Selker H P, Griffith J L, D'Agostino R B
Department of Medicine, New England Medical Center, Boston, MA 02111.
Med Care. 1994 Oct;32(10):1040-52. doi: 10.1097/00005650-199410000-00005.
The purpose of this study was to develop a "time-insensitive" predictive instrument (TIPI) for acute hospital mortality due to congestive heart failure. In Phase 1, based on prospectively collected data on 401 congestive heart failure patients among 5,773 study patients who presented to six New England hospitals over a 2-year period whose chief complaints were chest pain, shortness of breath, or other cardiac symptoms, a multivariable logistic regression was used to develop the TIPI for acute mortality. Discrimination between patients who lived and those who died was reflected by receiver-operating characteristic (ROC) curve area of 0.90. Predicted mortality was found to not vary significantly from actual mortality rates across deciles of predicted probabilities from 0% to 100%. In Phase 2, the six hospitals' actual mortality rates for their congestive heart failure patients were compared to their respective rates predicted by the TIPI. Actual hospital mortality rates ranged from 3.6% to 11.3%, with no hospital having a statistically significantly higher rate. Predicted mortality rates ranged from 4% to 9%, with one hospital having a significantly lower predicted rate (P = .01), and one hospital having a borderline significantly higher predicted rate (P = .07). Individual hospitals' differences between actual and predicted mortality ranged from -3.8% to +4.7% (all NS). When grouped by hospital type, respectively for urban teaching, smaller city teaching, and rural non-teaching hospitals, the actual mortality rates were 5.1%, 10.5%, and 5.4%, (NS). The predicted mortality rates were 8.3%, 6.1%, and 5.4%, respectively, with the rate for urban major teaching centers being significantly higher (P = .03). No hospital type had significant differences between their actual and predicted mortality rates (NS). This congestive heart failure mortality TIPI (CHFM-TIPI) shows potential for risk-adjusted studies of hospitals, mortality for multi-hospital groups, hospital-to-hospital comparisons, and potentially for within-hospital assessment and if further validated, potentially also for real-time clinical use.
本研究的目的是开发一种用于预测因充血性心力衰竭导致的急性医院死亡率的“时间不敏感”预测工具（TIPI）。在第一阶段，基于前瞻性收集的5773例研究患者中401例充血性心力衰竭患者的数据，这些患者在两年内前往新英格兰的六家医院就诊，主要症状为胸痛、呼吸急促或其他心脏症状，采用多变量逻辑回归来开发急性死亡率的TIPI。生存患者和死亡患者之间的区分通过受试者操作特征（ROC）曲线面积为0.90来反映。发现在预测概率从0%到100%的十分位数范围内，预测死亡率与实际死亡率没有显著差异。在第二阶段，将六家医院充血性心力衰竭患者的实际死亡率与其TIPI预测的各自死亡率进行比较。实际医院死亡率范围为3.6%至11.3%，没有一家医院的死亡率在统计学上显著更高。预测死亡率范围为4%至9%，有一家医院的预测率显著较低（P = 0.01），有一家医院的预测率略高于临界值（P = 0.07）。各医院实际死亡率与预测死亡率之间的差异范围为-3.8%至+4.7%（均无统计学意义）。按医院类型分组时，城市教学医院、小城市教学医院和农村非教学医院的实际死亡率分别为5.1%、10.5%和5.4%（无统计学意义）。预测死亡率分别为8.3%、6.1%和5.4%，城市大型教学中心的预测率显著更高（P = 0.03）。没有一种医院类型的实际死亡率与预测死亡率之间存在显著差异（无统计学意义）。这种充血性心力衰竭死亡率TIPI（CHFM-TIPI）在医院风险调整研究、多医院组死亡率、医院间比较以及潜在的医院内评估方面显示出潜力，如果进一步验证，也可能用于实时临床应用。
