Tilford J M, Roberson P K, Lensing S, Fiser D H
Department of Pediatrics, University of Arkansas for Medical Sciences, and Arkansas Children's Hospital, Little Rock 72202-3591, USA.
Crit Care Med. 1998 Oct;26(10):1737-43. doi: 10.1097/00003246-199810000-00032.
To compare pediatric intensive care unit (ICU) mortality risk using models from two distinct time periods; and to discuss the implications of changing mortality risk for severity systems and quality-of-care assessment.
Consecutive admissions (n = 10,833) from 16 pediatric ICUs across the United States that participate in the Pediatric Critical Care Study Group were recorded prospectively. Data collection occurred during a 12-mo period beginning in January 1993.
Data collection for the development and validation of the original Pediatric Risk of Mortality (PRISM) score occurred from 1980 to 1985. The original PRISM coefficients were used to calculate mortality probabilities in the current data set. Updated estimates of mortality probabilities were calculated, using coefficients from a logistic regression analysis using the original PRISM variable set. Quality-of-care tests were performed using standardized mortality ratios.
Risk of mortality from pediatric ICU admission improved considerably between the two periods. Overall, the reduction in mortality risk averaged 15% (p < .001). Analysis of mortality risk by age indicated a large improvement for younger infants. The mortality risk for infants <1 mo improved by 39% (p < .001). Mortality risk improved by 28% (p < .001) for infants between 1 and 12 mos. Analysis of mortality risk by principal diagnosis indicated substantial improvement in respiratory diseases, including respiratory diseases developing in the perinatal period. The mortality risk for respiratory diseases improved by 45% (p < .001). The improvement in mortality risk substantially deteriorated the calibration of the original PRISM severity system (p < .001). As a result of changing mortality risk, the standardized mortality ratios across the 16 pediatric ICUs demonstrated substantial disparities, depending on the choice of models.
This study documents differences in pediatric ICU risk of mortality over time that are consistent with a general improvement in the quality of pediatric intensive care. Despite continued widespread use of the original PRISM, recent improvements in pediatric ICU quality of care have negated its usefulness for many intended applications, including quality-of-care assessment.
使用两个不同时间段的模型比较儿科重症监护病房（ICU）的死亡风险；并探讨死亡风险变化对严重程度系统和护理质量评估的影响。
前瞻性记录了美国16家参与儿科重症监护研究组的儿科ICU的连续入院病例（n = 10,833）。数据收集于1993年1月开始的12个月期间进行。
1980年至1985年收集数据用于开发和验证原始儿科死亡风险（PRISM）评分。使用原始PRISM系数计算当前数据集中的死亡概率。使用原始PRISM变量集进行逻辑回归分析的系数计算更新后的死亡概率估计值。使用标准化死亡率进行护理质量测试。
两个时期之间儿科ICU入院的死亡风险有显著改善。总体而言，死亡风险平均降低了15%（p < .001）。按年龄分析死亡风险表明，小婴儿有很大改善。<1个月婴儿的死亡风险降低了39%（p < .001）。1至12个月婴儿的死亡风险降低了28%（p < .001）。按主要诊断分析死亡风险表明，包括围生期发生的呼吸系统疾病在内的呼吸系统疾病有显著改善。呼吸系统疾病的死亡风险降低了45%（p < .001）。死亡风险的改善极大地恶化了原始PRISM严重程度系统的校准（p < .001）。由于死亡风险的变化，16家儿科ICU的标准化死亡率根据模型选择显示出很大差异。
本研究记录了儿科ICU死亡风险随时间的差异，这与儿科重症监护质量的总体改善一致。尽管原始PRISM仍在广泛使用，但儿科ICU护理质量的近期改善已使其在许多预期应用中失去作用，包括护理质量评估。
