Zimmerman J E, Wagner D P, Draper E A, Wright L, Alzola C, Knaus W A
The Department of Anesthesiology, George Washington University Medical Center, Washington, DC, USA.
Crit Care Med. 1998 Aug;26(8):1317-26. doi: 10.1097/00003246-199808000-00012.
To assess the accuracy and validity of Acute Physiology and Chronic Health Evaluation (APACHE) III hospital mortality predictions in an independent sample of U.S. intensive care unit (ICU) admissions.
Nonrandomized, observational, cohort study.
Two hundred eighty-five ICUs in 161 U.S. hospitals, including 65 members of the Council of Teaching Hospitals and 64 nonteaching hospitals.
A consecutive sample of 37,668 ICU admissions during 1993 to 1996; including 25,448 admissions at hospitals with >400 beds and 1,074 admissions at hospitals with <200 beds.
None.
We used demographic, clinical, and physiologic information recorded during ICU day 1 and the APACHE III equation to predict the probability of hospital mortality for each patient. We compared observed and predicted mortality for all admissions and across patient subgroups and assessed predictive accuracy using tests of discrimination and calibration. Aggregate hospital death rate was 12.35% and predicted hospital death rate was 12.27% (p =.541). The model discriminated between survivors and nonsurvivors well (area under receiver operating curve = 0.89). A calibration curve showed that the observed number of hospital deaths was close to the number of deaths predicted by the model, but when tested across deciles of risk, goodness-of-fit (Hosmer-Lemeshow statistic, chi-square = 48.71, 8 degrees of freedom, p< .0001) was not perfect. Observed and predicted hospital mortality rates were not significantly (p < .01) different for 55 (84.6%) of APACHE III's 65 specific ICU admission diagnoses and for 11 (84.6%) of the 13 residual organ system-related categories. The most frequent diagnoses with significant (p < .01) differences between observed and predicted hospital mortality rates included acute myocardial infarction, drug overdose, nonoperative head trauma, and nonoperative multiple trauma.
APACHE III accurately predicted aggregate hospital mortality in an independent sample of U.S. ICU admissions. Further improvements in calibration can be achieved by more precise disease labeling, improved acquisition and weighting of neurologic abnormalities, adjustments that reflect changes in treatment outcomes over time, and a larger national database.
在美国重症监护病房（ICU）收治患者的独立样本中，评估急性生理与慢性健康状况评价系统（APACHE）Ⅲ对医院死亡率预测的准确性和有效性。
非随机、观察性队列研究。
美国161家医院的285个ICU，包括65家教学医院理事会成员医院和64家非教学医院。
1993年至1996年期间连续入选的37668例ICU收治患者；包括床位>400张医院的25448例收治患者和床位<200张医院的1074例收治患者。
无。
我们使用ICU第1天记录的人口统计学、临床和生理学信息以及APACHEⅢ方程来预测每位患者的医院死亡概率。我们比较了所有收治患者以及不同患者亚组的观察到的死亡率和预测的死亡率，并使用鉴别和校准检验评估预测准确性。总体医院死亡率为12.35%，预测的医院死亡率为12.27%（p = 0.541）。该模型能很好地区分存活者和非存活者（受试者工作特征曲线下面积 = 0.89）。校准曲线显示，观察到的医院死亡人数接近模型预测的死亡人数，但在按风险十分位数进行测试时，拟合优度（Hosmer-Lemeshow统计量，卡方 = 48.71，8个自由度，p < 0.0001）并不理想。对于APACHEⅢ的65种特定ICU收治诊断中的55种（占84.6%）以及13个与残余器官系统相关类别中的11种（占84.6%），观察到的和预测的医院死亡率差异无统计学意义（p < 0.01）。观察到的和预测的医院死亡率之间存在显著差异（p < 0.01）的最常见诊断包括急性心肌梗死、药物过量、非手术性头部创伤和非手术性多发伤。
APACHEⅢ在美国ICU收治患者的独立样本中准确预测了总体医院死亡率。通过更精确的疾病分类、改善神经功能异常的获取和加权、反映治疗结果随时间变化的调整以及更大的国家数据库，可以进一步提高校准效果。
