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Assessing contemporary intensive care unit outcome: an updated Mortality Probability Admission Model (MPM0-III)
Thomas L Higgins1, Daniel Teres, Wayne S Copes
1Critical Care Division, Baystate Medical Center, Springfield, MA, USA.
Objective:
To update the Mortality Probability Model at intensive care unit (ICU) admission (MPM0-II) using contemporary data.
Design:
Retrospective analysis of data from 124,855 patients admitted to 135 ICUs at 98 hospitals participating in Project IMPACT between 2001 and 2004. Independent variables considered were 15 MPM0-II variables, time before ICU admission, and code status. Univariate analysis and multivariate logistic regression were used to identify risk factors associated with hospital mortality.
Setting:
One hundred thirty-five ICUs at 98 hospitals.
Patients:
Patients in the Project IMPACT database eligible for MPM0-II scoring.
Interventions:
None.
Measurements And Main Results:
Hospital mortality rate in the current data set was 13.8% vs. 20.8% in the MPM0-II cohort. All MPM0-II variables remained associated with mortality. Clinical conditions with high relative risks in MPM0-II also had high relative risks in MPM0-III. Gastrointestinal bleeding is now associated with lower mortality risk. Two factors have been added to MPM0-III: "full code" resuscitation status at ICU admission, and "zero factor" (absence of all MPM0-II risk factors except age). Seven two-way interactions between MPM0-II variables and age were included and reflect the declining marginal contribution of acute and chronic medical conditions to mortality risk with increasing age. Lead time before ICU admission and pre-ICU location influenced individual outcomes but did not improve model discrimination or calibration. MPM0-III calibrates well by graphic comparison of actual vs. expected mortality, overall standardized mortality ratio (1.018; 95% confidence interval, 0.996-1.040) and a low Hosmer-Lemeshow goodness-of-fit statistic (11.62; p = .31). The area under the receiver operating characteristic curve was 0.823.
Conclusions:
MPM0-II risk factors remain relevant in predicting ICU outcome, but the 1993 model significantly overpredicts mortality in contemporary practice. With the advantage of a much larger sample size and the addition of new variables and interaction effects, MPM0-III provides more accurate comparisons of actual vs. expected ICU outcomes.
Insights
The updated Mortality Probability Model (MPM0-III) uses current data to more accurately predict intensive care unit (ICU) mortality. This revised model improves risk assessment for ICU patients compared to the older MPM0-II.
Area of Science:
- Critical Care Medicine
- Health Services Research
- Biostatistics
Background:
- The Mortality Probability Model at intensive care unit (ICU) admission (MPM0-II) is a tool for predicting patient outcomes.
- Contemporary ICU data may differ from the data used to develop the MPM0-II, potentially affecting its accuracy.
- Updating predictive models with current data is essential for relevant clinical decision-making and resource allocation.
Purpose of the Study:
- To update the Mortality Probability Model at ICU admission (MPM0-II) using contemporary patient data.
- To assess the continued relevance of MPM0-II risk factors in current ICU populations.
- To develop an improved model (MPM0-III) for predicting hospital mortality in ICU patients.
Main Methods:
- Retrospective analysis of 124,855 patients from 135 ICUs (Project IMPACT, 2001-2004).
- Utilized 15 MPM0-II variables, pre-ICU admission time, and code status.
- Employed univariate and multivariate logistic regression to identify mortality risk factors.
Main Results:
- Hospital mortality decreased from 20.8% (MPM0-II cohort) to 13.8% (current data).
- MPM0-II variables remained significant predictors; gastrointestinal bleeding risk decreased.
- MPM0-III incorporates 'full code' status and 'zero factor', plus age interactions, showing good calibration (SMR 1.018, AUC 0.823).
Conclusions:
- Original MPM0-II risk factors are still relevant but the 1993 model overpredicts contemporary ICU mortality.
- MPM0-III, with a larger dataset and new variables/interactions, offers more accurate prediction of ICU outcomes.
- The updated model provides better comparisons of actual versus expected ICU outcomes in current practice.
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