Division of Trauma and Critical Care, Department of Surgery, University of Washington, Seattle, WA.
Division of General Surgery, Department of Surgery, Indiana University, Indianapolis, IN.
Acad Emerg Med. 2019 Jun;26(6):621-630. doi: 10.1111/acem.13727. Epub 2019 Apr 3.
OBJECTIVES: Early identification of geriatric patients at high risk for mortality is important to guide clinical care, medical decision making, palliative discussions, quality assurance, and research. We sought to identify injured older adults at highest risk for 30-day mortality using an empirically derived scoring system from available data and to compare it with current prognostic scoring systems. METHODS: This was a retrospective cohort study of injured adults ≥ 65 years transported by 44 emergency medical services (EMS) agencies to 49 emergency departments in Oregon and Washington from January 1, 2011, through December 31, 2011, with follow-up through December 31, 2012. We matched data from EMS to Medicare, inpatient, trauma registries, and vital statistics. Using a primary outcome of 30-day mortality, we empirically derived a new risk score using binary recursive partitioning and compared it to the Charlson Comorbidity Index (CCI), modified frailty index, geriatric trauma outcome score (GTOS), GTOS II, and Injury Severity Score (ISS). RESULTS: There were 4,849 patients, of whom 234 (4.8%) died within 30 days and 1,040 (21.5%) died within 1 year. The derived score, the geriatric trauma risk indicator (GTRI; emergent airway or CCI ≥ 2), had 87.2% sensitivity (95% confidence interval [CI] = 83.0% to 91.5%) and 30.6% specificity (95% CI = 29.3% to 31.9%) for 30-day mortality (area under the receiving operating characteristic curve [AUROC] = 0.589, 95% CI = 0.566 to 0.611). AUROC values for other scoring systems ranged from 0.592 to 0.678. When the sensitivity for each existing score was held at 90%, specificity values ranged from 7.5% (ISS) to 30.6% (GTRI). CONCLUSIONS: Older, injured adults transported by EMS to a large variety of trauma and nontrauma hospitals were more likely to die within 30 days if they required emergent airway management or had a higher comorbidity burden. When compared to other risk measures and holding sensitivity constant near 90%, the GTRI had higher specificity, despite a lower AUROC. Using GTOS II or the GTRI may better identify high-risk older adults than traditional scores, such as ISS, but identification of an ideal prognostic tool remains elusive.
目的：及早识别出病死率较高的老年患者，对于指导临床护理、医疗决策、姑息治疗讨论、质量保证和研究至关重要。本研究旨在利用现有数据建立经验性评分系统，识别病死率较高的老年创伤患者，并与现有的预后评分系统进行比较。
方法：这是一项回顾性队列研究，纳入 2011 年 1 月 1 日至 2011 年 12 月 31 日期间，由 44 家急救医疗服务机构（EMS）转运至俄勒冈州和华盛顿州 49 家急诊科的 65 岁及以上的成年创伤患者，随访至 2012 年 12 月 31 日。我们将 EMS 数据与医疗保险、住院、创伤登记和生命统计数据进行匹配。以 30 天病死率为主要结局，采用二项递归分割法建立新的风险评分，并与 Charlson 合并症指数（CCI）、改良衰弱指数、老年创伤结局评分（GTOS）、GTOS II 和损伤严重度评分（ISS）进行比较。
结果：共纳入 4849 例患者，其中 234 例（4.8%）在 30 天内死亡，1040 例（21.5%）在 1 年内死亡。经验性评分系统“老年创伤风险指标（GTRI；需紧急气道管理或 CCI≥2）”的敏感性为 87.2%（95%置信区间[CI]为 83.0%91.5%），特异性为 30.6%（95% CI 为 29.3%31.9%），用于预测 30 天病死率的曲线下面积（AUROC）为 0.589（95% CI 为 0.5660.611）。其他评分系统的 AUROC 值在 0.5920.678 之间。当每个现有评分的敏感性保持在 90%时，特异性值范围为 7.5%（ISS）至 30.6%（GTRI）。
结论：由 EMS 转运至多家创伤和非创伤医院的老年创伤患者，如果需要紧急气道管理或合并症负担较重，其在 30 天内死亡的可能性更高。与其他风险指标相比，当敏感性接近 90%时，GTRI 的特异性较高，尽管 AUROC 较低。与传统评分（如 ISS）相比，使用 GTOS II 或 GTRI 可能更好地识别出病死率较高的老年患者，但理想的预后工具仍难以确定。
J Trauma Acute Care Surg. 2019-5
J Trauma Acute Care Surg. 2017-9
Diagnostics (Basel). 2024-9-26
Eur J Trauma Emerg Surg. 2023-4
Zotero 插件