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Prediction of survival of critically ill patients by admission comorbidity
R M Poses1, D K McClish, W R Smith
1Department of Internal Medicine, Medical College of Virginia, Richmond 23298, USA.
Insights
The Charlson index effectively predicts mortality in critically ill patients, outperforming the APACHE II comorbidity score. Detailed comorbidity assessment improves prognostic accuracy for intensive care unit patients.
Area of Science:
- Critical Care Medicine
- Prognostic Research
- Epidemiology
Background:
- Accurate prediction of mortality in critically ill patients is essential for clinical decision-making and resource allocation.
- Comorbidity assessment is a key factor in predicting outcomes for intensive care unit (ICU) patients.
- Existing scoring systems like APACHE II incorporate comorbidity but may not fully capture its impact.
Purpose of the Study:
- To evaluate the predictive performance of the Charlson Comorbidity Index for mortality in critically ill patients.
- To compare the predictive ability of the Charlson index against the comorbidity component (Chronic Health Points) of the APACHE II system.
- To determine if the Charlson index provides additional prognostic information beyond the APACHE II system.
Main Methods:
- Prospective cohort study of 201 critically ill patients admitted to an ICU and intermediate ICU.
- Data collection included all variables for APACHE II scoring and Charlson index calculation.
- Outcome measures were in-hospital death versus survival at discharge; receiver operating characteristic (ROC) curve analysis was used.
Main Results:
- The Charlson index demonstrated significant ability to discriminate between survivors and non-survivors (ROC area = 0.67).
- The Chronic Health Points of APACHE II showed no significant discrimination (ROC area = 0.57), while the full APACHE II system was an excellent predictor (ROC area = 0.87).
- Logistic regression indicated the Charlson index added significant prognostic information to APACHE II components (p = 0.03), but Chronic Health Points did not (p = 0.19).
Conclusions:
- The Charlson index is a valuable tool for predicting mortality in critically ill patients.
- Detailed comorbidity assessment using the Charlson index can enhance prognostic accuracy beyond standard scoring systems like APACHE II.
- Incorporating the Charlson index may improve risk stratification and patient management in intensive care settings.
Abstract:
The objective of this study was to determine how well the Charlson index of comorbidity would predict mortality of critically ill patients; and how the predictive ability of the index would compare with that of the comorbidity component (Chronic Health Points) of the APACHE II system. This prospective cohort study included in its setting an intensive care unit (ICU) and intermediate ICU (IICU) in a teaching hospital. Patients included a previously assembled inception cohort of 201 patients consecutively admitted to either unit, followed until death or discharge from the hospital, excluding patients admitted after coronary artery bypass grafting, for planned dialysis, or transferred to the IICU from another intensive care unit. Main outcome measures were recorded as death in hospital versus survival at discharge. For each patient we had prospectively obtained all data necessary to predict the probability of in-hospital death using the APACHE II system, and to classify comorbidity using the Charlson index. The Charlson index had significant ability to discriminate between patients who would live and who would die (ROC curve area = 0.67, SE = 0.05). The Chronic Health Points component of APACHE II had no significant discriminating ability (ROC area = 0.57, SE = 0.05), although the full APACHE II system was an excellent predictor (area = 0.87, SE = 0.04). Logistic regression analyses suggested that the Charlson index could contribute significant (p = 0.03) prognostic information to that obtained from the components of APACHE II other than Chronic Health, i.e., acute physiological derangement, age, and reason for admission, but the Chronic Health Points component of APACHE II could not so contribute to the rest of APACHE II (p = 0.19). Our conclusion is that use of the detailed information about comorbidity captured by the Charlson index could improve prognostic predictions even for critically ill patients.