国际早期预警评分的制定和外部验证：改善急诊科年龄和性别调整住院死亡率预测。
Development and External Validation of the International Early Warning Score for Improved Age- and Sex-Adjusted In-Hospital Mortality Prediction in the Emergency Department.
机构信息
Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands.
Department of Emergency Medicine, Máxima Medical Center, Veldhoven, The Netherlands.
出版信息
Crit Care Med. 2023 Jul 1;51(7):881-891. doi: 10.1097/CCM.0000000000005842. Epub 2023 Mar 23.
OBJECTIVES
Early Warning Scores (EWSs) have a great potential to assist clinical decision-making in the emergency department (ED). However, many EWS contain methodological weaknesses in development and validation and have poor predictive performance in older patients. The aim of this study was to develop and externally validate an International Early Warning Score (IEWS) based on a recalibrated National Early warning Score (NEWS) model including age and sex and evaluate its performance independently at arrival to the ED in three age categories (18-65, 66-80, > 80 yr).
DESIGN
International multicenter cohort study.
SETTING
Data was used from three Dutch EDs. External validation was performed in two EDs in Denmark.
PATIENTS
All consecutive ED patients greater than or equal to 18 years in the Netherlands Emergency department Evaluation Database (NEED) with at least two registered vital signs were included, resulting in 95,553 patients. For external validation, 14,809 patients were included from a Danish Multicenter Cohort (DMC).
MEASUREMENTS AND MAIN RESULTS
Model performance to predict in-hospital mortality was evaluated by discrimination, calibration curves and summary statistics, reclassification, and clinical usefulness by decision curve analysis. In-hospital mortality rate was 2.4% ( n = 2,314) in the NEED and 2.5% ( n = 365) in the DMC. Overall, the IEWS performed significantly better than NEWS with an area under the receiving operating characteristic of 0.89 (95% CIs, 0.89-0.90) versus 0.82 (0.82-0.83) in the NEED and 0.87 (0.85-0.88) versus 0.82 (0.80-0.84) at external validation. Calibration for NEWS predictions underestimated risk in older patients and overestimated risk in the youngest, while calibration improved for IEWS with a substantial reclassification of patients from low to high risk and a standardized net benefit of 5-15% in the relevant risk range for all age categories.
CONCLUSIONS
The IEWS substantially improves in-hospital mortality prediction for all ED patients greater than or equal to18 years.
目的
早期预警评分（EWS）在急诊科（ED）的临床决策中有很大的辅助作用。然而，许多 EWS 在开发和验证过程中存在方法学上的缺陷，并且在老年患者中的预测性能较差。本研究的目的是基于重新校准的国家早期预警评分（NEWS）模型开发和外部验证一个国际早期预警评分（IEWS），该模型包含年龄和性别，并在三个年龄组（18-65 岁、66-80 岁、>80 岁）到达 ED 时独立评估其性能。
设计
国际多中心队列研究。
地点
数据来自荷兰三个 ED 的荷兰急诊部评估数据库（NEED）。外部验证在丹麦的两个 ED 进行。
患者
荷兰急诊部评估数据库（NEED）中所有年龄大于或等于 18 岁且至少有两个登记生命体征的连续 ED 患者均被纳入，共纳入 95553 例患者。对于外部验证，从丹麦多中心队列（DMC）中纳入 14809 例患者。
测量和主要结果
通过区分度、校准曲线和汇总统计、重新分类以及决策曲线分析评估预测院内死亡率的模型性能。在 NEED 中，院内死亡率为 2.4%（n=2314），在 DMC 中为 2.5%（n=365）。总体而言，IEWS 的表现明显优于 NEWS，在 NEED 中的接收者操作特征曲线下面积为 0.89（95%置信区间，0.89-0.90），而在 DMC 中的面积为 0.87（0.85-0.88）。校准预测对老年患者的风险低估，对最年轻患者的风险高估，而 IEWS 的校准得到改善，患者从低风险到高风险的重新分类显著，所有年龄组的相关风险范围内的标准化净收益为 5%-15%。
结论
IEWS 大大提高了所有大于或等于 18 岁的 ED 患者的院内死亡率预测。
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