Teres D, Lemeshow S
Adult Critical Care Division, Baystate Medical Center, Springfield, MA.
Crit Care Clin. 1994 Jan;10(1):93-110; discussion 111-5.
There are now two validated time points for predicting hospital mortality of ICU patients--at admission and at 24 hours. The best purposes include evaluation of high clinical performance ICUs and for patients being enrolled in clinical trials. For the latter purpose, the model must be calibrated in the individual hospital to ensure that the model is applicable. This can be estimated by using goodness-of-fit testing. There are fewer uses for physiology scores and increased emphasis on converting scores to probabilities. For individual patient application, the model should be demonstrated to have high discrimination, as measured by the area under the receiver operating characteristic curve, and high calibration, as defined by goodness-of-fit testing. Although models have improved substantially and are now based on much larger databases, there is considerable uncertainty in their application for insurance purposes, triage, regulatory applications, sanctions against individual physicians, and cost containment. Current models may not adequately describe important ICU conditions such as adult respiratory distress syndrome and multi-organ dysfunction occurring after 24 hours into ICU care. For family discussions regarding prognosis of individual patients, ICU severity models must be used cautiously at admission or after 24 hours, with the understanding of the strengths and weakness of estimating probabilities of hospital mortality. The mathematical link between physiology score and estimation of hospital mortality is established only for the time point of 24 hours after ICU admission. Calibration and discrimination of the admission and 24-hour models also must be performed within each hospital in which individual probabilities are presented to families. It may be possible to customize a probability model such as MPM to achieve a high level of calibration at the individual hospital level.
目前有两个经过验证的预测重症监护病房（ICU）患者医院死亡率的时间点——入院时和24小时时。其最佳用途包括评估临床绩效高的ICU以及用于纳入临床试验的患者。对于后一个目的，该模型必须在各个医院进行校准，以确保其适用性。这可以通过拟合优度检验来估计。生理学评分的用途较少，并且越来越强调将评分转换为概率。对于个体患者应用，该模型应被证明具有高辨别力（通过受试者操作特征曲线下面积衡量）和高校准度（由拟合优度检验定义）。尽管模型有了很大改进，现在基于更大的数据库，但在其用于保险目的、分诊、监管应用、对个体医生的制裁以及成本控制方面仍存在相当大的不确定性。当前模型可能无法充分描述重要的ICU病症，如成人呼吸窘迫综合征和在ICU护理24小时后出现的多器官功能障碍。对于关于个体患者预后的家庭讨论，在入院时或24小时后使用ICU严重程度模型时必须谨慎，要了解估计医院死亡率概率的优势和劣势。生理学评分与医院死亡率估计之间的数学联系仅在ICU入院后24小时这个时间点建立。入院和24小时模型的校准和辨别力也必须在向家属提供个体概率估计的每家医院内进行。有可能定制一个概率模型，如死亡率预测模型（MPM），以在个体医院层面实现高水平的校准。
