Center for Health Quality, Outcomes and Economic Research, Bedford VAMC, Bedford, MA, Boston, MA, USA.
J Am Coll Surg. 2011 Jun;212(6):968-976.e1-2. doi: 10.1016/j.jamcollsurg.2011.01.001. Epub 2011 Apr 13.
The Agency for Healthcare Research and Quality Patient Safety Indicator postoperative physiologic and metabolic derangement (PMD) uses ICD-9-CM codes to screen for potentially preventable acute kidney injury (AKI) requiring dialysis plus diabetes-related complications after elective surgery. Data on PMD's accuracy in identifying true events are limited. We examined the indicator's positive predictive value (PPV) in the Veterans Health Administration (VA).
Trained abstractors reviewed medical records of 119 PSI software-flagged PMD cases. We calculated PPVs overall and separately for renal- and diabetes-related complications. We also examined false positives to determine reasons for incorrect identification, and true positives to determine PMD-related outcomes and risk factors.
Overall 75 cases were true positives (PPV 63%, 95% CI 54% to 72%); 73 of 104 AKI cases were true positives (PPV 70%, 60% to 79%); only 2 of 15 diabetes cases were true positives (PPV 13%, 2% to 40%). Of all false positives, 70% represented nonelective admissions and 23% had the complication present on admission. Of AKI true positives, 37% died and 26% were discharged on dialysis; 55% had chronic kidney disease (≥ stage 3) present on admission. Cardiac surgery represented the largest category of AKI-associated index procedures (30%). AKI was most commonly attributed to perioperative renal hypoperfusion (84% of true positives), followed by nephrotoxins (33%) including contrast (11%).
Due to its low PPV, we recommend removing diabetes complications from the indicator and focusing on AKI. PMD's PPV could be significantly improved by using present-on-admission codes, and specific to the VA, by introduction of admission status codes. Many PMD-identified cases appeared to be at high risk based on patient- and procedure-related factors. The degree to which such cases are truly preventable events requires further assessment.
医疗保健研究与质量机构的术后生理和代谢紊乱（PMD）患者安全指标使用 ICD-9-CM 代码筛选接受择期手术后需要透析的潜在可预防急性肾损伤（AKI）和与糖尿病相关的并发症。有关 PMD 识别真实事件准确性的数据有限。我们在退伍军人健康管理局（VA）中检查了该指标的阳性预测值（PPV）。
经过培训的摘要作者审查了 119 例 PSI 软件标记的 PMD 病例的医疗记录。我们总体计算了 PPV，分别计算了肾脏和糖尿病相关并发症的 PPV。我们还检查了假阳性病例，以确定错误识别的原因，并检查了真正的阳性病例，以确定 PMD 相关的结果和危险因素。
总体而言，有 75 例为真阳性（PPV63%，95%CI54%至 72%）；104 例 AKI 病例中有 73 例为真阳性（PPV70%，60%至 79%）；仅 15 例糖尿病病例中有 2 例为真阳性（PPV13%，2%至 40%）。所有假阳性病例中，70%为非择期入院，23%在入院时就存在并发症。在 AKI 的真阳性病例中，37%死亡，26%出院时需要透析；55%在入院时就存在慢性肾脏病（≥3 期）。心脏手术是 AKI 相关指标手术中最大的类别（30%）。AKI 最常见的原因是围手术期肾脏低灌注（84%的真阳性），其次是肾毒性药物（33%），包括造影剂（11%）。
由于其低 PPV，我们建议从指标中删除糖尿病并发症，并专注于 AKI。通过使用入院时的代码，PMD 的 PPV 可以显著提高，而在 VA 中，通过引入入院状态代码，可以进一步提高。根据患者和手术相关因素，PMD 识别的许多病例似乎风险很高。这些病例在多大程度上确实是可预防的事件需要进一步评估。
