow/Imrie (1, 17%) SIRS (1, 17%) Balthazar (5, 23%) BISAP (3, 50%) Other (1, 17%) SIRS (5, 23%) SIRS (1, 17%) Other (1, 5%) HAPS (1, 17%)

Which scores or classification systems Ranson (40, 91%) do you use? (Q 8) APACHE II (8, 18%) Atlanta 2012 (7, 16%) Determinant based classification (1, 2%) BISAP (1, 2%) Balthazar-Score (10, 23%) SIRS (3, 7%) Other (1, 2%)

Do you use CT imaging for severity assessment? (Q 10)

Yes (41, 72%) No (10, 18%) Other (6, 11%)

Ranson (42, 89%) APACHE II (13, 28%) Atlanta 2012 (2, 4%) Determinant based classification (1, 2%) BISAP (1, 2%) Balthazar (5, 11%) SIRS (7, 15%) Glasgow/Imrie (5, 1%) PANC-3 (1, 2%) SOFA (1, 2%) CAB (1, 2%) Yes (28, 68%) No (8, 20%) Other (5, 12%)

major drawbacks: it is cumbersome and requires 48 h for completion, potentially leading to the loss of an important time window. The APACHE II score is the runner-up. Unlike the Ranson score, it is recommended in multiple guidelines (Table 5) for early risk stratification in AP. Its advantages are mainly its wide validation and the fact that it can be calculated at any time. However, it is impractical, as most of its parameters are not routinely available. A smaller number of Swiss clinicians use the simpler SIRS score, which can also be measured at any time. It is more sensitive than other scores (at a cut-off of 2 points), but less specific, unless SIRS persists for 48 h. Even though the IAP/APA [12] recommends using this score, it is very rarely used in our collective. As this score is easy to calculate, it might be a good candidate to replace the Ranson score in the community of Swiss clinicians, especially in a busy clinical environment. Even though the revised Atlanta classification is advocated by a number of associations, it still plays a marginal role in our collective: only 12% of our responders use it. Unfortunately, we did not ask why it is not used more frequently. Possible answers may be

Yes (14, 64%) No (4, 18%) Other (4, 18%)

Gastroenterology

Yes (1, 13%) No (6, 75%) Other (1, 13%)

Other

Yes (1, 20%) No (1, 20%) Other (3, 60%)

that it is not known or is considered insufficiently useful or too laborious. This might be a rewarding question to investigate further, because it would then be possible to take more precise measures to extend the reach of this classification. Another noteworthy result was the large number of clinicians who use CT imaging for severity assessment. 63% of clinicians answered that they used CT imaging to assess severity. When asked about the time point, most said that they performed a CT -scan in case of clinical worsening, rising inflammation parameters, or suspected severe pancreatitis. Only a minority of 16% routinely performed a CT scan at a defined time point. This is in line with the recommendations of most guidelines, which do not advocate routine use of CT scanning, especially not in the first 48e72 h of admission. The impact on patient management is marginal at this time, the extent of pancreatic necrosis cannot reliably be assessed, the administration of contrast media can impair renal function possibly set off a cascade of organ failure, and secondary complications often need more time to develop and are thus not visible so early.

Please cite this article in press as: Staubli SM, et al., Assessing the severity of acute pancreatitis (ASAP) in Switzerland: A nationwide survey on severity assessment in daily clinical practice, Pancreatology (2017), http://dx.doi.org/10.1016/j.pan.2017.02.006

8

S.M. Staubli et al. / Pancreatology xxx (2017) 1e8

It is characteristic of the Swiss healthcare system that a great number of hospitals, including small institutions, and multiple medical disciplines are involved in the treatment of AP. In this light, it is noteworthy that all of the items in the questionnaire were answered fairly uniformly. Meanwhile, an important feature of AP is that no particular medical specialty plays a clear leading role in the treatment of patients with this diagnosis. Surgeons and internists triage these patients to their own respective units. This renders the spread of new guidelines even more difficult, as the target audience is broad and consists of surgeons, internists, emergency doctors, gastroenterologists, and intensive care specialists with different medical backgrounds. A substantial number of the clinicians questioned for this study are not satisfied with the current situation and expressed the need for improvements in the process of assessment and prediction of severity in AP. This is mirrored by the fact that many different guidelines exist, with a broad spectrum of recommendations. The clinicians were particularly dissatisfied with the scoring systems, perhaps reflecting the fact that no ideal scoring system has yet been developed. In our opinion, different measures should be taken to improve the approach to the patient with AP: Firstly, since only doctors who are aware of the existence the Atlanta classification can employ it, the awareness of this system needs to be further increased. One way could be to use conventional channels such as lectures in universities, but also other channels such web-based information platforms might be useful. Secondly, further research is needed in this field. Several authors have sought to find an ideal biomarker that indicates severe AP at an early timepoint, quite similiarly to the role of procalcitonin in exacerbated COPD. To date, no ideal parameter has been found, however, researchers are still active in this field and an ideal parameter might emerge in the future. We conclude that much work remains to be done, not only to improve and refine the tools for the reliable prediction and assessment of severity, but also to establish these tools in everyday clinical practice. Research in this exciting and fast-moving field will remain “de l'art pour l'art” (art for art's sake) unless its findings can be translated into beneficial and widely implemented innovations in clinical practice. Funding sources The list of hospitals by the Swiss hospital association (H-Plus) is normally only supplied for a fee but was provided to us free of cost. The costs for the web platform were covered by the investigators. Potential conflicts of interest None.

Acknowledgements We would like to thank the many participating colleagues for taking the time to answer our questionnaire. The authors also thank Ethan Taub, M.D., (University Hospital Basel) for language editing.

Appendix A. Supplementary data Supplementary data related to this article can be found at http:// dx.doi.org/10.1016/j.pan.2017.02.006.

References [1] Munigala S, Yadav D. Case-fatality from acute pancreatitis is decreasing but its population mortality shows little change. Pancreatology 2016. [2] Singh VK, Bollen TL, Wu BU, Repas K, Maurer R, Yu S, et al. An assessment of the severity of interstitial pancreatitis. Clin Gastroenterol Hepatol 2011;9: 1098e103. [3] Petrov MS, Shanbhag S, Chakraborty M, Phillips AR, Windsor JA. Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis. Gastroenterology 2010;139:813e20. [4] Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitise2012: revision of the atlanta classification and definitions by international consensus. Gut 2013;62:102e11. [5] Forsmark CE, Gardner TB. Prediction and management of severe acute pancreatitis. New York: Springer; 2015. [6] Mounzer R, Langmead CJ, Wu BU, Evans AC, Bishehsari F, Muddana V, et al. Comparison of existing clinical scoring systems to predict persistent organ failure in patients with acute pancreatitis. Gastroenterology 2012;142: 1476e82. quiz e1415e1476. [7] Andersson B, Andren-Sandberg A, Nilsson J, Andersson R. Survey of the management of acute pancreatitis in surgical departments in Sweden. Scand J Gastroenterol 2012;47:1064e70. [8] Rebours V, Levy P, Bretagne JF, Bommelaer G, Hammel P, Ruszniewski P. Do guidelines influence medical practice? Changes in management of acute pancreatitis 7 years after the publication of the french guidelines. Eur J Gastroenterol Hepatol 2012;24:143e8. [9] Lankisch PG, Weber-Dany B, Lerch MM. Clinical perspectives in pancreatology: compliance with acute pancreatitis guidelines in Germany. Pancreatology 2005;5:591e3. [10] Aly EA, Milne R, Johnson CD. Non-compliance with national guidelines in the management of acute pancreatitis in the United Kingdom. Dig Surg 2002;19: 192e8. [11] Forsmark CE, Baillie J. Practice AGAIC, Economics C, Board AGAIG: aga institute technical review on acute pancreatitis. Gastroenterology 2007;132:2022e44. [12] Working Group IAPAPAAPG. Iap/apa evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013;13:e1e15. [13] Tenner S, Baillie J, DeWitt J, Vege SS. American College of G: american college of gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol 2013;108:1400e15. 1416. [14] Yokoe M, Takada T, Mayumi T, Yoshida M, Isaji S, Wada K, et al. Japanese guidelines for the management of acute pancreatitis: japanese guidelines 2015. J Hepatobiliary Pancreat Sci 2015;22:405e32. [15] Pezzilli R, Zerbi A, Di Carlo V, Bassi C, Delle fave GF. working group of the italian association for the study of the pancreas on acute P: practical guidelines for acute pancreatitis. Pancreatology 2010;10:523e35.

Please cite this article in press as: Staubli SM, et al., Assessing the severity of acute pancreatitis (ASAP) in Switzerland: A nationwide survey on severity assessment in daily clinical practice, Pancreatology (2017), http://dx.doi.org/10.1016/j.pan.2017.02.006