Kruser Jacqueline M, Sharma Kartikey, Holl Jane L, Nohadani Omid
Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI.
Zuse Institute, Department of AI in Society, Science, and Technology, Berlin, Germany.
Crit Care Explor. 2023 Oct 19;5(10):e0984. doi: 10.1097/CCE.0000000000000984. eCollection 2023 Oct.
Characterizing medical interventions delivered to ICU patients over time and their relationship to outcomes can help set expectations and inform decisions made by patients, clinicians, and health systems.
To determine whether distinct and clinically relevant pathways of medical intervention can be identified among adult ICU patients with acute respiratory failure.
Retrospective observational study using all-payer administrative claims data from 2012 to 2014. Patients were identified from the Healthcare Cost and Utilization Project State Inpatient Databases from Maryland, Massachusetts, Nevada, and Washington.
Patterns of cumulative medical intervention delivery, over time, using temporal k-means clustering of interventions delivered up to hospital days 0, 5, 10, 20, and up to discharge.
A total of 12,175 admissions were identified and divided into training (75%; = 9,130) and validation sets (25%; = 3,045). Without applying a priori classification and using only medical interventions to cluster, we identified three distinct pathways of intervention accounting for 93.5% of training set admissions. We found 45.9% of admissions followed a "cardiac" intervention pathway (e.g., cardiac catheterization, cardioversion); 36.7% followed a "general" pathway (e.g., diagnostic interventions); and 17.4% followed a "prolonged" pathway (e.g., tracheostomy, gastrostomy). Prolonged pathway admissions had longer median hospital length of stay (13 d; interquartile range [IQR], 7.5-18.5 d) compared with cardiac (5; IQR, 2.5-7.5) and general (5; IQR, 3-7). In-hospital death occurred in 24.6% of prolonged pathway admissions compared with 17.9% of cardiac and 6.9% of general. Findings were confirmed in the validation set.
Most ICU admissions for acute respiratory failure follow one of three clinically relevant pathways of medical intervention which are associated with hospitalization outcomes. This study helps define the longitudinal nature of critical care delivery, which can inform efforts to predict patient outcomes, communicate with patients and their families, and organize critical care resources.
描述随着时间推移给予重症监护病房（ICU）患者的医疗干预措施及其与预后的关系，有助于设定预期，并为患者、临床医生和卫生系统做出的决策提供依据。
确定在患有急性呼吸衰竭的成年ICU患者中，是否能识别出不同且具有临床相关性的医疗干预途径。
设计、设置与参与者：一项回顾性观察研究，使用2012年至2014年的全付费者行政索赔数据。患者从马里兰州、马萨诸塞州、内华达州和华盛顿州的医疗成本和利用项目州住院数据库中识别出来。
使用在住院第0天、第5天、第10天、第20天直至出院时给予的干预措施进行时间聚类分析，以确定随着时间推移累积医疗干预的模式。
共识别出12175例入院病例，并分为训练集（75%；n = 9130）和验证集（25%；n = 3045）。在未进行先验分类且仅使用医疗干预措施进行聚类的情况下，我们识别出三种不同的干预途径，占训练集入院病例的93.5%。我们发现45.9%的入院病例遵循“心脏”干预途径（如心导管插入术、心脏复律）；36.7%遵循“一般”途径（如诊断性干预）；17.4%遵循“延长”途径（如气管切开术、胃造口术）。与心脏途径（5天；四分位间距[IQR]，2.5 - 7.5天）和一般途径（5天；IQR，3 - 7天）相比，延长途径入院病例的中位住院时间更长（13天；IQR，7.5 - 18.5天）。延长途径入院病例的院内死亡率为24.6%，而心脏途径为17.9%，一般途径为6.9%。在验证集中证实了这些发现。
大多数因急性呼吸衰竭入住ICU的病例遵循三种具有临床相关性的医疗干预途径之一，这些途径与住院结局相关。本研究有助于明确重症监护的纵向性质，可为预测患者结局、与患者及其家属沟通以及组织重症监护资源的工作提供信息。
