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Adaptation of the Acute Organ Failure Score for Use in a Medicare Population.

ABSTRACT: OBJECTIVES:Without widely available physiologic data, a need exists for ICU risk adjustment methods that can be applied to administrative data. We sought to expand the generalizability of the Acute Organ Failure Score by adapting it to a commonly used administrative database. DESIGN:Retrospective cohort study. SETTING:One hundred fifty-one hospitals in Pennsylvania. PATIENTS:A total of 90,733 ICU admissions among 77,040 unique patients between January 1, 2009, and December 1, 2009, in the Medicare Provider Analysis and Review database. MEASUREMENTS AND MAIN RESULTS:We used multivariable logistic regression on a random split cohort to predict 30-day mortality, and to examine the impact of using different comorbidity measures in the model and adding historical claims data. Overall 30-day mortality was 17.6%. In the validation cohort, using the original Acute Organ Failure Score model's ? coefficients resulted in poor discrimination (C-statistic, 0.644; 95% CI, 0.639-0.649). The model's C-statistic improved to 0.721 (95% CI, 0.711-0.730) when the Medicare cohort was used to recalibrate the ? coefficients. Model discrimination improved further when comorbidity was expressed as the COmorbidity Point Score 2 (C-statistic, 0.737; 95% CI, 0.728-0.747; p < 0.001) or the Elixhauser index (C-statistic, 0.748; 95% CI, 0.739-0.757) instead of the Charlson index. Adding historical claims data increased the number of comorbidities identified, but did not enhance model performance. CONCLUSIONS:Modification of the Acute Organ Failure Score resulted in good model discrimination among a diverse population regardless of comorbidity measure used. This study expands the use of the Acute Organ Failure Score for risk adjustment in ICU research and outcomes reporting using standard administrative data.

SUBMITTER: Courtright KR

PROVIDER: S-EPMC6435264 | biostudies-literature | 2017 Nov

REPOSITORIES: biostudies-literature

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Adaptation of the Acute Organ Failure Score for Use in a Medicare Population.

Courtright Katherine R KR Halpern Scott D SD Bayes Brian B Harhay Michael O MO Raneses Eli E Kipnis Patricia P Escobar Gabriel J GJ Kerlin Meeta Prasad MP

Critical care medicine 20171101 11

<h4>Objectives</h4>Without widely available physiologic data, a need exists for ICU risk adjustment methods that can be applied to administrative data. We sought to expand the generalizability of the Acute Organ Failure Score by adapting it to a commonly used administrative database.<h4>Design</h4>Retrospective cohort study.<h4>Setting</h4>One hundred fifty-one hospitals in Pennsylvania.<h4>Patients</h4>A total of 90,733 ICU admissions among 77,040 unique patients between January 1, 2009, and De ...[more]

PMID: 28777196

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Project description:The Sequential Organ Failure Assessment (SOFA) was chosen in the definition of sepsis due to superior validity in predicting mortality. However, few studies have assessed the contributions of acute versus chronic organ failures to SOFA for mortality prediction.ObjectivesThe main objective in this study was to assess the relative importance of chronic and acute organ failures in mortality prediction in patients with suspected sepsis at hospital admission. We also evaluated how the presence of infection influenced the ability of SOFA to predict 30-day mortality.Design setting and participantsSingle-center prospective cohort study including 1,313 adult patients with suspected sepsis in rapid response teams in the emergency department.Main outcomes and measuresThe main outcome was 30-day mortality. We measured the maximum total SOFA score during admission (SOFATotal), whereas preexisting chronic organ failure SOFA (SOFAChronic) score was assessed by chart review, allowing calculation of the corresponding acute SOFA (SOFAAcute) score. Likelihood of infection was determined post hoc as "No infection" or "Infection."ResultsSOFAAcute and SOFAChronic were both associated with 30-day mortality, adjusted for age and sex (adjusted odds ratios [AORs], 1.3; 95% CI, 1.3-14 and 1.3; 1.2-1.7), respectively. Presence of infection was associated with lower 30-day mortality (AOR, 0.4; 95% CI, 0.2-0.6), even when corrected for SOFA. In "No infection" patients, SOFAAcute was not associated with mortality (AOR, 1.1; 95% CI, 1.0-1.2), and in this subgroup, neither SOFAAcute greater than or equal to 2 (relative risk [RR], 1.1; 95% CI, 0.6-1.8) nor SOFATotal greater than or equal to 2 (RR, 3.6; 95% CI, 0.9-14.1) was associated with higher mortality.Conclusions and relevanceChronic and acute organ failures were equally associated with 30-day mortality in suspected sepsis. A substantial part of the total SOFA score was due to chronic organ failure, calling for caution when using total SOFA in defining sepsis and as an outcome in intervention studies. SOFA's mortality prediction ability was highly dependent on actual presence of infection.

Project description:ImportanceThe Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) uses the Sequential Organ Failure Assessment (SOFA) score to grade organ dysfunction in adult patients with suspected infection. However, the SOFA score is not adjusted for age and therefore not suitable for children.ObjectivesTo adapt and validate a pediatric version of the SOFA score (pSOFA) in critically ill children and to evaluate the Sepsis-3 definitions in patients with confirmed or suspected infection.Design, setting, and participantsThis retrospective observational cohort study included all critically ill children 21 years or younger admitted to a 20-bed, multidisciplinary, tertiary pediatric intensive care unit between January 1, 2009 and August 1, 2016. Data on these children were obtained from an electronic health record database. The pSOFA score was developed by adapting the original SOFA score with age-adjusted cutoffs for the cardiovascular and renal systems and by expanding the respiratory criteria to include noninvasive surrogates of lung injury. Daily pSOFA scores were calculated from admission until day 28 of hospitalization, discharge, or death (whichever came first). Three additional pediatric organ dysfunction scores were calculated for comparison.ExposuresOrgan dysfunction measured by the pSOFA score, and sepsis and septic shock according to the Sepsis-3 definitions.Main outcomes and measuresThe primary outcome was in-hospital mortality. The daily pSOFA scores and additional pediatric organ dysfunction scores were compared. Performance was evaluated using the area under the curve. The pSOFA score was then used to assess the Sepsis-3 definitions in the subgroup of children with confirmed or suspected infection.ResultsIn all, 6303 patients with 8711 encounters met inclusion criteria. Each encounter was treated independently. Of the 8482 survivors of hospital encounters, 4644 (54.7%) were male and the median (interquartile range [IQR]) age was 69 (17-156) months. Among the 229 nonsurvivors, 127 (55.4%) were male with a median (IQR) age of 43 (8-144) months. In-hospital mortality was 2.6%. The maximum pSOFA score had excellent discrimination for in-hospital mortality, with an area under the curve of 0.94 (95% CI, 0.92-0.95). The pSOFA score had a similar or better performance than other pediatric organ dysfunction scores. According to the Sepsis-3 definitions, 1231 patients (14.1%) were classified as having sepsis and had a mortality rate of 12.1%, and 347 (4.0%) had septic shock and a mortality rate of 32.3%. Patients with sepsis were more likely to die than patients with confirmed or suspected infection but no sepsis (odds ratio, 18; 95% CI, 11-28). Of the 229 patients who died during their hospitalization, 149 (65.0%) had sepsis or septic shock during their course.Conclusions and relevanceThe pSOFA score was adapted and validated with age-adjusted variables in critically ill children. Using the pSOFA score, the Sepsis-3 definitions were assessed in children with confirmed or suspected infection. This study is the first assessment, to date, of the Sepsis-3 definitions in critically ill children. Use of these definitions in children is feasible and shows promising results.

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Adaptation of the Acute Organ Failure Score for Use in a Medicare Population.

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Adaptation of the Acute Organ Failure Score for Use in a Medicare Population.

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