Hospitalization for severe skin disease improves quality of life in the United Kingdom and the United States: a comparative study

Generalized pustular psoriasis in Brazil: A public claims database study

Background

Generalized pustular psoriasis (GPP) is a rare and severe phenotype of psoriasis characterized by sudden outbreak of widespread coalescent sterile pustules associated with a spectrum of systemic symptoms.

Objective

We aimed to describe the epidemiology and treatment of GPP in Brazil from the public health care system perspective.

Methods

This was a retrospective public claims database study, using outpatient and inpatient databases, with information from January 2018 to August 2020, based on records of health resource utilization by patients with GPP. Outpatient treatment regimens and fatal inpatient outcomes were described.

Results

In total, 1458 outpatients of all ages were identified, of whom 53% were women. We estimated the GPP prevalence in Brazil to be between 0.7 and 0.9 per 100,000. Acitretin was the most commonly dispensed drug. Of all the outpatients, 769 outpatients could be tracked in the inpatient database, and 151 had hospital admissions during the study period. Of them, 5.3% had a fatal outcome during hospitalization. A primary skin condition or an infection was the most frequent hospitalization cause.

Limitation

The International Classification of Diseases codes for GPP and psoriasis have not been previously validated in this context.

Conclusion

GPP is a rare disease in Brazil and affects individuals of all ages and both sexes. Hospitalizations and disease-related deaths highlight the need for its prompt diagnosis, close medical follow-up, and effective treatment.

Profile of dermatology inpatients and admissions over a four year period in a tertiary level government teaching hospital in North India

BACKGROUND

Although dermatology is mostly an outpatient specialty, some patients with severe skin disease need hospital admission for management. There is a paucity of data regarding the profile of these dermatology in-patient admissions.

AIMS

We studied the profile of patients admitted to the dermatology ward of our tertiary care government hospital in North India.

METHODS

This was a retrospective analysis of discharge sheets of patients admitted in the dermatology ward from January 1, 2014 to December 31, 2017.

RESULTS

Discharge sheets of 2032 admissions for 1664 patients were analyzed. The most common diagnoses in the admitted patients were immunobullous disorders (576, 28%), connective tissue diseases (409, 20%), infections, including leprosy and sexually transmitted infections (179, 8.8%), psoriasis (153, 7.5%) and reactive arthritis (92, 4.5%). The mean duration of admission was 13.95±11.67 days (range 1-118 days). Two hundred and fifty-six patients (15.38%) were re-admitted, accounting for 368 (18.11%) re-admissions. Patients with immunobullous disorders (OR 1.72, 95% CI 1.29-2.28) and psoriasis (OR 1.62, 95% CI 1.02-2.55) were more likely to be re-admitted. Adult patients, those who were admitted for more than four weeks, those who had comorbidities, and those who developed a complication during the hospital stay also had a greater likelihood of being re-admitted.

LIMITATIONS

The retrospective design of the study, and the non-availability of data regarding transfers to other specialties or intensive care units and deaths were the main limitations of this study.

CONCLUSION

This study describes the profile of patients admitted in a dermatology ward of a tertiary care centre center in North India. The patient profile and admission characteristics associated with a higher probability of re-admission were identified.

Quality of life in patients with Mycosis Fungoides and Sézary Syndrome: a systematic review of the literature

Cutaneous T‐cell Lymphoma’s (CTCL) are a rare, heterogeneous group of T‐cell lymphomas that primarily manifest in the skin. Mycosis fungoides (MF) and Sézary syndrome (SS) are considered the classic types of CTCL. The diverse manifestation of CTCL results in a wide range of symptoms with a possible mild to severe impact on Quality of Life (QoL) depending on the disease stage. Previous studies on QoL in CTCL patients report diverse patient populations and use many different QoL instruments. In the current literature, a clear overview on the influence of the different stages of disease (early MF, late‐stage MF/SS or total group) on the QoL is lacking. Therefore, a systematic search of the literature was conducted using the PubMed, Embase, PsycINFO and Web of Science databases. Studies were included if they described QoL in patients with MF and SS retrieved by standardized instruments or qualitative interviews. In total, 24 studies were included using 18 different questionnaires to report on dermatology‐specific, cancer‐specific and generic QoL. The effect on QoL was found to be greater in patients with late‐stage disease as compared to early stage disease, with significant impairments on functional, emotional and physical domains. Nonetheless, even in patients with limited disease, QoL was mildly to moderately affected. Overall, pruritus was the most frequent reported and most bothersome symptom. Significant influence of the disease on daily life activities were found, not only in patients but also on caregivers and family. This broad, structured overview on QoL in MF and SS patients underlines the influence of disease stage on QoL, and therefore, recommends future studies to distinguish between disease stages when reporting results. Furthermore, this overview can inform clinicians in clinical practice by creating awareness of QoL deficits according to disease stage.

Inpatient dermatology: Where are we headed? A nationwide population-based study of Spain from 2006 to 2016

BACKGROUND AND OBJECTIVES

Information about hospital admissions for skin diseases is restricted to studies describing admissions to single centers, to specific wards, or only for a few diagnoses, and there is no information about the outcomes between different wards. The aim of this research is to describe hospital admissions due to dermatological diseases.

PATIENTS AND METHODS

Cross-sectional study of hospital discharges at Spanish hospitals. Discharges were assumed to be the same as admissions.

RESULTS

519,440 discharges (1.1 % of total discharges) were identified. Most admissions (60.1 %) were done from emergency departments. Only 7 % of cases were admitted to dermatology wards. The most prevalent group was cellulitis and acute lymphangitis. Median age was 57 years, and men were more common. The median length of hospital stay was four days; 40,823 (7.9 %) cases required readmission. There were 13,558 (2.6 %) hospital deaths. After adjusted analysis (by age, sex and group of diagnosis), the OR of readmission was 1.49 (95 % CI: 1.42-1.57) times higher and length of stay was 0.22 (95 % CI: 0.15-0.29) days longer in non-dermatology wards (P < 0.0001). From 2006-2016, admissions to dermatology wards decreased 38 %, while in non-dermatology wards they increased 8 %.

CONCLUSIONS

A non-negligible number of patients require dermatological inpatient management. This is mainly provided by non-dermatologists. Some of our findings may indicate an improved overall care by dermatologists.

Methods to improve quality of life, beyond medicines. Position statement of the European Academy of Dermatology and Venereology Task Force on Quality of Life and Patient Oriented Outcomes

The pharmaceutical approach to skin disease has been hugely successful, but despite effective drugs being available and used, there are still vast numbers of people who continue to have some level of persisting skin disease and continue to experience quality of life (QoL) impairment. So the question that needs to be answered, while we await further advances in our drug-based armamentarium, is how can we improve patients' QoL, beyond drugs? A working group was formed from members of the EADV Task Force on QoL and Patient Oriented Outcomes. Participants were asked to suggest all the ways in which they considered patients' QoL may be improved beyond medicines. Four groups of management approaches that may improve QoL in dermatology were identified: interventions within the dermatology service (hospitalization, multidisciplinary teams, patch testing and establishing relevant allergens and education), external services (corrective make-up, climatotherapy and balneotherapy), psychological (psychological intervention, cognitive therapy, hypnosis), lifestyle (lifestyle behavioural changes, religion and spirituality and music). The ultimate aim of therapy is to eradicate a disease in an individual and return the person's life to normal. But until the day comes when this has been achieved for every skin disease and for every patient there will be a need to support and assist many patients in additional non-pharmaceutical ways. These 'adjuvant' approaches receive too little attention while dermatologists and researchers strive for better pharmacological therapy. The different ways in which patients may benefit have been reviewed in our paper, but the reality is that most have a very poor evidence base. The research challenges that we have to meet are to identify those approaches that might be of value and to provide evidence for their optimal use. In the meantime, clinicians should consider the use of these approaches where QoL remains impaired despite optimal use of standard therapy.

The Evolution of Quality of Life Assessment and Use in Dermatology

The creation of the Dermatology Life Quality Index (DLQI) questionnaire facilitated many studies on the impact of skin diseases on patients' quality of life (QoL). Many national and international guidelines recommend QoL assessment in dermatology, and some of them contain detailed recommendations on treatment goals and changes of treatment approaches based on DLQI score banding and minimal clinically important difference. The methodology of QoL in strument development and validation is constantly becoming more rigorous. Initiatives on selection of core outcome sets for skin diseases are focused on clinical trials but may also be beneficial for clinicians. There are various benefits of using QoL information in clinical practice, but experience of this is very limited at the moment. QoL assessment in dermatology is a rapidly developing field with a gradual shift from theory to practice.

Inpatient Dermatology: Characteristics of Patients and Admissions in a Tertiary Level Hospital in Eastern India

Introduction:

Dermatology is primarily a non-acute, outpatient-centered clinical specialty, but substantial number of patients need indoor admission for adequate management. Over the years, the need for inpatient facilities in Dermatology has grown manifold; however, these facilities are available only in some tertiary centers.

Aims and Objectives:

To analyze the characteristics of the diseases and outcomes of patients admitted in the dermatology inpatient Department of a tertiary care facility in eastern India.

Materials and Methods:

We undertook a retrospective analysis of the admission and discharge records of all patients, collected from the medical records department, admitted to our indoor facility from 2011 to 2014. The data thus obtained was statistically analyzed with special emphasis on the patient's demographic profile, clinical diagnosis, final outcome, and duration of stay.

Results and Analysis:

A total of 375 patients were admitted to our indoor facility during the period. Males outnumbered females, with the median age in the 5th decade. Immunobullous disorders (91 patients, 24.27%) were the most frequent reason for admissions, followed by various causes of erythroderma (80 patients, 21.33%) and infective disorders (73 patients, 19.47%). Other notable causes included cutaneous adverse drug reactions, psoriasis, vasculitis, and connective tissue diseases. The mean duration of hospital stay was 22.2±15.7 days; ranging from 1 to 164 days. Majority of patients (312, 83.2%) improved after hospitalization; while 29 (7.73%) patients died from their illness. About 133 patients (35.64%) required referral services during their stay, while 8 patients (2.13%) were transferred to other departments for suitable management.

Conclusion:

Many dermatoses require inpatient care for their optimum management. Dermatology inpatient services should be expanded in India to cater for the large number of cases with potentially highly severe dermatoses.

Inpatient treatment for severe atopic dermatitis in a Traditional Korean Medicine hospital: introduction and retrospective chart review

OBJECTIVES

Patients with atopic dermatitis increasingly seek complementary and alternative medical treatment. A number of studies have demonstrated the efficacy of herbs and acupuncture in the treatment of atopic dermatitis. Some patients with extensive disease, outpatient treatment failure, acute deterioration or highly impaired everyday functioning require inpatient care. The aim of this study was to introduce and evaluate inpatient treatments for severe atopic dermatitis patients at a Traditional Korean Medicine hospital.

DESIGN AND SUBJECTS

We performed a retrospective chart review of inpatients with severe atopic dermatitis between March 2008 and October 2011. Eligibility criteria for inclusion were: (1) a diagnosis of atopic dermatitis according to the criteria established by Hanifin and Rajka and (2) hospitalisation because of severe atopic dermatitis (objective scoring atopic dermatitis (SCORAD) score ≥ 40).

MAIN OUTCOME MEASUREMENT

The SCORAD score was assessed by trained investigators at admission and discharge.

RESULTS

Among 37 inpatients, there were 29 patients who met the criteria. Patients received treatments including acupuncture, herbal medicine and herbal wet wrap dressings. The mean total scoring SCORAD decreased from 60.63 to 37.37 during hospitalisation. Despite the relatively small sample size, these findings were statistically significant.

CONCLUSION

In atopic dermatitis, Traditional Korean Medicine effectively decreased clinical disease severity. This study's weaknesses include the relatively small number of patients, some aspects of the study design, lack of follow-up assessment and lack of second measurement.

The main organizational changes in dermatological practice in the Lombardy Region, Italy, from 2001 to 2009

BACKGROUND

Changes in financing health care delivery, including the adoption of diagnosis-related groups (DRG), has deeply influenced dermatological practice across Europe.

OBJECTIVE

To define the current status of dermatological care in the Lombardy Region, Italy, and compare the status of 2009 to that of 2001.

METHODS

Data were analysed from the annual reports of the Healthcare General Department of the Lombardy Region; legislative and administrative data were taken into consideration.

RESULTS

Beds for inpatients in Dermatologic Wards decreased from 251.7 (2001) to 49.07 (2009). In 2009, a large proportion of inpatients with skin diseases were admitted to non-dermatological departments. Beds for day-hospital activities increased from 55.9 (2001) to 61.0 (2009), and the proportion of admissions for surgical purposes progressively increased. In addition, the complexity and quality of surgical procedures increased, in view of the need to justify a day-hospital admission. The total number of services for outpatients increased from 1,090,052 (2001) to 1,503,692 (2009); in addition, the weighted numbers (an indicator of complexity) increased from 2,117,000 (2001) to 3,644,032 (2009). The number of dermatologists with unlimited contracts decreased, and the number of low paid scholarship recipients and external consultants increased. Three of six medical faculties currently do not have a university department of Dermatology.

CONCLUSION

Over the last decade, the number of patients hospitalized in Dermatological Departments has declined; moreover, patients hospitalized with dermatological disorders have been increasingly admitted to wards with a non-dermatologist attending physician.

Care in the Context of the Complexity of Psoriasis

Previous research has demonstrated the multidimensional challenges of living with psoriasis and dermatology wards provide a unique setting in which to reach people strongly affected by this disease. The aim of this study is to determine the components of care that psoriasis patients and dermatology nurses consider to be important during hospitalization. A purposeful sample of seven psoriasis inpatients and seven dermatology nurses were interviewed in depth during a 3-month period in 2006-2007. The data are analyzed with a modified version of Giorgi’s phenomenological method. Patients consider hospitalization a relief from everyday life with psoriasis and describe its treatment as the focus of nursing care. Despite their knowledge of the psychosocial aspects of psoriasis, nurses consider the physical manifestations of the disease most important. The patients’ descriptions of the challenges in their everyday lives illustrate an area of concern among psoriasis inpatients that is not actively addressed by nursing care.

The Dermatology Life Quality Index 1994-2007: a comprehensive review of validation data and clinical results

BACKGROUND

The Dermatology Life Quality Index (DLQI) is one of the most widely used dermatology-specific quality of life instruments. Over the last 5 years there has been great interest in its use.

OBJECTIVES

To collect and present all information regarding the technical properties and the clinical use of the DLQI from the date it was published to the end of 2007 for use as a single source of reference.

METHODS

A detailed literature search was conducted using electronic reference databases and the DLQI library in the Department of Dermatology, Cardiff University. All publications mentioning any aspect of the DLQI, from the time of its development to the end of 2007, were identified and the data concerning the DLQI in terms of its psychometric analysis, and use in clinical trials, epidemiological studies and health services research, were extracted and tabulated with all the relevant references.

RESULTS

In total, 272 full articles which have included the DLQI were reviewed. Studies described in these articles were divided into five main categories: psychometric studies, descriptive/epidemiological studies, drug (topical and systemic) trials, clinical practice research, and therapeutic interventions. The DLQI has been used in 33 different skin conditions in 32 countries and is available in 55 languages. Psychometric aspects of the DLQI such as validity, reliability, responsiveness to change, factor structure, and minimal important difference were described in 115 studies. The DLQI has been used in 33 studies assessing the effectiveness of 14 different types of therapeutic interventions and in 37 studies evaluating nine types of clinical practice research. Sixty studies have used it alone or in parallel with other instruments as an outcome measure in clinical trials of 18 systemic drugs while 22 studies have used it in 14 different topical drug trials. The DLQI has also been used in 27 multinational studies.

CONCLUSIONS

During the last 14 years there has been a gradual increase in the international use of the DLQI. The brevity and simplicity of use of the DLQI has resulted in its popularity both in clinical practice and in research. However, there are various issues in particular regarding its unidimensionality, differential item functioning, and minimal clinically important difference, which require further research. This article should facilitate the work of potential users of the DLQI by providing a readily available source of references for different aspects of the DLQI.

The impact of changes in clinical severity on psychiatric morbidity in patients with psoriasis: a follow-up study

BACKGROUND

Psoriasis has a strong impact on quality of life and is correlated to psychopathological states. It is important to investigate the effect of clinical changes on psychological status.

OBJECTIVES

To analyse the extent of clinical change and its effect on the presence of psychiatric morbidity in a group of patients with psoriasis.

METHODS

All eligible adults hospitalized with psoriasis in a dermatological hospital (February 2000-February 2002) were given the self-administered Psoriasis Area and Severity Index (SAPASI) to assess clinical severity, the 12-item General Health Questionnaire (GHQ-12) to detect patients with psychological problems (defined as 'cases') and the Skindex-29 to evaluate symptoms. The same questionnaires were completed by the patients a month after hospital discharge.

RESULTS

In our population of 414 patients, the incidence of GHQ cases becoming noncases was correlated with the SAPASI percentage improvement, ranging from 17.6% in patients with SAPASI worsened or unchanged at follow-up, to 68.2% in patients with clearance of psoriasis. Also, the proportion of patients who became GHQ noncases was much higher in patients with improvement of >/= 50% in symptoms, compared with patients with no improvement or worsening (70% vs. 32%, respectively). In a multivariate model the possible determinants of the passage from GHQ case to noncase were: SAPASI improvement, symptom improvement, no localization on the face, and gender (i.e. women were less likely to improve psychologically).

CONCLUSIONS

The improvement in clinical severity and symptoms was associated with a decreased frequency of psychiatric disturbance. However, dermatologists should be aware that even in the presence of vast clinical improvement patients may still substantially suffer psychologically.

Motifs d’hospitalisation des malades atteints de psoriasis

BACKGROUND

Currently, out-patient care is the traditional approach for the management of patients with psoriasis. However, some patients still require hospitalization. The aim of this study was to assess the main reasons for hospitalization of psoriasis patients.

PATIENTS AND METHODS

Data are presented from a retrospective study performed in a single centre over a 15-year period (1990-2005). Hospitalizations of psoriasis patients were identified using the coding L 40.X from the CM10 (out-patients were excluded). For each hospitalization, the following details were recorded: age, sex, associated disorders, mean length of stay, number of re-hospitalizations, clinical type of psoriasis (vulgaris, pustular or erythrodermic), onset factors and treatments.

RESULTS

One hundred and twenty-two patients corresponding to 211 hospitalizations were included in this study. Two distinct patient populations could be identified. The first consisted of patients with chronic psoriasis vulgaris (143/211 hospitalizations, 67.8%), chiefly male (n=95, sex-ratio=1.98, p=0.001), alcoholic in 47/95 hospitalizations, 49.5% (p=0.004) and requiring frequent re-hospitalization. The second consisted of patients with acute forms of psoriasis, either pustular (38/211 hospitalizations, 18%) or erythrodermic (30/211 hospitalizations, 14.2%). Most of these patients were female (sex-ratio=0.66) and the onset of their psoriasis was sometimes triggered by an infection (7/38 hospitalizations, 18% of psoriasis pustular, p=0.16) or intake of a new drug (6/30 hospitalizations, 20% of erythrodermic psoriasis, p=0.007).

DISCUSSION

Hospitalization in acute care hospitals is not often used in the management of patients with psoriasis. Hospitalizations concern two different populations: the first with chronic psoriasis vulgaris and commonly associated disorders (alcohol abuse), and the second with acute forms of psoriasis, namely pustular and erythrodermic.

Death from psoriasis: representative US data

OBJECTIVES

Psoriasis can be associated with severe, life-threatening exacerbations. We sought to approximate the mortality associated with hospitalizations for psoriasis.

MATERIALS AND METHODS

We analyzed data from two sources to estimate a death rate associated with psoriasis.

RESULTS

There were 471 hospital admissions for psoriasis from 1988 to 2001 with a corresponding mortality rate of 1.5%. Documented on nationwide death certificates, there were a total of 29, 33, and 25 deaths attributable to psoriasis in 2001, 2000, and 1999, respectively.

CONCLUSIONS

Though effective therapies for severe psoriasis are available, access to them is not guaranteed. It is disturbing to think that the deaths observed here could, at least in part, be prevented with the appropriate use of treatments.

Effectiveness of Inpatient Treatment on Quality of Life and Clinical Disease Severity in Atopic Dermatitis and Psoriasis Vulgaris – A Prospective Study

BACKGROUND

Financial constraints challenge evidence of the effectiveness of dermatological inpatient management.

OBJECTIVE

To evaluate the effectiveness of hospitalization in atopic dermatitis and psoriasis regarding initial and sustained benefits.

METHODS

Prospective study on adults with psoriasis vulgaris (n = 22) and atopic dermatitis (n = 14). At admission, discharge, and 3 months after discharge, validated outcomes of objective and subjective disease severity were assessed by trained investigators.

RESULTS

Hospitalization resulted in substantial benefit in quality of life and clinical disease severity. Looking at mean scores, the observed benefit appeared stable until 3-month follow-up. The analysis of individual patient data revealed significant changes in disease severity between discharge and 3-month follow-up with some patients relapsing, others further improving. Reasons for hospitalization and treatment performed were not related to sustained benefit.

CONCLUSIONS

In psoriasis vulgaris and atopic dermatitis, hospitalization effectively improved quality of life and clinical disease severity. Further research should focus on prognostic factors for sustained improvement.

Psoriasisschulung für erwachsene Patienten nach den Regeln der Arbeitsgemeinschaft Dermatologische Prävention

BACKGROUND

Psoriasis vulgaris is a chronic inflammatory skin disease with a substantial impairment of quality of life. Interdisciplinary outpatient educational programs are an innovative supplementary therapy form for the management of this disorder.

SUBJECTS AND METHODS

The Task Force on Dermatological Prevention developed a concept for outpatient instruction of psoriasis patients. Five 2-hour classes by dermatologists, psychotherapists/psychologists and dieticians focus on central topics relevant for the patients and the management of the disease.

RESULTS

The results presented are based on own experiences with this educational program. The interdisciplinary program is accepted very well and seen as helpful by the concerned. A structure analysis of the effects in a greater number of cases is a current goal. In some areas, health insurance companies are paying for the classes.

CONCLUSION

The educational program for the management of psoriasis vulgaris according to the rules of the Task Force on Dermatological Prevention is a supplement of the treatment of patients with this chronic skin disease. Broader implementation in Germany is desirable.

Current severe psoriasis and the rule of tens

This review addresses the problems of defining severity of psoriasis. Concepts of severity depend on the timescale perspective from which judgement is made. Measurement needs to include assessment of signs, impact on the patient's life and the history of the disease. The concept of severity in relationship to quality of life measurement scores has been defined, so it is now possible to postulate a standard, easily remembered concept to help define 'severe psoriasis' in the clinic. The proposed Rule of Tens for current severe psoriasis from the clinician's viewpoint is: 'Current Severe Psoriasis = Body Surface Area involved > 10% or Psoriasis Area and Severity Index score > 10 or Dermatology Life Quality Index score > 10'.

Clinical management decisions are related to the impact of psoriasis on patient-rated quality of life

BACKGROUND

Clinical decisions over psoriasis are based on many factors. Patients' quality of life (QOL) is not directly related to disease severity alone as judged by physical signs, so decisions should not be based on physical assessments alone. This is increasingly important as new potent biological therapies become available.

OBJECTIVES

This study aimed to determine whether clinicians' routine decisions in psoriasis correlate with patient-rated QOL.

PATIENTS AND METHODS

Over 35 weeks all 687 outpatient psoriasis consultations by 13 clinicians were included. Each patient received a Dermatology Life Quality Index (DLQI) questionnaire following their consultation. Case notes were analysed to assign management decisions taken by clinicians to one of 11 categories. Patient-rated DLQI was correlated with the type of management decision.

RESULTS

Three hundred and eighty-three completed DLQI questionnaires were analysed. Within the 'no change to main type of therapy' group the mean DLQI for patients not changing the potency, dose or frequency of main treatment was 8.9. For patients in whom the potency, dose or frequency of main treatment was increased, the mean DLQI was 11.9. For patients in whom the potency, dose or frequency of main treatment was decreased, the mean DLQI was 6.2. Major management decisions were associated with a high mean DLQI such as change of topical therapy (11.2), topical to systemic therapy (14.8), change of systemic therapy (16.7), starting photo(chemo)therapy (13) and requiring hospital admission (14.4). By contrast, patients discharged reported low DLQI values (mean 4.0). The cohort of patients in whom a decision was taken to start day treatment had a surprisingly low mean DLQI of 8.6. Significant differences in mean DLQI were seen in the cohorts classified by type of management decision. For example, when the mean DLQI values in each cohort were compared (Mann-Whitney U-test), significant differences were seen between the cohorts in whom treatment was increased in potency, dose or frequency, compared with the cohorts whose treatment was unchanged (P < 0.05) or decreased (P < 0.01) or who were discharged from clinic (P < 0.01).

CONCLUSIONS

In psoriasis there is a relationship between the type of management decision and the patient-rated QOL. However, there is a very wide score scatter for each management decision, challenging the appropriateness of some clinical decisions.