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Jett J, Fossi A, Blonsky H, Ross W, Townsend S, Stephens MM, Chicoine B, Santoro SL. Retrospective review of the code status of individuals with Down syndrome during the COVID-19 era. AMERICAN JOURNAL OF MEDICAL GENETICS. PART C, SEMINARS IN MEDICAL GENETICS 2024; 196:e32080. [PMID: 38087874 DOI: 10.1002/ajmg.c.32080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 11/15/2023] [Accepted: 11/22/2023] [Indexed: 03/13/2024]
Abstract
Code status is a label in the medical record indicating a patient's wishes for end-of-life (EOL) care in the event of a cardiopulmonary arrest. People with intellectual disabilities had a higher risk of both diagnosis and mortality from coronavirus infections (COVID-19) than the general population. Clinicians and disability advocates raised concerns that bias, diagnostic overshadowing, and ableism could impact the allocation of code status and treatment options, for patients with intellectual disabilities, including Down syndrome (DS). To study this, retrospective claims data from the Vizient® Clinical Data Base (used with permission of Vizient, all rights reserved.) of inpatient encounters with pneumonia (PNA) and/or COVID-19 at 825 hospitals from January 2019 to June 2022 were included. Claims data was analyzed for risk of mortality and risk of "Do Not Resuscitate" (DNR) status upon admission, considering patient age, admission source, Elixhauser comorbidities (excluding behavioral health), and DS. Logistic regression models with backward selection were created. In total, 1,739,549 inpatient encounters with diagnoses of COVID-19, PNA, or both were included. After controlling for other risk factors, a person with a diagnosis of DS and a diagnosis of COVID-19 PNA had 6.321 odds ratio of having a DNR status ordered at admission to the hospital compared with those with COVID-19 PNA without DS. The diagnosis of DS had the strongest association with DNR status after controlling for other risk factors. Open and honest discussions among healthcare professionals to foster equitable approaches to EOL care and code status are needed.
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Affiliation(s)
- Jennifer Jett
- Department of Palliative Care, Intermountain Health, Salt Lake City, Utah, USA
| | - Alexander Fossi
- Center for Autism and Neurodiversity, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Wendy Ross
- Center for Autism and Neurodiversity, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sabra Townsend
- Center for Autism and Neurodiversity, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mary M Stephens
- Department of Family and Community Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Center for Special Healthcare Needs, Christiana Care, Christiana, Delaware, USA
| | - Brian Chicoine
- Advocate Medical Group Adult Down Syndrome Center, Department of Family Medicine, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
| | - Stephanie L Santoro
- Division of Medical Genetics and Metabolism, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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Sahebi-Fakhrabad A, Kemahlioglu-Ziya E, Handfield R, Wood S, Patel MD, Page CP, Chang L. In-Hospital Code Status Updates: Trends Over Time and the Impact of COVID-19. Am J Hosp Palliat Care 2023:10499091231222188. [PMID: 38111223 DOI: 10.1177/10499091231222188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
OBJECTIVE The primary objective was to evaluate if the percentage of patients with missing or inaccurate code status documentation at a Trauma Level 1 hospital could be reduced through daily updates. The secondary objective was to examine if patient preferences for DNR changed during the COVID-19 pandemic. METHODS This retrospective study, spanning March 2019 to December 2022, compared the code status in ICU and ED patients drawn from two data sets. The first was based on historical electronic medical records (EHR), and the second involved daily updates of code status following patient admission. RESULTS Implementing daily updates upon admission was more effective in ICUs than in the ED in reducing missing code status documentation. Around 20% of patients without a specific code status chose DNR under the new system. During COVID-19, a decrease in ICU patients choosing DNR and an increase in full code (FC) choices were observed. CONCLUSION This study highlights the importance of regular updates and discussions regarding code status to enhance patient care and resource allocation in ICU and ED settings. The COVID-19 pandemic's influence on shifting patient preferences towards full code status underscores the need for adaptable documentation practices. Emphasizing patient education about DNR implications and benefits is key to supporting informed decisions that reflect individual health contexts and values. This approach will help balance the considerations for DNR and full code choices, especially during health care crises.
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Affiliation(s)
| | - Eda Kemahlioglu-Ziya
- Department of Business Management, Poole College of Management, NC State University, Raleigh, NC, USA
| | - Robert Handfield
- Department of Business Management, Poole College of Management, NC State University, Raleigh, NC, USA
| | - Stacy Wood
- Department of Business Management, Poole College of Management, NC State University, Raleigh, NC, USA
| | - Mehul D Patel
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Cristen P Page
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lydia Chang
- Asheville Pulmonary and Critical Care Associates, Asheville, NC, USA
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Osterman E, Jakobsson S, Larsson C, Linder F. Effect of the COVID-19 pandemic on the care for acute cholecystitis: a Swedish multicentre retrospective cohort study. BMJ Open 2023; 13:e078407. [PMID: 38035739 PMCID: PMC10689379 DOI: 10.1136/bmjopen-2023-078407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/08/2023] [Indexed: 12/02/2023] Open
Abstract
OBJECTIVES The present study aimed to investigate if and how the panorama of acute cholecystitis changed in 2020 in Sweden. Seven aspects were identified, the incidence of cholecystitis, the Tokyo grade, the timing of diagnosis and treatment, the proportion treated with early surgery, the proportion of patients treated with delayed surgery, and new complications from gallstones. DESIGN Retrospective multicentre cohort study. SETTING 3 hospitals in Sweden, covering 675 000 inhabitants. PARTICIPANTS 1634 patients with cholecystitis. OUTCOMES The incidence, treatment choice and diagnostic and treatment delay were investigated by comparing prepandemic and pandemic patients. RESULTS Patients diagnosed with cholecystitis during the pandemic were more comorbid (American Society of Anesthesiologists 2-5, 86% vs 81%, p=0.01) and more often had a diagnostic CT (67% vs 59%, p=0.01). There were variations in the number of patients corresponding with the pandemic waves, but there was no overall increase in the number of patients with cholecystitis (78 vs 76 cases/100 000 inhabitants, p=0.7) or the proportion of patients treated with surgery during the pandemic (50% vs 50%, p=0.4). There was no increase in time to admission from symptoms (both median 1 day, p=0.7), or surgery from admission (both median 1 day, p=0.9). The proportion of grades 2-3 cholecystitis was not higher during the pandemic (46% vs 44%, p=0.9). The median time to elective surgery increased (184 days vs 130 days, p=0.04), but there was no increase in new gallstone complications (35% vs 39%, p=0.3). CONCLUSION Emergency surgery for cholecystitis was not impacted by the pandemic in Sweden. Patients were more comorbid but did not have more severe cholecystitis nor was there a delay in seeking care. Fewer patients non-operatively managed had elective surgery within 6 months of their initial diagnosis but there was no corresponding increase in gallstone complications.
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Affiliation(s)
- Erik Osterman
- CKF Gävleborg, Uppsala University, Gävle, Sweden
- Department of Surgery, Gävle Sjukhus, Gävle, Sweden
| | - Sofia Jakobsson
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Fredrik Linder
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Department of Surgery, Uppsala University Hospital, Uppsala, Sweden
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Molitch-Hou E, Zhang H, Gala P, Tate A. Impact of the COVID-19 Public Health Crisis and a Structured COVID Unit on Physician Behaviors in Code Status Ordering. Am J Hosp Palliat Care 2023:10499091231204943. [PMID: 37786255 PMCID: PMC10985045 DOI: 10.1177/10499091231204943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023] Open
Abstract
Purpose: Code status orders are standard practice impacting end-of-life care for individuals. This study reviews the impact of a COVID unit on physician behaviors towards goal-concordant end-of-life care at an urban academic tertiary-care hospital. Methods: We conducted a retrospective cohort study of code status ordering on adult inpatients comparing the pre-pandemic period to patients who tested positive, negative and were not tested during the pandemic from January 1, 2019, to December 31, 2020. Results: We analyzed 59,471 unique patient encounters (n = 35,317 pre-pandemic and n = 24,154 during). 1,631 cases of COVID-19 were seen. The rate of code status orders among all inpatients increased from 22% pre-pandemic to 29% during the pandemic (P < .001). Code status orders increased for both patients who were COVID-negative (32% P < .001) and COVID-positive (65% P < .001). Being in a cohorted COVID unit increased code status ordering by an odds of 4.79 (P < .001). Compared to the pre-pandemic cohort, the COVID-positive cohort is less female (50% to 56% P < .001), more Black (66% to 61% P < .001), more Hispanic (6.5% to 5%) and less white (26% to 30% P < .001). Compared to Black patients, white patients had lower odds (.86) of code status ordering (P < .001). Other race/ethnicity categories were not significant. Conclusions: Code status ordering remains low. Compared to pre-pandemic rates, the frequency of orders placed significantly increased for all patients during the pandemic. The largest increase occurred in patients with COVID-19. This increase likely occurred due to protocols in the COVID unit and disease uncertainty.
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Affiliation(s)
- Ethan Molitch-Hou
- Department of Medicine, Section of Hospital Medicine, University of Chicago, Chicago, IL, USA
| | - Hui Zhang
- Center for Health and The Social Sciences, The University of Chicago, Chicago, IL, USA
| | - Pooja Gala
- NYU Grossman School of Medicine, New York University, New York, NY, USA
| | - Alexandra Tate
- Department of Medicine, Section of Hospital Medicine, University of Chicago, Chicago, IL, USA
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Jacobson E, Troost JP, Epler K, Lenhan B, Rodgers L, O'Callaghan T, Painter N, Barrett J. Change in Code Status Orders of Hospitalized Adults With COVID-19 Throughout the Pandemic: A Retrospective Cohort Study. J Palliat Med 2023; 26:1188-1197. [PMID: 37022771 PMCID: PMC10623069 DOI: 10.1089/jpm.2022.0578] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 04/07/2023] Open
Abstract
Aim: Our aim was to examine how code status orders for patients hospitalized with COVID-19 changed over time as the pandemic progressed and outcomes improved. Methods: This retrospective cohort study was performed at a single academic center in the United States. Adults admitted between March 1, 2020, and December 31, 2021, who tested positive for COVID-19, were included. The study period included four institutional hospitalization surges. Demographic and outcome data were collected and code status orders during admission were trended. Data were analyzed with multivariable analysis to identify predictors of code status. Results: A total of 3615 patients were included with full code (62.7%) being the most common final code status order followed by do-not-attempt-resuscitation (DNAR) (18.1%). Time of admission (per every six months) was an independent predictor of final full compared to DNAR/partial code status (p = 0.04). Limited resuscitation preference (DNAR or partial) decreased from over 20% in the first two surges to 10.8% and 15.6% of patients in the last two surges. Other independent predictors of final code status included body mass index (p < 0.05), Black versus White race (0.64, p = 0.01), time spent in the intensive care unit (4.28, p = <0.001), age (2.11, p = <0.001), and Charlson comorbidity index (1.05, p = <0.001). Conclusions: Over time, adults admitted to the hospital with COVID-19 were less likely to have a DNAR or partial code status order with persistent decrease occurring after March 2021. A trend toward decreased code status documentation as the pandemic progressed was observed.
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Affiliation(s)
- Emily Jacobson
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Jonathan P. Troost
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Katharine Epler
- Department of Internal Medicine, University of California San Diego, San Diego, California, USA
| | - Blair Lenhan
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Lily Rodgers
- Department of Internal Medicine, University of Washington, Seattle, Washington, USA
| | - Thomas O'Callaghan
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Natalia Painter
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Julie Barrett
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
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Amacher SA, Blatter R, Briel M, Appenzeller-Herzog C, Bohren C, Becker C, Beck K, Gross S, Tisljar K, Sutter R, Marsch S, Hunziker S. Predicting neurological outcome in adult patients with cardiac arrest: systematic review and meta-analysis of prediction model performance. Crit Care 2022; 26:382. [PMID: 36503620 PMCID: PMC9741710 DOI: 10.1186/s13054-022-04263-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/10/2022] [Indexed: 12/14/2022] Open
Abstract
This work aims to assess the performance of two post-arrest (out-of-hospital cardiac arrest, OHCA, and cardiac arrest hospital prognosis, CAHP) and one pre-arrest (good outcome following attempted resuscitation, GO-FAR) prediction model for the prognostication of neurological outcome after cardiac arrest in a systematic review and meta-analysis. A systematic search was conducted in Embase, Medline, and Web of Science Core Collection from November 2006 to December 2021, and by forward citation tracking of key score publications. The search identified 1'021 records, of which 25 studies with a total of 124'168 patients were included in the review. A random-effects meta-analysis of C-statistics and overall calibration (total observed vs. expected [O:E] ratio) was conducted. Discriminatory performance was good for the OHCA (summary C-statistic: 0.83 [95% CI 0.81-0.85], 16 cohorts) and CAHP score (summary C-statistic: 0.84 [95% CI 0.82-0.87], 14 cohorts) and acceptable for the GO-FAR score (summary C-statistic: 0.78 [95% CI 0.72-0.84], five cohorts). Overall calibration was good for the OHCA (total O:E ratio: 0.78 [95% CI 0.67-0.92], nine cohorts) and the CAHP score (total O:E ratio: 0.78 [95% CI 0.72-0.84], nine cohorts) with an overestimation of poor outcome. Overall calibration of the GO-FAR score was poor with an underestimation of good outcome (total O:E ratio: 1.62 [95% CI 1.28-2.04], five cohorts). Two post-arrest scores showed good prognostic accuracy for predicting neurological outcome after cardiac arrest and may support early discussions about goals-of-care and therapeutic planning on the intensive care unit. A pre-arrest score showed acceptable prognostic accuracy and may support code status discussions.
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Affiliation(s)
- Simon A. Amacher
- grid.410567.1Intensive Care, University Hospital Basel, Basel, Switzerland ,grid.410567.1Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland
| | - René Blatter
- grid.410567.1Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland
| | - Matthias Briel
- grid.6612.30000 0004 1937 0642Meta-Research Centre, Department of Clinical Research, University of Basel and University Hospital Basel, Basel, Switzerland ,grid.25073.330000 0004 1936 8227Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, Canada ,grid.6612.30000 0004 1937 0642Medical Faculty, University of Basel, Basel, Switzerland
| | | | - Chantal Bohren
- grid.410567.1Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland
| | - Christoph Becker
- grid.410567.1Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland ,grid.410567.1Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland
| | - Katharina Beck
- grid.410567.1Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland
| | - Sebastian Gross
- grid.410567.1Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland
| | - Kai Tisljar
- grid.410567.1Intensive Care, University Hospital Basel, Basel, Switzerland
| | - Raoul Sutter
- grid.410567.1Intensive Care, University Hospital Basel, Basel, Switzerland ,grid.6612.30000 0004 1937 0642Medical Faculty, University of Basel, Basel, Switzerland
| | - Stephan Marsch
- grid.410567.1Intensive Care, University Hospital Basel, Basel, Switzerland ,grid.6612.30000 0004 1937 0642Medical Faculty, University of Basel, Basel, Switzerland
| | - Sabina Hunziker
- grid.410567.1Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland ,grid.6612.30000 0004 1937 0642Medical Faculty, University of Basel, Basel, Switzerland
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Shared decision-making in advance care planning among hospitalized older COVID-19 patients: a multicenter, retrospective cohort study. Aging Clin Exp Res 2022; 34:3165-3169. [PMID: 36334244 PMCID: PMC9638468 DOI: 10.1007/s40520-022-02281-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022]
Abstract
Background In the Netherlands, it is customary to discuss directives regarding resuscitation, intubation, and ICU-admission with patients and/or their relatives upon hospital-admission. The outcome of this discussion is documented in a code status. Ideally, these advance care planning (ACP)-related decisions are made by a patient (and/or their relatives) and a professional together in a shared decision-making (SDM) process, to improve patient satisfaction and prevent undesired care. Given the bad outcomes in older COVID-19 patients, it is particularly important to discuss the code status upon admission. This study aims to describe the practice of SDM regarding code status during the COVID-pandemic. Specific aims were to find out to what extend patients took part in this decision-making process and whether all key elements of SDM for a shared decision were documented in medical reports. Methods In this retrospective cohort study, we included COVID-19 patients aged 70 years and older, admitted to two large teaching hospitals in the Netherlands, during the first months of the COVID-19 pandemic in 2020. Data about code status and the decision-making process were extracted from electronic healthcare records. Results Code status was documented for 274 of 275 included patients. Patient participation in the decision-making process was described in 48%. In 19% all key elements of shared decision-making have been described. Key elements of SDM were defined as the presence of a completed code status form, the presence of clinical notes showing that both patient’s wishes and values and the opinion of the healthcare professional about the predicted outcome was taken into consideration and clinical notes of a patient–healthcare professional interaction during the admission. Conclusion Our results show that a proper SDM process regarding code status is possible, even in hectic times like the COVID-19-pandemic. However, shared decision-making was not common practice in older patients with COVID-19 regarding code status (an ACP-related decision) in the early phase of the COVID-19 pandemic. Only in 19% of the patients, all key elements of SDM regarding code status were described.
Supplementary Information The online version contains supplementary material available at 10.1007/s40520-022-02281-y.
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Briedé S, van Goor HMR, de Hond TAP, van Roeden SE, Staats JM, Oosterheert JJ, van den Bos F, Kaasjager KAH. Code status documentation at admission in COVID-19 patients: a descriptive cohort study. BMJ Open 2021; 11:e050268. [PMID: 34758991 PMCID: PMC8587534 DOI: 10.1136/bmjopen-2021-050268] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 10/26/2021] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES The COVID-19 pandemic pressurised healthcare with increased shortage of care. This resulted in an increase of awareness for code status documentation (ie, whether limitations to specific life-sustaining treatments are in place), both in the medical field and in public media. However, it is unknown whether the increased awareness changed the prevalence and content of code status documentation for COVID-19 patients. We aim to describe differences in code status documentation between infectious patients before the pandemic and COVID-19 patients. SETTING University Medical Centre of Utrecht, a tertiary care teaching academic hospital in the Netherlands. PARTICIPANTS A total of 1715 patients were included, 129 in the COVID-19 cohort (a cohort of COVID-19 patients, admitted from March 2020 to June 2020) and 1586 in the pre-COVID-19 cohort (a cohort of patients with (suspected) infections admitted between September 2016 to September 2018). PRIMARY AND SECONDARY OUTCOME MEASURES We described frequency of code status documentation, frequency of discussion of this code status with patient and/or family, and content of code status. RESULTS Frequencies of code status documentation (69.8% vs 72.7%, respectively) and discussion (75.6% vs 73.3%, respectively) were similar in both cohorts. More patients in the COVID-19 cohort than in the before COVID-19 cohort had any treatment limitation as opposed to full code (40% vs 25%). Within the treatment limitations, 'no intensive care admission' (81% vs 51%) and 'no intubation' (69% vs 40%) were more frequently documented in the COVID-19 cohort. A smaller difference was seen in 'other limitation' (17% vs 9%), while 'no resuscitation' (96% vs 92%) was comparable between both periods. CONCLUSION We observed no difference in the frequency of code status documentation or discussion in COVID-19 patients opposed to a pre-COVID-19 cohort. However, treatment limitations were more prevalent in patients with COVID-19, especially 'no intubation' and 'no intensive care admission'.
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Affiliation(s)
- Saskia Briedé
- Internal Medicine and Dermatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Harriet M R van Goor
- Internal Medicine and Dermatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Titus A P de Hond
- Internal Medicine and Dermatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Sonja E van Roeden
- Internal Medicine and Dermatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Judith M Staats
- Internal Medicine and Dermatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jan Jelrik Oosterheert
- Internal Medicine and Dermatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Frederiek van den Bos
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Karin A H Kaasjager
- Internal Medicine and Dermatology, University Medical Centre Utrecht, Utrecht, The Netherlands
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