Iezzoni L I, Ash A S, Shwartz M, Daley J, Hughes J S, Mackiernan Y D
Harvard Medical School, Beth Israel Hospital, Boston University Medical Center, Massachusetts, USA.
Ann Intern Med. 1995 Nov 15;123(10):763-70. doi: 10.7326/0003-4819-123-10-199511150-00004.
To determine whether assessments of illness severity, defined as risk for in-hospital death, varied across four severity measures.
Retrospective cohort study.
100 hospitals using the MedisGroups severity measure.
11 880 adults managed medically for acute myocardial infarction; 1574 in-hospital deaths (13.2%).
For each patient, probability of death was predicted four times, each time by using patient age and sex and one of four common severity measures: 1) admission MedisGroups scores for probability of death scores; 2) scores based on values for 17 physiologic variables at time of admission; 3) Disease Staging's probability-of-mortality model; and 4) All Patient Refined Diagnosis Related Groups (APR-DRGs). Patients were ranked according to probability of death as predicted by each severity measure, and rankings were compared across measures. The presence or absence of each of six clinical findings considered to indicate poor prognosis in patients with myocardial infarction (congestive heart failure, pulmonary edema, coma, low systolic blood pressure, low left ventricular ejection fraction, and high blood urea nitrogen level) was determined for patients ranked differently by different severity measures.
MedisGroups and the physiology score gave 94.7% of patients similar rankings. Disease Staging, MedisGroups, and the physiology score gave only 78% of patients similar rankings. MedisGroups and APR-DRGs gave 80% of patients similar rankings. Patients whose illnesses were more severe according to MedisGroups and the physiology score were more likely to have the six clinical findings than were patients whose illnesses were more severe according to Disease Staging and APR-DRGs.
Some pairs of severity measures assigned very different severity levels to more than 20% of patients. Evaluations of patient outcomes need to be sensitive to the severity measures used for risk adjustment.
确定将疾病严重程度评估定义为住院死亡风险时，四种严重程度衡量指标之间是否存在差异。
回顾性队列研究。
100家使用MedisGroups严重程度衡量指标的医院。
11880名因急性心肌梗死接受药物治疗的成年人；1574例住院死亡（13.2%）。
对每位患者进行四次死亡概率预测，每次使用患者年龄和性别以及四种常见严重程度衡量指标之一：1）入院时MedisGroups死亡概率评分；2）基于入院时17项生理变量值的评分；3）疾病分期的死亡概率模型；4）所有患者精细诊断相关组（APR-DRGs）。根据每种严重程度衡量指标预测的死亡概率对患者进行排名，并比较各指标之间的排名。确定了六种被认为表明心肌梗死患者预后不良的临床发现（充血性心力衰竭、肺水肿、昏迷、低收缩压、低左心室射血分数和高血尿素氮水平）在不同严重程度衡量指标下排名不同的患者中是否存在。
MedisGroups和生理评分对94.7%的患者给出了相似的排名。疾病分期、MedisGroups和生理评分对仅78%的患者给出了相似的排名。MedisGroups和APR-DRGs对80%的患者给出了相似的排名。与根据疾病分期和APR-DRGs被判定病情更严重的患者相比，根据MedisGroups和生理评分病情更严重的患者更有可能出现这六种临床发现。
一些严重程度衡量指标对超过20%的患者给出了非常不同的严重程度等级。对患者预后的评估需要对用于风险调整的严重程度衡量指标敏感。
