Relationship between functional status prior to onset of critical illness and mortality: a prospective multicentre cohort study.

This prospective study aimed to assess the association between prior functional status and hospital mortality for patients admitted to four intensive care units in Spain between 2006 and 2012. Prior functional status was classified into three groups, using a modification of the Glasgow Outcome Scale (GOS), including group 1 with no limitations on activities of daily living; group 2 with some limitations but self-sufficient; and group 3 who were dependent on others for their activities of daily living. Of the 1,757 patients considered (mean Simplified Acute Physiology Score [SAPS] predicted mortality 14.8% and hospital mortality 13.7%), group 1 had the lowest observed hospital mortality (8.3%) compared to the SAPS 3 predicted mortality (11.6%). The observed mortality for group 2 (20.6%) and group 3 (27.4%) were both higher than predicted (19.2% and 21.2% respectively; odds ratio [OR] 1.97, 95% confidence interval [CI] 1.38-2.82 for group 2 and OR 2.90, 95% CI 1.78-4.72 for group 3 compared to group 1). Combining prior functional status and Sequential Organ Failure Assessment (SOFA) score with SAPS 3 further improved the ability of the SAPS 3 scores in predicting hospital mortality (area under the receiver operating characteristic curve 0.85 [95% CI 0.82-0.88] versus 0.84 [95% CI 0.81-0.87] respectively). In summary, patients with limited functional status prior to ICU admission had a higher risk of observed hospital mortality than predicted. Assessing prior functional status using a relatively simple questionnaire, such as a modified GOS, has the potential to improve the accuracy of existing prognostic models.

External validation of the Simplified Acute Physiology Score (SAPS) 3 in Spain

OBJECTIVE: To evaluate SAPS 3 performance in Spain, assessing discrimination and calibration in a multicenter study. DESIGN: A prospective, multicenter study was carried out. Patients and setting: A prospective cohort study was performed in Spanish hospitals between 2006 and 2011. Measurements and results: A total of 2171 patients were included in the study. The mean age was 61.4 ± 16.09 years, the ICU mortality was 11.6%, and hospital mortality 16.03%. The SAPS 3 score was 46.29 ± 14.34 points, with a probability of death for our geographical area of 18.57%, and 17.97% for the general equation. The differences between observed-to-predicted mortality were analyzed with the Hosmer-Lemeshow test, which yielded H = 31.71 (p < 0.05) for our geographical area and H = 20.05 (p < 0.05) for the general equation. SAPS 3 discrimination with regard to hospital mortality, tested using the area under the ROC curve, was 0.845 (0.821-0.869). CONCLUSION: Our study shows good discrimination of the SAPS 3 system in Spain, but also inadequate calibration, with differences between predicted and observed mortality. There are more similarities with regard to the general equation than with respect to our geographical area equation, and in both cases the SAPS 3 system overestimates mortality. According to our results, Spanish ICU mortality is lower than in other hospitals included in the multicenter study that developed the SAPS 3 system, in patients with similar characteristics and severity of illness

OBJETIVO: Analizar el funcionamiento del sistema SAPS3 en España, evaluando la discriminación y calibración en un estudio multicéntrico. DISEÑO: Estudio prospectivo de cohortes, multicéntrico. Ámbito: Hospitales españoles entre 2006 y 2011. Variables de interés y resultados: Se incluyó en el estudio a un total de 2171 pacientes. La edad media fue 61,4 ± 16,09 años, la mortalidad en UCI fue del 11,6% y la mortalidad hospitalaria 16,03%. El score SAPS 3 fue de 46,29 ± 14,34 puntos, con la probabilidad de morir por la ecuación de nuestra área geográfica 18.57%, y 17.97% para la ecuación general. Las diferencias entre la mortalidad observada y la predicha se analizaron mediante el test de Hosmer-Lemeshow. Este test mostró H = 31,71 (p < 0,05) para nuestra área geográfica y H = 20,05 (p < 0,05) para la ecuación general. La discriminación del SAPS 3 con respecto a la mortalidad hospitalaria, testada mediante el área bajo la curva ROC, fue 0.845 (0,821-0,869). CONCLUSIÓN: Nuestro estudio muestra, en España, una buena discriminación del sistema pronóstico SAPS 3 pero una inadecuada calibración, con diferencias entre la mortalidad predicha y, la observada. Hay más similitudes con respecto a la ecuación general que con la ecuación de nuestra zona geográfica, y en ambos casos, el sistema SAPS 3 sobreestima la mortalidad. De acuerdo con los resultados, la mortalidad en UCI es menor que la de otros hospitales incluidos en el estudio multicéntrico que se utilizaron para desarrollar el sistema SAPS 3, en pacientes con similares características y severidad de la enfermedad

External validation of the Simplified Acute Physiology Score (SAPS) 3 in Spain.

OBJECTIVE: To evaluate SAPS 3 performance in Spain, assessing discrimination and calibration in a multicenter study. DESIGN: A prospective, multicenter study was carried out. PATIENTS AND SETTING: A prospective cohort study was performed in Spanish hospitals between 2006 and 2011. MEASUREMENTS AND RESULTS: A total of 2171 patients were included in the study. The mean age was 61.4±16.09 years, the ICU mortality was 11.6%, and hospital mortality 16.03%. The SAPS 3 score was 46.29±14.34 points, with a probability of death for our geographical area of 18.57%, and 17.97% for the general equation. The differences between observed-to-predicted mortality were analyzed with the Hosmer-Lemeshow test, which yielded H=31.71 (p<0.05) for our geographical area and H=20.05 (p<0.05) for the general equation. SAPS 3 discrimination with regard to hospital mortality, tested using the area under the ROC curve, was 0.845 (0.821-0.869). CONCLUSION: Our study shows good discrimination of the SAPS 3 system in Spain, but also inadequate calibration, with differences between predicted and observed mortality. There are more similarities with regard to the general equation than with respect to our geographical area equation, and in both cases the SAPS 3 system overestimates mortality. According to our results, Spanish ICU mortality is lower than in other hospitals included in the multicenter study that developed the SAPS 3 system, in patients with similar characteristics and severity of illness.

Relationship between mortality and first-day events index from routinely gathered physiological variables in ICU patients

Objective: To test the hypothesis that the degree and duration of alterations in physiological variables routinely gathered by intensive care unit (ICU) monitoring systems during the first day of admission to the ICU, together with a few additional routinely recorded data, yield information similar to that obtained by traditional mortality prediction systems. Design: A prospective observational multicenter study (EURICUS II) was carried out. Setting: Fifty-five European ICUs. Patients: A total of 17,598 consecutive patients admitted to the ICU over a 10-month period. Interventions: None. Main variables of interest: Hourly data were manually gathered on alterations or "events" in systolic blood pressure, heart rate and oxygen saturation throughout ICU stay to construct an events index and mortality prediction models. Results: The mean first-day events index was 6.37±10.47 points, and was significantly associated to mortality (p: <0.001), with a discrimination capacity for hospital mortality of 0.666 (area under the ROC curve). A second index included this first-day events index, age, pre-admission location, and the Glasgow coma score. A model constructed with this second index plus diagnosis upon admission was validated by using the Jackknife method (Hosmer-Lemeshow,H: =13.8554, insignificant); the area under ROC curve was 0.818. Conclusions: A prognostic index with performance very similar to that of habitual systems can be constructed from routine ICU data with only a few patient characteristics. These results may serve as a guide for the possible automated construction of ICU prognostic indexes (AU)

Objetivo: Comprobar si el grado y duración de las alteraciones en las variables fisiológicas recogidas en la monitorización rutinaria en UCI durante el primer día de estancia, junto con pocos datos adicionales, proporcionan información similar a la obtenida con los sistemas tradicionales de predicción de mortalidad. Diseño: Estudio observacional, prospectivo y multicéntrico (EURICUS-II). Ámbito: 55 UCIs de Europa. Pacientes: 17.598 pacientes consecutivos, ingresados durante 10 meses. Intervenciones: ninguna. Variables de interés principales: se recogieron manualmente datos horarios sobre alteraciones o "eventos" en la presión arterial sistólica, frecuencia cardiaca y saturación de oxígeno, para construir un índice basado en estos eventos y un modelo de predicción de mortalidad. Resultados: El índice de eventos el primer día fue 6,37±10,47 puntos y se asoció significativamente con la mortalidad (p<0,001), con una capacidad de discriminación (área bajo la curva ROC) para la mortalidad de 0.666. Se construyó un segundo índice que incluye este índice de eventos en el primer día, la edad, procedencia del ingreso y puntuación de la Escala de Coma de Glasgow. Un modelo construido con este segundo índice más el diagnóstico fue validado mediante el método jackknife (Hosmer-Lemeshow, H=13.8554, no significativo), con un área bajo la curva ROC de 0,818. Conclusiones: Se puede construir un índice pronóstico con rendimiento similar al de los sistemas habituales a partir de los datos de monitorización de los pacientes en la UCI junto a escasas características del paciente. Nuestros resultados pueden servir de guía para la posible construcción automatizada de índices pronósticos (AU)

Relationship between mortality and first-day events index from routinely gathered physiological variables in ICU patients.

OBJECTIVE: To test the hypothesis that the degree and duration of alterations in physiological variables routinely gathered by intensive care unit (ICU) monitoring systems during the first day of admission to the ICU, together with a few additional routinely recorded data, yield information similar to that obtained by traditional mortality prediction systems. DESIGN: A prospective observational multicenter study (EURICUS II) was carried out. SETTING: Fifty-five European ICUs. PATIENTS: A total of 17,598 consecutive patients admitted to the ICU over a 10-month period. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Hourly data were manually gathered on alterations or "events" in systolic blood pressure, heart rate and oxygen saturation throughout ICU stay to construct an events index and mortality prediction models. RESULTS: The mean first-day events index was 6.37±10.47 points, and was significantly associated to mortality (p<0.001), with a discrimination capacity for hospital mortality of 0.666 (area under the ROC curve). A second index included this first-day events index, age, pre-admission location, and the Glasgow coma score. A model constructed with this second index plus diagnosis upon admission was validated by using the Jackknife method (Hosmer-Lemeshow, H=13.8554, insignificant); the area under ROC curve was 0.818. CONCLUSIONS: A prognostic index with performance very similar to that of habitual systems can be constructed from routine ICU data with only a few patient characteristics. These results may serve as a guide for the possible automated construction of ICU prognostic indexes.

Tiss 76 and Tiss 28: correlation of two therapeutic activity indices on a Spanish multicenter ICU database.

OBJECTIVES: To evaluate the performance of the Simplified Therapeutic Intervention Scoring System (TISS 28) on an independent database and to determine its relation to the original Therapeutic Intervention Scoring System (TISS 76). DESIGN: Analysis of the database of the Spanish prospective multicenter study PAEEC (Project for the Epidemiological Analysis of Critical Care Patients). SETTING: 86 intensive care units (ICUs) in Spain. PATIENTS: Data on 8838 patients admitted to the ICUs. MEASUREMENTS AND RESULTS: Administrative data, main diagnostic category, severity score [Acute Physiology and Chronic Health Evaluation (APACHE) II and III] and data for the calculation of the TISS 76 and TISS 28 were collected during the first 24 h after the patient's ICU admission. TISS 76 and TISS 28 scores were calculated and analyzed on how they varied according to other variables (diagnostic group, severity level, hospital size and age). The association between TISS 76 and TISS 28 was studied. The TISS 76 score was 21 +/- 10.5 points and the TISS 28 score 23.3 +/- 8.8 points. There was a good correlation between TISS 76 and TISS 28 (r = 0.85). The regression equation was: TISS 28 = 8.35 + (0.712 x TISS 76). The TISS 28 score behaved similarly to the TISS 76 score in relation to the other variables, with a positive correlation between the therapeutic and the severity level (APACHE II and III) and a negative correlation between therapeutic activity and age, with very similar correlation coefficients. Both TISS 28 and TISS 76 scores were higher in larger hospitals. CONCLUSIONS: There is a strong correlation between TISS 28 and TISS 76 scores in the PAEEC database and TISS 28 works correctly in our setting.

Limitation of therapeutic activity in elderly critically ill patients. Project for the Epidemiological Analysis of Critical Care Patients.

OBJECTIVE: To establish whether the age of patients admitted into the intensive care unit (ICU) influences the amount of therapy received. DESIGN: Observational, prospective, multicenter study. SETTING: Eighty-six multidisciplinary ICUs in Spain, including coronary patients. PATIENTS: The patients (n = 8,838) were studied during a 6-month period between 1992 and 1993. Patients < 16 yrs of age and patients dying within the first 6 hrs were excluded from the study. MEASUREMENTS AND MAIN RESULTS: We collected data on age, gender, type of diagnosis at the time of admission, severity level by Acute Physiology and Chronic Health Evaluation (APACHE) II and III, quality of life survey score, therapeutic activity during the first 24 hrs by Therapeutic Intervention Scoring System, and ICU and hospital mortality rates. In the sample of patients, 12.5% were > 75 yrs of age. Compared with younger patients, these patients had higher APACHE II (18.41 +/- 0.23 vs. 15.14 +/- 0.09 points, p < .001) and APACHE III (65.8 +/- 0.81 vs. 53.32 +/- 0.33 points, p < .001) scores, a higher quality of life survey score (i.e., worse quality of life, 7.19 +/- 0.19 vs. 3.86 +/- 0.05 points, p < .001), and a greater ICU mortality rate (21.9% vs. 15.3%, p < .00001) and hospital mortality rate (30.8% vs. 19.3%, p < .00001). However, patients > 75 yrs had a lower Therapeutic Intervention Scoring System score (19.83 +/- 0.28 vs. 21.17 +/- 0.12 points, p < .001). Multivariate analysis showed that once severity, need for mechanical ventilation, diagnostic group, and mortality rate were taken into account, there was less therapeutic activity in patients > 75 yrs of age. CONCLUSIONS: Patients > 75 yrs of age represent a large proportion of patients in Spanish ICUs. Although their mortality rate and severity scores were higher than those values in younger patients, patients > 75 yrs of age received less therapy.