Teno J M, Harrell F E, Knaus W, Phillips R S, Wu A W, Connors A, Wenger N S, Wagner D, Galanos A, Desbiens N A, Lynn J
Center for Gerontology and Health Care Research, Brown University, Providence, Rhode Island 02912, USA.
J Am Geriatr Soc. 2000 May;48(S1):S16-24. doi: 10.1111/j.1532-5415.2000.tb03126.x.
To develop and validate a model estimating the survival time of hospitalized persons aged 80 years and older.
A prospective cohort study with mortality follow-up using the National Death Index.
Four teaching hospitals in the US.
Hospitalized patients enrolled between January 1993 and November 1994 in the Hospitalized Elderly Longitudinal Project (HELP). Patients were excluded if their length of hospital stay was 48 hours or less or if admitted electively for planned surgery.
A log-normal model of survival time up to 711 days was developed with the following variables: patient demographics, disease category, nursing home residence, severity of physiologic imbalance, chart documentation of weight loss, current quality of life, exercise capacity, and functional status. We assessed whether model accuracy could be improved by including symptoms of depression or history of recent fall, serum albumin, physician's subjective estimate of prognosis, and physician and patient preferences for general approach to care.
A total of 1266 patients were enrolled over a 10-month period, (median age 84.9, 61% female, 68% with one or more dependency), and 505 (40%) died during an average follow-up of more than 2 years. Important prognostic factors included the Acute Physiology Score of APACHE III collected on the third hospital day, modified Glasgow coma score, major diagnosis (ICU categories together, congestive heart failure, cancer, orthopedic, and all other), age, activities of daily living, exercise capacity, chart documentation of weight loss, and global quality of life. The Somers' Dxy for a model including these factors was 0.48 (equivalent to a receiver-operator curve (ROC) area of 0.74, suggesting good discrimination). Bootstrap estimation indicated good model validation (corrected Dxy of 0.46, ROC of 0.73). A nomogram based on this log-normal model is presented to facilitate calculation of median survival time and 10th and 90th percentile of survival time. A count of geriatric syndromes or comorbidities did not add explanatory power to the model, nor did the hospital of patient recruitment, depression, or the patient preferences for general approach to care. The physician's perception of the patient's preferences and the physician's subjective estimate of the patient's prognosis improved the estimate of survival time significantly.
Accurate estimation of length of life for older hospitalized persons may be calculated using a limited amount of clinical information available from the medical chart plus a brief interview with the patient or surrogate. The accuracy of this model can be improved by including measures of the physician's perception of the patient's preferences for care and the physician's subjective estimate of prognosis.
开发并验证一个用于估计80岁及以上住院患者生存时间的模型。
一项前瞻性队列研究，通过国家死亡指数进行死亡率随访。
美国的四家教学医院。
1993年1月至1994年11月期间纳入老年住院患者纵向研究项目（HELP）的住院患者。如果患者住院时间为48小时或更短，或者因计划手术而择期入院，则被排除。
建立了一个生存时间长达711天的对数正态模型，纳入以下变量：患者人口统计学特征、疾病类别、养老院居住情况、生理失衡严重程度、体重减轻的病历记录、当前生活质量、运动能力和功能状态。我们评估了纳入抑郁症状或近期跌倒史、血清白蛋白、医生对预后的主观估计以及医生和患者对一般护理方法的偏好是否可以提高模型准确性。
在10个月期间共纳入1266例患者（中位年龄84.9岁，61%为女性，68%有一项或多项依赖），在平均超过2年的随访期间，505例（40%）死亡。重要的预后因素包括入院第三天收集的急性生理学与慢性健康状况评分系统（APACHE III）的急性生理学评分、改良格拉斯哥昏迷评分、主要诊断（重症监护病房类别合并、充血性心力衰竭、癌症、骨科及所有其他）、年龄、日常生活活动能力、运动能力、体重减轻的病历记录以及整体生活质量。包含这些因素的模型的Somers' Dxy为0.48（相当于受试者工作特征曲线（ROC）面积为0.74，表明有良好的区分度）。自助法估计表明模型验证良好（校正后的Dxy为0.46，ROC为0.73）。基于此对数正态模型给出了一个列线图，以方便计算中位生存时间以及生存时间的第10和第90百分位数。老年综合征或合并症的计数并未增加模型的解释力，患者招募医院、抑郁或患者对一般护理方法的偏好也未增加模型的解释力。医生对患者偏好的感知以及医生对患者预后的主观估计显著改善了生存时间的估计。
使用病历中有限的临床信息加上对患者或代理人的简短访谈，可以准确估计老年住院患者的寿命长度。通过纳入医生对患者护理偏好的感知以及医生对预后的主观估计等指标，可以提高该模型的准确性。
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