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Physiological scoring systems and audit

O Boyd1, R M Grounds

  • 1Department of Medicine, St George's Hospital, London, UK.

Lancet (London, England)
|June 19, 1993
PubMed
Summary
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The Acute Physiology and Chronic Health Evaluation (APACHE) system, used for intensive care unit (ICU) patient severity scoring, is not suitable for comparing hospital units due to its susceptibility to medical interventions influencing outcomes.

Area of Science:

  • Critical Care Medicine
  • Health Services Research
  • Medical Informatics

Background:

  • Scoring systems are utilized to assess patient illness severity for hospital unit comparisons and resource allocation.
  • The Acute Physiology and Chronic Health Evaluation (APACHE) system is a widely used tool for evaluating intensive care unit (ICU) patient severity.

Purpose of the Study:

  • To critically evaluate the suitability of the APACHE system for comparing different hospital units.
  • To question the assumption that actual-to-predicted mortality ratios derived from APACHE scores are valid for audit purposes.

Main Methods:

  • Conceptual analysis of the impact of medical and nursing interventions on physiological data used in scoring systems.
  • Examination of how interventions can alter both patient severity scores and actual mortality outcomes.

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Main Results:

  • Physiological data used by scoring systems like APACHE can be influenced by clinical interventions, affecting their reliability for audit.
  • Effective care can paradoxically lower both actual and predicted mortality, potentially masking differences in care quality.
  • Patients receiving suboptimal care may exhibit similar mortality ratios to those receiving excellent care, compromising comparative analysis.

Conclusions:

  • The accuracy of APACHE in assessing illness severity inherently limits its utility for comparative audits of hospital units.
  • Relying on APACHE scores for comparing ICUs may lead to inaccurate conclusions about standards of care.
  • Alternative methods are needed for robust hospital unit comparison and resource allocation that account for interventions.