肺栓塞后早期死亡率预后规则的外部验证：基于索赔和三种基于临床方法的评估
External validation of prognostic rules for early post-pulmonary embolism mortality: assessment of a claims-based and three clinical-based approaches.
作者信息
Weeda Erin R, Kohn Christine G, Fermann Gregory J, Peacock W Frank, Tanner Christopher, McGrath Daniel, Crivera Concetta, Schein Jeff R, Coleman Craig I
机构信息
School of Pharmacy, University of Connecticut, 69 North Eagleville Road, Storrs, CT 06269 USA ; University of Connecticut/Hartford Hospital Evidence-Based Practice Center, Hartford, CT USA.
University of Saint Joseph School of Pharmacy, Hartford, CT USA ; University of Connecticut/Hartford Hospital Evidence-Based Practice Center, Hartford, CT USA.
出版信息
Thromb J. 2016 Mar 14;14:7. doi: 10.1186/s12959-016-0081-5. eCollection 2016.
BACKGROUND
Studies show the In-hospital Mortality for Pulmonary embolism using Claims daTa (IMPACT) rule can accurately identify pulmonary embolism (PE) patients at low-risk of early mortality in a retrospective setting using only claims for the index admission. We sought to externally validate IMPACT, Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI) and Hestia for predicting early mortality.
METHODS
We identified consecutive adults admitted for objectively-confirmed PE between 10/21/2010 and 5/12/2015. Patients undergoing thrombolysis/embolectomy within 48 h were excluded. All-cause in-hospital and 30 day mortality (using available Social Security Death Index data through January 2014) were assessed and prognostic accuracies of IMPACT, PESI, sPESI and Hestia were determined.
RESULTS
Twenty-one (2.6 %) of the 807 PE patients died before discharge. All rules classified 26.1-38.3 % of patients as low-risk for early mortality. Fatality among low-risk patients was 0 % (sPESI and Hestia), 0.4 % (IMPACT) and 0.6 % (PESI). IMPACT's sensitivity was 95.2 % (95 % confidence interval [CI] = 74.1-99.8 %), and the sensitivities of clinical rules ranged from 91 (PESI)-100 % (sPESI and Hestia). Specificities of all rules ranged between 26.8 and 39.1 %. Of 573 consecutive patients in the 30 day mortality analysis, 33 (5.8 %) died. All rules classified 27.9-38.0 % of patients as low-risk, and fatality occurred in 0 (Hestia)-1.4 % (PESI) of low-risk patients. IMPACT's sensitivity was 97.0 % (95%CI = 82.5-99.8 %), while sensitivities for clinical rules ranged from 91 (PESI)-100 % (Hestia). Specificities of rules ranged between 29.6 and 39.8 %.
CONCLUSION
In this analysis, IMPACT identified low-risk PE patients with similar accuracy as clinical rules. While not intended for prospective clinical decision-making, IMPACT appears useful for identification of low-risk PE patient in retrospective claims-based studies.
背景
研究表明，使用理赔数据的院内肺栓塞死亡率（IMPACT）规则可以在回顾性研究中，仅通过首次住院理赔数据准确识别早期死亡低风险的肺栓塞（PE）患者。我们试图对IMPACT、肺栓塞严重程度指数（PESI）、简化PESI（sPESI）和赫斯提亚（Hestia）规则预测早期死亡的能力进行外部验证。
方法
我们确定了2010年10月21日至2015年5月12日期间因客观确诊的PE而连续入院的成年人。排除在48小时内接受溶栓/栓子切除术的患者。评估全因院内死亡率和30天死亡率（使用截至2014年1月的可用社会保障死亡指数数据），并确定IMPACT、PESI、sPESI和Hestia规则的预后准确性。
结果
807例PE患者中有21例（2.6%）在出院前死亡。所有规则将26.1%-38.3%的患者分类为早期死亡低风险。低风险患者的死亡率为0%（sPESI和Hestia）、0.4%（IMPACT）和0.6%（PESI）。IMPACT的敏感性为95.2%（95%置信区间[CI]=74.1%-99.8%），临床规则的敏感性范围为91%（PESI）-100%（sPESI和Hestia）。所有规则的特异性范围在26.8%至39.1%之间。在30天死亡率分析中的573例连续患者中，33例（5.8%）死亡。所有规则将27.9%-38.0%的患者分类为低风险，低风险患者的死亡率为0（Hestia）-1.4%（PESI）。IMPACT的敏感性为97.0%（95%CI=82.5%-99.8%），而临床规则的敏感性范围为91%（PESI）-100%（Hestia）。规则的特异性范围在29.6%至39.8%之间。
结论
在本分析中，IMPACT识别低风险PE患者的准确性与临床规则相似。虽然不用于前瞻性临床决策，但IMPACT在基于回顾性理赔的研究中似乎有助于识别低风险PE患者。
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