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Physician risk assessment and APACHE scores in cardiac care units
1University of Minnesota Medical School, Minneapolis, USA.
Insights
Physicians can identify high-risk coronary care unit (CCU) patients, but the APACHE II score is inadequate for cardiac patients. New risk assessment methods are needed for CCU outcomes.
Area of Science:
- Cardiology
- Critical Care Medicine
- Health Services Research
Background:
- Accurate risk assessment for coronary care unit (CCU) patients is crucial for outcome data correction but remains a challenge.
- Existing risk prediction models may not adequately capture the complexity of CCU patient populations.
Purpose of the Study:
- To evaluate the feasibility of using physician opinions for predicting mortality in CCU patients.
- To compare the predictive accuracy of physician assessments with the Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system.
Main Methods:
- A prospective observational study was conducted in a university-affiliated CCU over two months.
- Physician assessments of in-hospital mortality risk (MD Prognosis Score) were collected and compared with APACHE II scores.
Main Results:
- A low correlation (r=0.3) was observed between MD Prognosis Scores and APACHE II scores.
- Physician scores effectively identified patients with fatal outcomes, with three of four deceased patients receiving the highest risk score (7).
- APACHE II scores did not accurately predict high mortality risk in this CCU cohort.
Conclusions:
- The APACHE II scoring system demonstrates inadequacy for risk assessment in cardiac patients within a CCU setting.
- Physician expertise can identify high-risk CCU patients, but practical implementation faces challenges.
- Development of novel risk assessment tools is essential for reliable comparison of CCU outcomes across institutions.
Background:
The need to correct outcome data for case mix is well recognized, but risk assessment for coronary care unit (CCU) patients remains problematic.
Hypothesis:
This study determined the feasibility of using physicians' opinions to predict mortality for CCU patients and compared their results to Acute Physiology and Chronic Health Evaluation II (APACHE II) scores.
Methods:
A prospective observational study was performed on consecutive patients admitted to a university-affiliated Veterans Affairs Medical Center CCU over a 2-month period. Physician assessment of likely mortality during hospitalization, obtained using an MD Prognosis Score ranging from 1 (best) to 7 (worst), was compared with APACHE II scores.
Results:
MD Prognosis Scores were obtained on 122 of the 237 eligible patients (51% response rate) and averaged 2.3 +/- 1.4 (mean +/- standard deviation). APACHE II scores on these patients averaged 9.9 +/- 4.8 (range 2-29) with very poor correlation between the two methods (r = 0.3). Of the four patients who died, three had MD prognosis scores of 7. None of the survivors had scores of 7 and only three had scores of 6. APACHE II did not predict a high likelihood that any of the patients would die (none with > 90% likelihood of mortality).
Conclusions:
APACHE scores are inadequate for cardiac patients. Although physicians can identify CCU patients most likely to die, reliance on physician scoring systems is limited by difficulties in obtaining their opinion. A new method of risk assessment for acutely ill cardiac patients is needed if CCU outcomes are to be compared across institutions.
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