Identifying potentially ineffective care in the sickest critically III patients on the third ICU day

Bekele Afessa, Mark T. Keegan, Zulfiqar Mohammad, Javier D. Finkielman, Steve G. Peters

Research output: Contribution to journalArticle

Abstract

Objective: To determine if an increase in the third-ICU-day acute physiology score (APS) of the APACHE (acute physiology and chronic health evaluation) III prognostic system can identify potentially ineffective care. Design: Retrospective cohort study. Setting: Academic medical center. Patients: Adult patients with first-ICU-day predicted mortality rate ≥ 80%. Measurements: Demographics, ICU admission source, admission type, ICU admission diagnosis, first- and third-ICU-day APSs, APACHE III score, APACHE III-predicted hospital mortality, hospital discharge status, 100-day survival, and ICU and hospital length of stay. Results: A total of 302 patients (age [mean ± SD], 64.7 ± 15.8 years; 54.3% male gender) were included in the study. Respiratory failure was the most common reason for ICU admission. Nonoperative admissions accounted for 94.7%. The first- and third-ICU-day APSs were 106.8 ± 19.8 and 70.5 ± 29.9, respectively. The first- and third-ICU-day predicted hospital mortality rates were 87.8 ± 5.3% and 86.5 ± 14.8%, respectively. The hospital mortality rate was 61.3%, and the 100-day survival rate 28.5%. The third-ICU-day APS was higher than the first-ICU-day APS in 34 patients (11.3%). Only 2 of these 34 patients (6%) survived to hospital discharge, compared to 115 of 268 patients (43%) without an increase in APS (p <0.0001). Of the two hospital survivors with increased APS, only one patient survived 100 days after hospital discharge. In predicting 100-day mortality, the sensitivity of an increase in the third-ICU-day APS was 15.3% (95% confidence interval, 11.1 to 20.7%), specificity was 98.8% (95% confidence interval, 93.7 to 99.8%), positive predictive value was 97.1% (95% confidence interval, 85.1 to 99.5%), and negative predictive value was 31.7% (95% confidence interval, 26.4 to 37.5%). Conclusions: A higher APS on the third ICU day, compared to the first ICU day, identifies potentially ineffective care in patients with the first-day predicted hospital mortality rate ≥ 80%.

Original languageEnglish (US)
Pages (from-to)1905-1909
Number of pages5
JournalChest
Volume126
Issue number6
DOIs
StatePublished - Dec 2004
Externally publishedYes

Fingerprint

Hospital Mortality
APACHE
Mortality
Confidence Intervals
Length of Stay
Respiratory Insufficiency
Survivors
Patient Care
Cohort Studies
Survival Rate
Retrospective Studies
Demography
Survival

Keywords

  • Acute physiology and chronic health evaluation
  • Hospital mortality
  • ICU
  • Length of stay
  • Medical futility
  • Prognosis

ASJC Scopus subject areas

  • Pulmonary and Respiratory Medicine

Cite this

Afessa, B., Keegan, M. T., Mohammad, Z., Finkielman, J. D., & Peters, S. G. (2004). Identifying potentially ineffective care in the sickest critically III patients on the third ICU day. Chest, 126(6), 1905-1909. https://doi.org/10.1378/chest.126.6.1905

Identifying potentially ineffective care in the sickest critically III patients on the third ICU day. / Afessa, Bekele; Keegan, Mark T.; Mohammad, Zulfiqar; Finkielman, Javier D.; Peters, Steve G.

In: Chest, Vol. 126, No. 6, 12.2004, p. 1905-1909.

Research output: Contribution to journalArticle

Afessa, B, Keegan, MT, Mohammad, Z, Finkielman, JD & Peters, SG 2004, 'Identifying potentially ineffective care in the sickest critically III patients on the third ICU day', Chest, vol. 126, no. 6, pp. 1905-1909. https://doi.org/10.1378/chest.126.6.1905
Afessa, Bekele ; Keegan, Mark T. ; Mohammad, Zulfiqar ; Finkielman, Javier D. ; Peters, Steve G. / Identifying potentially ineffective care in the sickest critically III patients on the third ICU day. In: Chest. 2004 ; Vol. 126, No. 6. pp. 1905-1909.
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abstract = "Objective: To determine if an increase in the third-ICU-day acute physiology score (APS) of the APACHE (acute physiology and chronic health evaluation) III prognostic system can identify potentially ineffective care. Design: Retrospective cohort study. Setting: Academic medical center. Patients: Adult patients with first-ICU-day predicted mortality rate ≥ 80{\%}. Measurements: Demographics, ICU admission source, admission type, ICU admission diagnosis, first- and third-ICU-day APSs, APACHE III score, APACHE III-predicted hospital mortality, hospital discharge status, 100-day survival, and ICU and hospital length of stay. Results: A total of 302 patients (age [mean ± SD], 64.7 ± 15.8 years; 54.3{\%} male gender) were included in the study. Respiratory failure was the most common reason for ICU admission. Nonoperative admissions accounted for 94.7{\%}. The first- and third-ICU-day APSs were 106.8 ± 19.8 and 70.5 ± 29.9, respectively. The first- and third-ICU-day predicted hospital mortality rates were 87.8 ± 5.3{\%} and 86.5 ± 14.8{\%}, respectively. The hospital mortality rate was 61.3{\%}, and the 100-day survival rate 28.5{\%}. The third-ICU-day APS was higher than the first-ICU-day APS in 34 patients (11.3{\%}). Only 2 of these 34 patients (6{\%}) survived to hospital discharge, compared to 115 of 268 patients (43{\%}) without an increase in APS (p <0.0001). Of the two hospital survivors with increased APS, only one patient survived 100 days after hospital discharge. In predicting 100-day mortality, the sensitivity of an increase in the third-ICU-day APS was 15.3{\%} (95{\%} confidence interval, 11.1 to 20.7{\%}), specificity was 98.8{\%} (95{\%} confidence interval, 93.7 to 99.8{\%}), positive predictive value was 97.1{\%} (95{\%} confidence interval, 85.1 to 99.5{\%}), and negative predictive value was 31.7{\%} (95{\%} confidence interval, 26.4 to 37.5{\%}). Conclusions: A higher APS on the third ICU day, compared to the first ICU day, identifies potentially ineffective care in patients with the first-day predicted hospital mortality rate ≥ 80{\%}.",
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AU - Keegan, Mark T.

AU - Mohammad, Zulfiqar

AU - Finkielman, Javier D.

AU - Peters, Steve G.

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N2 - Objective: To determine if an increase in the third-ICU-day acute physiology score (APS) of the APACHE (acute physiology and chronic health evaluation) III prognostic system can identify potentially ineffective care. Design: Retrospective cohort study. Setting: Academic medical center. Patients: Adult patients with first-ICU-day predicted mortality rate ≥ 80%. Measurements: Demographics, ICU admission source, admission type, ICU admission diagnosis, first- and third-ICU-day APSs, APACHE III score, APACHE III-predicted hospital mortality, hospital discharge status, 100-day survival, and ICU and hospital length of stay. Results: A total of 302 patients (age [mean ± SD], 64.7 ± 15.8 years; 54.3% male gender) were included in the study. Respiratory failure was the most common reason for ICU admission. Nonoperative admissions accounted for 94.7%. The first- and third-ICU-day APSs were 106.8 ± 19.8 and 70.5 ± 29.9, respectively. The first- and third-ICU-day predicted hospital mortality rates were 87.8 ± 5.3% and 86.5 ± 14.8%, respectively. The hospital mortality rate was 61.3%, and the 100-day survival rate 28.5%. The third-ICU-day APS was higher than the first-ICU-day APS in 34 patients (11.3%). Only 2 of these 34 patients (6%) survived to hospital discharge, compared to 115 of 268 patients (43%) without an increase in APS (p <0.0001). Of the two hospital survivors with increased APS, only one patient survived 100 days after hospital discharge. In predicting 100-day mortality, the sensitivity of an increase in the third-ICU-day APS was 15.3% (95% confidence interval, 11.1 to 20.7%), specificity was 98.8% (95% confidence interval, 93.7 to 99.8%), positive predictive value was 97.1% (95% confidence interval, 85.1 to 99.5%), and negative predictive value was 31.7% (95% confidence interval, 26.4 to 37.5%). Conclusions: A higher APS on the third ICU day, compared to the first ICU day, identifies potentially ineffective care in patients with the first-day predicted hospital mortality rate ≥ 80%.

AB - Objective: To determine if an increase in the third-ICU-day acute physiology score (APS) of the APACHE (acute physiology and chronic health evaluation) III prognostic system can identify potentially ineffective care. Design: Retrospective cohort study. Setting: Academic medical center. Patients: Adult patients with first-ICU-day predicted mortality rate ≥ 80%. Measurements: Demographics, ICU admission source, admission type, ICU admission diagnosis, first- and third-ICU-day APSs, APACHE III score, APACHE III-predicted hospital mortality, hospital discharge status, 100-day survival, and ICU and hospital length of stay. Results: A total of 302 patients (age [mean ± SD], 64.7 ± 15.8 years; 54.3% male gender) were included in the study. Respiratory failure was the most common reason for ICU admission. Nonoperative admissions accounted for 94.7%. The first- and third-ICU-day APSs were 106.8 ± 19.8 and 70.5 ± 29.9, respectively. The first- and third-ICU-day predicted hospital mortality rates were 87.8 ± 5.3% and 86.5 ± 14.8%, respectively. The hospital mortality rate was 61.3%, and the 100-day survival rate 28.5%. The third-ICU-day APS was higher than the first-ICU-day APS in 34 patients (11.3%). Only 2 of these 34 patients (6%) survived to hospital discharge, compared to 115 of 268 patients (43%) without an increase in APS (p <0.0001). Of the two hospital survivors with increased APS, only one patient survived 100 days after hospital discharge. In predicting 100-day mortality, the sensitivity of an increase in the third-ICU-day APS was 15.3% (95% confidence interval, 11.1 to 20.7%), specificity was 98.8% (95% confidence interval, 93.7 to 99.8%), positive predictive value was 97.1% (95% confidence interval, 85.1 to 99.5%), and negative predictive value was 31.7% (95% confidence interval, 26.4 to 37.5%). Conclusions: A higher APS on the third ICU day, compared to the first ICU day, identifies potentially ineffective care in patients with the first-day predicted hospital mortality rate ≥ 80%.

KW - Acute physiology and chronic health evaluation

KW - Hospital mortality

KW - ICU

KW - Length of stay

KW - Medical futility

KW - Prognosis

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