Article Text

Original research
Validation of a delirium predictive model in patients admitted to surgical intensive care units: a multicentre prospective observational cohort study
  1. Onuma Chaiwat1,2,
  2. Kaweesak Chittawatanarat3,4,
  3. Sirirat Mueankwan5,
  4. Sunthiti Morakul6,
  5. Pitchaya Dilokpattanamongkol7,
  6. Chayanan Thanakiattiwibun2,
  7. Arunotai Siriussawakul1,2
  1. 1Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
  2. 2Integrated Perioperative Geriatric Excellent Research Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
  3. 3Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
  4. 4Clinical Surgical Research Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
  5. 5Surgical Critical Care Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
  6. 6Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
  7. 7Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
  1. Correspondence to Dr Onuma Chaiwat; onuma.cha{at}mahidol.ac.th

Abstract

Objective To internally and externally validate a delirium predictive model for adult patients admitted to intensive care units (ICUs) following surgery.

Design A prospective, observational, multicentre study.

Setting Three university-affiliated teaching hospitals in Thailand.

Participants Adults aged over 18 years were enrolled if they were admitted to a surgical ICU (SICU) and had the surgery within 7 days before SICU admission.

Main outcome measures Postoperative delirium was assessed using the Thai version of the Confusion Assessment Method for the ICU. The assessments commenced on the first day after the patient’s operation and continued for 7 days, or until either discharge from the ICU or the death of the patient. Validation was performed of the previously developed delirium predictive model: age+(5×SOFA)+(15×benzodiazepine use)+(20×DM)+(20×mechanical ventilation)+(20×modified IQCODE>3.42).

Results In all, 380 SICU patients were recruited. Internal validation on 150 patients with the mean age of 75±7.5 years resulted in an area under a receiver operating characteristic curve (AUROC) of 0.76 (0.683 to 0.837). External validation on 230 patients with the mean age of 57±17.3 years resulted in an AUROC of 0.85 (0.789 to 0.906). The AUROC of all validation cohorts was 0.83 (0.785 to 0.872). The optimum cut-off value to discriminate between a high and low probability of postoperative delirium in SICU patients was 115. This cut-off offered the highest value for Youden’s index (0.50), the best AUROC, and the optimum values for sensitivity (78.9%) and specificity (70.9%).

Conclusions The model developed by the previous study was able to predict the occurrence of postoperative delirium in critically ill surgical patients admitted to SICUs.

Trial registration number Thai Clinical Trail Registry (TCTR20180105001).

  • adult intensive & critical care
  • intensive & critical care
  • delirium & cognitive disorders

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Strengths and limitations of this study

  • The developed delirium predictive model consists of six risk factors was able to predict the occurrence of postoperative delirium in critically ill surgical patients.

  • The internal and external validation demonstrated moderate to good statistical performance, with the area under a receiver operating characteristic curve being comparable to that of the development cohort.

  • The optimum cut-off value to discriminate between a high and low probability of postoperative delirium in surgical intensive care unit patients was 115.

Background

Delirium, a disturbance of consciousness, is both acute and fluctuating. Delirium is an extremely common condition among hospitalised patients. Its incidence varies with the study population, but higher rates are observed among geriatric, postsurgical, intensive care unit (ICU), cardiac surgery and hip-fracture patients.1–4 Postoperative delirium (POD) among patients who have been treated with surgery and anaesthesia is typically found during the first 3 postoperative days.5 Although the POD can be transient, it is linked to poor outcomes. These include long stays in postanesthesia care units, ICUs and hospitals; high medical-complication rates; and raised mortality levels.6

Several tools for assessing delirium have been validated. Among those is the Confusion Assessment Method for the ICU (CAM-ICU), which shows high sensitivity and specificity.7 The CAM-ICU has been translated into Thai, and it, too, has demonstrated good sensitivity and specificity for critically ill patients.8 In Thailand, there are limited data relating to POD as well as delirium among critically ill patients. Muangpaisan et al9 reported the incidence of delirium was 22.5% in hip surgery. Their investigation also identified the following risk factors: age, premorbid function, dementia/cognitive impairment, the non-stop administration of non-steroidal anti-inflammatory drugs and postoperative sedative use. Another study reported a 44.0% prevalence of delirium among critically ill, old patients at a medical ICU in northeastern Thailand. That work found that the independent factors related to delirium were the use of physical restraints, a history of stroke and multiple bed changes.10

Given that delirium can result in poor clinical outcomes, predictions of its occurrence among patients who are at risk of delirium are especially important. During the recent decade, some predictive scoring systems for delirium have been proposed for use with various populations. For instance, the PREdiction of DELIRlum in ICU patients delirium risk prediction tool was developed for intensive care patients.11 This model uses 10 parameters. It had an area under a receiver operating characteristic curve (AUROC) of 0.87 (95% CI 0.85 to 0.89). Temporal validation and external validation resulted in an AUROC of 0.89 (0.86 to 0.92) and 0.84 (0.82 to 0.87), respectively.11 Another tool, the Risk Model for Delirium, assesses a number of predisposing risk factors for delirium in hip fracture patients. This model showed good intraclass correlation coefficient (0.77), sensitivity (80.4%) and AUROC (0.73).12 Furthermore, Kim et al developed the DELirium Prediction based on Hospital Information (Delphi) system for general surgery patients. Delphi demonstrated good AUROCs for both the developed (0.91) and validated models (0.98).13 Nevertheless, each of the above models was developed for specific application with medical critically ill, general surgical or particular orthopaedic patients, and the scoring systems tend to be overly complicated.

The Siriraj Integrated Perioperative Geriatric Excellent Research Center has studied the incidence, risk factors and predictive scores of POD in critically ill surgical patients. The independent risk factors for delirium identified by a multivariate analysis were age, diabetes mellitus, severity of disease (assessed by the sequential organ failure assessment (SOFA) score), perioperative use of benzodiazepine, mechanical ventilation and dementia defined by the Thai version of the Modified Informant Questionnaire on Cognitive Decline in the Elderly (modified IQCODE) scores >3.42. The following predictive model was created:

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Its AUROC was 0.84 (95% CI 0.786 to 0.897). A cut-off value of 125 demonstrated a sensitivity of 72.1% and a specificity of 80.9%.14 Thus, we were interested in validating the model. To this end, internal validation was performed at our hospital, while external validation was conducted at two other academic hospitals. There has been no previous investigation of a predictive model for POD in patients in surgical ICUs (SICUs). The aim of this study was to validate the use of the proposed POD predictive scoring tool in SICUs in order to identify patients who tend to develop delirium.

Methods

Study esign

This was a multicentre prospective, observational, cohort study.

Study population

The study was conducted on 380 SICU patients at three hospitals: Siriraj, Ramathibodi and Maharaj Nakorn Chiang Mai.

The study population comprised patients who were at least 18 years of age and were admitted to an SICU within 7 days of surgery at Siriraj, Ramathibodi or Maharaj Nakorn Chiang Mai Hospital (table 1). In addition, patients for the internal validation cohort were 65 years or older and had been admitted to a Siriraj Hospital SICU15 16 for a stay anticipated to exceed 24 hours. At all three hospitals, we excluded SICU patients who had (1) not undergone any operations; (2) communication problems (unable to communicate in Thai, or having a severe visual or auditory impairment interfering with communication); or (3) a Richmond Agitation Sedation Scale (RASS) score of −4 or −5 during the whole of their ICU stay. A flowchart illustrating the patient selection processes for the development and validation cohorts is presented in figure 1.

Table 1

Characteristics of participating hospitals

Figure 1

Flowchart of development and validation studies. ICU, intensive care unit; RASS, Richmond Agitation Sedation Scale.

Patient and public involvement

No patient involved.

Measurement instruments

Delirium was assessed using the Thai version of the CAM-ICU (online supplemental file S1). Delirium was identified by the following four features: (1) a change or fluctuation in baseline mental status; (2) inattention; and either (3) an altered level of consciousness; or (4) disorganised thinking.17 The Thai version has demonstrated satisfactory validity and reliability (specificity, 94.7%; sensitivity, 92.3%).8 As to the level of consciousness, it was assessed by the RASS. It uses a 10-point scale ranging from −5 to +4. The delirium subtypes were recorded as hypoactive (RASS −1 to −3), hyperactive (RASS +1 to +4) and mixed type (hypoactive and hyperactive).18 With regard to dementia, it was evaluated via the Thai version of modified IQCODE (online supplemental file S2). The questionnaire consists of 32 items, with assessments of patients being made by their caregivers. The optimal cut-off score for the modified IQCODE is 3.42 (sensitivity, 90%; specificity, 95% and accuracy, 92%).19 Finally, the severity of illness at SICU admission was evaluated using the Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system, and SOFA scores.

Patients provided informed consent in writing. Delirium was evaluated at least two times per day (once during the 12 hours from 06.00, and once during the 12 hours after 18.00), and whenever patients developed a mental change. Delirium was screened routinely using a two-step process. Initially, the patients’ level of consciousness was assessed using the RASS. If the score was between −3 and +4, the evaluators proceeded to step 2 (assessment of the patient with the Thai version of CAM-ICU). However, if step 1 produced a −4 RASS score (responsive only to physical stimulus) or a −5 RASS score (unresponsive to physical and verbal stimulus), step 2 was not performed. If a patient was found to be sedated in the first step, the dose of the sedative medication was adjusted. The patient was later assessed with the CAM-ICU once a RASS score of −3 or higher was achieved.

The second step involved the determination of the patient’s delirium level using the Thai version of CAM-ICU, employing standard methodology. The assessments commenced on the first day after the patient’s operation and continued for 7 days, or until either discharge from the ICU or the death of the patient. Patients with delirium were further assessed until the CAM-ICU was negative for 24 hours. Thereafter, the ICU attending physician was notified for further management.

Data collection

The predisposing and precipitating factors potentially linked to the onset of delirium were grouped as preoperative, intraoperative and postoperative variables. The preoperative risk factors were demographic variables obtained from a review of an individual patient’s medical records and interviews with any proxies. Each patient’s cognitive status was measured using the modified IQCODE.19

The intraoperative variables were obtained from anaesthetic records. They consisted of the surgical type (abdominal, vascular, orthopaedic, urological, gynaecological, and head and neck); admission type (emergency or elective); operation time; intraoperative blood loss; amount of blood transfused; and total fluid intake. Intraoperative hypotension was deemed to be either a systolic pressure below 90 mm Hg or the need to be treated with medications.20 21 Intraoperative hypoxaemia was defined as an oxygen saturation (derived from pulse oximetry) of below 90% for any duration.

The postoperative variables were primarily obtained from the SICU data records. They were the use of mechanical ventilation, physical restraints or a Foley’s catheter; the presence of sleep deprivation or shock; exposure to psychoactive drugs (benzodiazepines, opioids and sedatives); and the presence of coma (indicated by a RASS score of −4 or −5).

Preparation of research team

The clinical researchers administering the Thai CAM-ICU were physicians and nurses who had been trained by the principal investigator. To ensure reliability among the assessors, inter-rater reliability scores were calculated. Once their kappa score reached 0.8, the trained physicians and nurses were permitted to perform the Thai CAM-ICU assessments.

Internal and external validation

After development of a predictive model from a prospective cohort study that took place between February 2016 and February 2017, we did a second prospective cohort study in the same hospital for internal validation of the model between April 2018 and December 2019. In the meantime, we externally validated the predictive model with data from intensive care surgical patients admitted to two other university hospitals in Thailand. They were Ramathibodi Hospital, Mahidol University, and Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University. Trained intensive care nurses at those hospitals used the CAM-ICU at least two times per day. The validation process was conducted according to the Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis Statement,22 a guideline specifically designed for the reporting of studies developing or validating a multivariable prediction model, whether for diagnostic or prognostic purposes.

Statistical analysis

The sample size was estimated based on the reported 78% accuracy of development predictive score.14 Based on the estimated accuracy of 80% (p=0.80) and a 4% error (d=0.04), an 5% alpha (α=0.05), the sample size of 380 cases was calculated. The sample size calculation was estimated using PASS V.14 (NCSS, Kaysville, Utah, USA).

Demographic variables are presented as mean±SD or median (IQR) for continuous data, and frequency and percentage for categorical data.

In both validation studies, we multiplied regression coefficients for each risk factor in the predictive model by the observed patients’ values. The outcome was a calculated predicted probability, on which we built a new AUROC. Finally, an ROC curve was plotted to determine the best cut-off in terms of Youden’s index, sensitivity, specificity and 95% CI. The Youden’s index was the difference between the true and the false positive rates. Maximising this index allows an optimal cut-off value to be found from the ROC curve, independently from the prevalence.23 24 Finally, to examine how well the model was calibrated, we calculated linear predictor values for each patient of every cohort by using the coefficients from the model. We used these linear predictors in a logistic regression model to test whether the prediction rule was well calibrated, resulting in a calibration slope and an intercept. A calibration slope of 1 and an intercept of 0 show a perfect calibration.25 26 Statistics were analysed using PASW Statistics for Windows (V.18; SPSS); and MedCalc statistical software (V.17.6; MedCalc Software BVBA, Ostend, Belgium).

Results

Patients

The patients were enrolled between February 2016 and February 201714 for the development cohort, and between April 2018 and December 2019 for the internal and external validation studies. In all, 1437 SICU patients were excluded for the reasons given in figure 1 and 380 were recruited. The mean age of the patients in the internal validation cohort was 75.1±7.5 years, while the mean for the patients in the external validation cohort was 56.9±17.3 years. The mean age of all of the patients in the two validation cohorts was 64.1±16.8 years. More than half of the patients in the validation cohort were males. Details relating to the demographic and intraoperative data, ICU admission and the medications used are given in table 2. There was a higher proportion of patients with hypertension, diabetes mellitus (DM) and cardiac disease in the internal validation cohort than the external validation cohort. The incidence of delirium was 40.0%, 21.3% and 28.7% in the internal, external, and all validation cohorts, respectively, compared with 24.4% in the development cohort. The majority of patients in all cohorts underwent intra-abdominal surgery. The median SOFA score was 4 (IQR 1–6) for all validation cohorts, which was higher than the median of 3 (IQR 2–6) for the development cohort. The percentage of benzodiazepine use in all external validation cohort was less than half of the development cohort (10% vs 25.2%; table 2).

Table 2

Characteristics of patients in development and validation groups

Development study

Of the 412 recruited patients, a total of 162 were excluded for the reasons detailed in figure 1. As a result, 250 patients were enrolled, 61 of whom (24.4%) developed delirium (table 2). The predictive model was derived from a multiple logistic regression that used significant risk factors. The final formula required six factors (two quantitative factors, and four binary factors). The formula of the model was:

Embedded Image

The AUROC was 0.84 (95% CI 0.786 to 0.897). The cut-off value of ≥125 demonstrated a sensitivity of 72.1% and a specificity of 80.9%.14

Validation study

Internal validation of predictive model

For the prospective validation study, we recruited 984 consecutive patients who were aged over 65 years; however, 834 were subsequently excluded (figure 1). Of the remaining 150 patients, 60 (40%) developed delirium (table 2). The internal validation resulted in an AUROC of 0.76 (0.683 to 0.837; figure 2A), and this AUROC was not significantly different from the AUROC of the developed predictive model (p=0.092), with a calibration slope of 0.972 and an intercept of 0.009 (figure 2B).

Figure 2

Receiver operating characteristic (ROC) curves and calculated areas under the curve (AUC), and Calibration plot of pooled data. (A and B) Internal validation study of the delirium predictive score. (C and D) External validation study of the delirium predictive score. (E and F) All validation study of the delirium predictive score.

External validation of predictive model

We performed the external validation study on critically ill surgical patients admitted to SICUs at Ramathibodi and Maharaj Nakorn Chiang Mai Hospitals. Of the 833 recruited patients, 603 were excluded (figure 1). As a result, 230 patients were enrolled: 62 (27%) at Ramathibodi Hospital, and 168 (73%) at Maharaj Nakorn Chiang Mai Hospital. The incidence of delirium in the external validation cohort was 21% (table 2). The external validation resulted in an AUROC of 0.85 (0.789 to 0.906; figure 2C), and it was not significantly different from the AUROC of the developed predictive model (p=0.865), with a calibration slope of 0.929 and an intercept of 0.006 (figure 2D).

Optimal cut-off value of predictive model

The AUROCs of the development, internal and external validation cohorts were comparable (0.84 for the development cohort, 0.76 for the internal validation cohort and 0.85 for the external validation cohort). As no significant differences in prediction existed between the three validation studies, we pooled the data of all validation cohorts (n=380). That revealed that 109 patients (29%) developed delirium (table 2). Consequently, the AUROC of all of the validation cohorts was 0.83 (0.785 to 0.872; figure 2E). The recalibration of all validation study showed a calibration slope of 0.945 and an intercept of 0.007 (figure 2F). The optimum cut-off value to discriminate between a high and low probability of POD in SICU patients was 115. This cut-off presented the highest value of Youden’s index (0.50), the best AUROC, and the optimum values for sensitivity (78.9%) and specificity (70.9%; table 3). The last two values were similar to the sensitivity (78.8%) and specificity (70.4%) of the development cohort.

Table 3

Cut-offvalues of the delirium prediction score

Discussion

Given the high costs of managing delirium and its consequential complications, it is essential to identify individuals at high risk of developing the condition and to deliver evidenced-based preventive measures. This multicentre study demonstrated the performance of the internal and external validation of a proposed model14 that had been developed to predict POD in patients admitted postoperatively to an SICU. It is essential to confirm the predictive performance of the model before its use outside the development setting. The external validation showed moderate to good statistical performance, with the AUROC of the external cohort being comparable to that of the development cohort. In addition, the new cut-off value also demonstrated optimum sensitivity and specificity values that were equivalent to those achieved for the development cohort. However, the performance of the internal validation cohort was not as high as the development and external validation cohort (AUROC, 0.76). This was because the internal validation cohort only included patients aged 65 years or older, resulting in a higher incidence of delirium.

Recently, two ICU delirium predictive models-the early predictive model for ICU delirium (E-PRE-DELIRIC), and the recalibrated predictive model for ICU delirium (PRE-DELIRIC) have been developed and validated.11 27 28 These two models are currently used in clinical practice and in research to predict the development of delirium in ICUs. The PRE-DELIRIC model consists of 10 predictors that are available during the first 24 hours after admission to an ICU.27 The E-PRE-DELIRIC is composed of nine parameters available at the time of ICU admission. Wassenaar et al29 recently conducted an external validation of both assessment tools, using either the CAM-ICU or the Intensive Care Delirium Screening Checklist for delirium assessment. The researchers reported moderate-to-good statistical performances. Nevertheless, the formulas for those two models were quite complicated, using several parameters, and they were developed in a mixed-ICU setting (medical and surgical populations). Given that cognitive impairment (including dementia) and severity of illness have been recognised as strong predictors for delirium in hospitalised patients,30 31 the E-PRE-DELIRIC system included only a history of cognitive impairment but no severity scores. In contrast, the PRE-DELIRIC model included only APACHE II scores, but no information on cognitive impairment.

The currently proposed predictive model for POD in critically ill surgical patients has several strengths. First, it was developed specifically for surgical patients, and it demonstrated high accuracy. In addition, it employs only five parameters, which makes it relatively easy to calculate. Furthermore, dementia is assessed by both the patient’s history and the modified IQCODE assessment tool. A previous study found that the prevalence of dementia among elderly delirious patients was five times higher when evaluated by the modified IQCODE tool than when using information obtained solely from history taking.32 Consequently, the proposed predictive model was validated in the same hospital and in two other academic hospitals. Although we recruited only elderly patients for the internal validation cohort, the AUROC showed an acceptable value. For the external validation cohort in the SICUs of the two other hospitals, we performed quality control by determining the inter-rater reliability of CAM-ICU assessment before commencing the study. There were differences in the patient case-mix of the external and development validation samples. In particular, relative to the development group, the external validation cohort had a lower age, a lower percentage of patients with mechanical ventilation, a higher percentage of dementia, and a lower percentage of benzodiazepine use. Despite that, the models’ discriminative performance showed the same value (AUROC 0.84 for the development cohort, and 0.85 for the external validation cohort). In short, for the all-validation cohort, the AUROC was approximately the same as that for the development and the external validation cohorts. A score of ≥115 was the best cut-off value to predict the occurrence of delirium in SICUs. This cut-off presented the highest value for Youden’s index (0.50), the best AUROC, and the optimum values for sensitivity (78.9%) and specificity (70.9%). Additionally, the predictive value depends on a disease’s prevalence in the population group that is being diagnosed.33 A good model must have sufficient prevalence, high sensitivity and high specificity, and it should allow diagnosis before a patient displays symptoms.33 34

Strengths and limitations

The significant strength of our study is that it was the first multicentre study in Thailand to evaluate the performance of a proposed predictive model for delirium in SICUs. The early prediction of the development of delirium in ICU patients facilitates the implementation of prevention protocols. These interventions can be non-pharmacological (such as cognitive stimulation, early mobilisation, and enhanced sleep)35 36 or pharmacological (like the prophylactic administration of dexmedetomidine37 to high-risk patients).

Several limitations need to be addressed. First, only the CAM-ICU was used to assess delirium. In the current work, the researchers (physicians and nurses) who evaluated delirium using this tool were well-trained, and their ratings are therefore regarded as accurate. However, other research showed that the accuracies of delirium assessments performed by bedside nurses in daily practice demonstrated lower sensitivity and specificity than our clinical researchers achieved.38 The skill level of staff undertaking assessments in a clinical setting may therefore influence the results of the predictive model. In addition, the internal validation cohort only included critically ill elderly patients. The optimum cut-off value that resulted in the best sensitivity and specificity might be different from the all-validation and development cohorts. Moreover, differences in risk factors might affect the predictive model. We did not perform a logistic regression for the validation cohort in order to identify independent risk factors for delirium. This is because the prognostic ability demonstrated by the AUROC of the internal and external validation groups showed moderate-to-good performance. Finally, the predictive model only used parameters available at the time of SICU admission. Any changes in patients’ conditions during their stay can affect the probability of their developing delirium. Our model did not account for such changes.

Conclusions

The model reported in this study can predict which critically ill surgical patients will develop POD in SICUs. Consequently, high-risk patients can be identified, and both non-pharmacological and pharmacological prevention protocols can be implemented to improve the clinical outcomes. The use of this selective strategy is appropriate in a resource-limited country, in which the administration of a prevention protocol for all critically ill patients is not viable.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statements

Patient consent for publication

Ethics approval

This study was conducted according to the ethical standards established by the 1964 Declaration of Helsinki. The study was approved by the Siriraj Institutional Review Board of the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand (Si 623/2017, Chairperson Professor Chairat Shayakul, MD) on 20 October 2017; the Committee on Human Rights Related to Research Involving Human Subjects, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (MURA 2017/574, Chairperson Assistant Professor Chusak Okascharoen, MD) on 27 November 2017; and Research Ethics Committee 4 at the Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand (SUR-2560-05016, Chairperson Emeritus Professor Panja Kulapongs, MD) on 28 November 2017. Written informed consent was obtained from the participants before their entry into the study. Participants gave informed consent to participate in the study before taking part.

Acknowledgments

The authors gratefully acknowledge the patients who generously agreed to participate in this study, and Assist. Prof. Dr. Chulaluk Komoltri, M.P.H. Biostatistics, for the statistical analyses.

References

Supplementary materials

  • Supplementary Data

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Footnotes

  • Contributors OC and AS contributed to the design of the study. OC, KC and SMorakul were involved in data management and oversaw the project. KC, SMueankwan, SMorakul, PD, contributed to data collection. CT contributed to data analysis. OC and CT contributed to the interpretation of the results and drafting the manuscript. All authors read and approved the final manuscript.

  • Funding This study was supported by the Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand (IO: R016132015).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.