Introdução à Medicina II 2011/2012 Class 12 1 Advisors: Rosa Oliveira 2 and Daniel Martins 3
description
Transcript of Introdução à Medicina II 2011/2012 Class 12 1 Advisors: Rosa Oliveira 2 and Daniel Martins 3
1
Case-mix and Optimization of Mortality Prognostic
Scores in Portuguese Pediatric Intensive Care Units
Introdução à Medicina II
2011/2012Class 121
Advisors: Rosa Oliveira2 and Daniel Martins3
2. [email protected]; 3. [email protected];
Table of Contents
2Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
• Introduction• Contextualization
• State of the Art• Background
• Are scores discriminative? And calibrated?• Differences in calibration… Why?• Should scores be recalibrated?• Problems…
• Research Questions• Aims• Methods• Expected results• Results• References• Acknowledgments
PICUs – Pediatric Intensive Care Units
Introduction
3Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
Introduction
Background
Research Questions
Aims
References
Acknowledgements
State of the Art
Contextualization
• A Pediatric Intensive Care Unit (PICU) is an area within a hospital specialized in the care of critically ill infants, children, and teenagers.
• The type and number of patients and the provided health care differs according to its location.
Frankel, Lorry R; DiCarlo, Joseph V (2003). “Pediatric Intensive Care”. In Bernstein, Daniel; Shelov, Steven P. Pediatrics for Medical Students (2nd ed.).
Methods
References
State of the Art
Background
Research Questions
Aims
Acknowledgements
Results
Introduction
Methods
Introduction
Background
Research Questions
Aims
References
Acknowledgements
State of the Art
Methods
Consume human and financial resources
Provide adequate treatment for severely ill children
PICUs – Pediatric Intensive Care Units
Introduction
4PICUs – Pediatric Intensive Care Units
Portuguese PICUs
Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
References
State of the Art
Background
Aims
Acknowledgements
Results
Methods
Research Questions
Introduction
PICUs – Pediatric Intensive Care Units
Introduction
Background
Research Questions
Aims
References
Acknowledgements
State of the Art
Methods
PICUs – Pediatric Intensive Care Units
Introduction
5PICUs – Pediatric Intensive Care Units
Portuguese PICUs
Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
References
State of the Art
Background
Aims
Acknowledgements
Results
Methods
Research Questions
Introduction
Provide adequate treatment for severely ill children
Major health quality resource Pacient stratification
Evaluation
Mortality rate Assistance quality
PICUs – Pediatric Intensive Care Units
Introduction
Background
Research Questions
Aims
References
Acknowledgements
State of the Art
Methods
PICUs – Pediatric Intensive Care Units
Introduction
6PICUs – Pediatric Intensive Care Units
Portuguese PICUs
Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
References
State of the Art
Background
Aims
Acknowledgements
Results
Methods
Research Questions
Introduction
Provide adequate treatment for severely ill children
Major health quality resource Pacient stratification
Evaluation
Mortality rate Assistance quality
PICUs – Pediatric Intensive Care Units
Introduction
Background
Research Questions
Aims
References
Acknowledgements
State of the Art
Methods
PICUs – Pediatric Intensive Care Units
Introduction
7PICUs – Pediatric Intensive Care Units
Portuguese PICUs
Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
References
State of the Art
Background
Aims
Acknowledgements
Results
Methods
Research Questions
Introduction
Provide adequate treatment for severely ill children
Major health quality resource Pacient stratification
Evaluation
Mortality rate Assistance quality
PICUs – Pediatric Intensive Care Units
Introduction
Background
Research Questions
Aims
References
Acknowledgements
State of the Art
Methods
PICUs – Pediatric Intensive Care Units
Introduction
8PICUs – Pediatric Intensive Care Units
Portuguese PICUs
Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
References
State of the Art
Background
Aims
Acknowledgements
Results
Methods
Research Questions
Introduction
Provide adequate treatment for severely ill children
Major health quality resource Pacient stratification
Evaluation
Mortality rate Assistance quality
PICUs – Pediatric Intensive Care Units
Introduction
Background
Research Questions
Aims
References
Acknowledgements
State of the Art
Methods
PICUs – Pediatric Intensive Care Units
Introduction
9PICUs – Pediatric Intensive Care Units
Portuguese PICUs
Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
References
State of the Art
Background
Aims
Acknowledgements
Results
Methods
Research Questions
Introduction
Provide adequate treatment for severely ill children
Major health quality resource Pacient stratification
Evaluation
Mortalit rate Assistance quality
PICUs – Pediatric Intensive Care Units
Introduction
Background
Research Questions
Aims
References
Acknowledgements
State of the Art
Methods
Consume human and financial resources
PICUs – Pediatric Intensive Care Units
Introduction
10PICUs – Pediatric Intensive Care Units
Portuguese PICUs
Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
References
State of the Art
Background
Aims
Acknowledgements
Results
Methods
Research Questions
Introduction
Provide adequate treatment for severely ill children
PICUs – Pediatric Intensive Care Units
Mortality Prognostic Scores
PIM PRISM
Introduction
11PICUs – Pediatric Intensive Care Units
Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
References
State of the Art
Background
Aims
Acknowledgements
Results
Methods
Research Questions
Introduction
PICUs – Pediatric Intensive Care Units
PIM – Pediatric Index of Mortality; PRISM – Pediatric Risk of Mortality
Mortality Prognostic Scores
PIM PRISM
Introduction
12PICUs – Pediatric Intensive Care Units
Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
References
State of the Art
Background
Aims
Acknowledgements
Results
Methods
Research Questions
Introduction
PICUs – Pediatric Intensive Care Units
PIM – Pediatric Index of Mortality; PRISM – Pediatric Risk of Mortality
Introduction
13PICUs – Pediatric Intensive Care Units
Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
References
State of the Art
Background
Aims
Acknowledgements
Expected results
Methods
Research Questions
Introduction
PICUs – Pediatric Intensive Care Units
PIM – Pediatric Index of Mortality; PRISM – Pediatric Risk of Mortality
PIM PRISM•Elective admission
•Subjacent conditions•Pupil reaction to light•Mecânical ventilation
•Blood Pressure•Blood alcalemia•Oxigen in blood
•Sistolic blood presure•Diastolic blood presure
•Cardic and respiratory frequency•Partial pressure of oxygen in the blood (PaO2)•Partial pressure of carbon dioxide in the blood
(PaCO2)•Glasgow Coma scale
•Pupil reactionsTP/TTP•Total bilirubin
•Potassium and calcium concentrations•Glucose index•Bicarbonate
• Observation during 1h •Observation during 24h
• Parameters in admission and one hour after •The hightest parameter in the first 24 hours
• Amount of information;• Duration of the observation period;
• Moment in which the information is collected. 1
1. Slater, A.M.B., FRACP, FJFICM; Shann, Frank MB, BS, MD, FRACP, FJFICM; the ANZICS Paediatric Study Group, The suitability of the Pediatric Index of Mortality (PIM), PIM2, the Pediatric Risk of Mortality (PRISM), and PRISM III for monitoring the quality of pediatric intensive care in Australia and New Zealand. Pediatric Critical Care Medicine, 2004. 5(5): p. 447-453.
Logit = (-4.873) + (values * Beta) + (0.021 * (absolute(SBP-120))) + (0.071 * (absolute base excess)) + (0.415 * (FiO2/PaO2))
Mortality Prediction Value= eLogit/ (1+eLogit)
State of the Art
Carmen Ferández, J.L.-H., Jose C. Flores, Dolores Galaviz, Marta Rupérez, Kay B. Brandstrup, Amaya Bustinza, Prognosis in critically ill children requiring continuous renal replacement therapy. IPNA, 2005.
State of the Art
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Background
Research Questions
Aims
References
Acknowledgements
Methods
Introduction
Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
References
State of the Art
Background
Aims
Acknowledgements
Results
Methods
Research Questions
Introduction
Are scores discriminative? And calibrated?
“Both PRISM and PIM scores have a good discriminatory performance. The
calibration with PRISM score is good but the PIM score displays poor
calibration.”
Taori RN, L. K., Tullu MS (2010). "Performance of PRISM (Pediatric Risk of Mortality) score and PIM (Pediatric Index of Mortality) score in a tertiary care pediatric ICU." Indian J Pediatr 77(3): 267-271.
Background
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Research Questions
Aims
References
Acknowledgements
Methods
Introduction
State of the Art
Background
Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
References
State of the Art
Background
Aims
Acknowledgements
Results
Methods
Research Questions
Introduction
PIM – Pediatric Index of Mortality; PRISM – Pediatric Risk of Mortality
Diferences in calibration... Why?
Background
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Research Questions
Aims
References
Acknowledgements
Methods
Introduction
State of the Art
Background
Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
References
State of the Art
Background
Aims
Acknowledgements
Results
Methods
Research Questions
Introduction
Different regions
Missing values
Recalibrations
→ Population case-mix→ Type of PICU→ Admission policy→ …
PICUs – Pediatric Intensive Care Units
Should scores be recalibrated?
“Subsequent validation of variables could improve the sensitivity and the
value of severity scoring in the future. Nevertheless, illness
severity scores will never be indicative of absolute irreversibility of disease or
impossibility of survival...” 2
“ In general, scoring systems should be used only in populations similar to
the reference population in which the prediction model was developed.” 1
Wells M, R.-F.J., Luyt DK, Dance M, Lipman J., Poor discriminatory performance of the Pediatric Risk of Mortality (PRISM) score in a South African intensive care unit. Crit Care Med., 1996. 24(9)
Unertl K, K.B., Prognostic scores in intensive care. Anaesthesist., 1997. 46(6): p. 471-80.
Background
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Research Questions
Aims
References
Acknowledgements
Methods
Introduction
State of the Art
Background
Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
References
State of the Art
Background
Aims
Acknowledgements
Results
Methods
Research Questions
Introduction
Problems...
Background
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Research Questions
Aims
References
Acknowledgements
Methods
Introduction
State of the Art
Background
Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
References
State of the Art
Background
Aims
Acknowledgements
Results
Methods
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Introduction
→ Inclusion and exclusion criteria of the data-base;
→ Time of collection;
→ Human resources;
→ Algorithm descalibration through time; → …
Recalibration Background
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PIM
PRISM
PIM-2
PRISM III
Assessment and Optimization of Mortality Pronostic Scores in Portuguese Pediatric Intensive Care
“Are they doing a good job?”
MARTINS, D. A. A. 1; SANTOS, L. R.1; FIGUEIREDO, M. A. R. M.1; GUERRA, M. D. L.1; MAGALHÃES, R. S.1; FRANCISCO, R. M. H.1; REBELO, C. A. B. S. T.1; ABREU, C. A. M. L. M.1; LAIGINHAS, A. R. A.1; DIAS, M. O.1; CHAVES, J. G. A. C.1; OLIVEIRA, R. C. S.1,2;
Aim: To evaluate the Pediatric Risk of Mortality (…) and the Pediatric Index of Mortality (…) performance at Portuguese Pediatric Intensive Care Units, where PIM2-R is the recalibrated PIM2 model using the Australia and New Zealand Pediatric Intensive Care 2008 coefficients (which is for the first time applied and analyzed in Portuguese context).
Lack of calibration and discrimination in Portuguese reality
Research Questions
Aims
References
Acknowledgements
Methods
Introduction
State of the Art
Background
Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
References
State of the Art
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Aims
Acknowledgements
Results
Methods
Background
Introduction
Research Questions
PIM-3
PIM – Pediatric Index of Mortality; PRISM – Pediatric Risk of Mortality
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References
Methods
State of the Art
Background
Research Questions
Aims
Expected results
Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
Carmen Ferández, J.L.-H., Jose C. Flores, Dolores Galaviz, Marta Rupérez, Kay B. Brandstrup, Amaya Bustinza, Prognosis in critically ill children requiring continuous renal replacement therapy. IPNA, 2005.
PIM AND PRISM underestimated the risk of death in other realities
Underestimated risk of death in Portugal
Optimize of the quality of the health care provided
We look forward to...
Acknowledgements
Introduction
We expect...
PIM – Pediatric Index of Mortality; PRISM – Pediatric Risk of Mortality
Results
• How do Pediatric Mortality Prognostic Scores (PIM-2) behave in Portuguese PICUs’ specific groups of diagnosis?
• Is it possible to enhance the performance of PIM-2 with a new recalibration?
• With what purpose are scores used in Portuguese PICUs’?
Research Questions
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Research Questions
Aims
References
Acknowledgements
Methods
Introduction
State of the Art
Background
Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
References
Research Questions
Aims
Acknowledgements
Results
Methods
Background
Introduction
State of the Art
PICUs – Pediatric Intensive Care Units; PIM – Pediatric Index of Mortality
• To assess calibration and discrimination of Pediatric Mortality Prognostic Scores in Portuguese PICUs and in the specific diagnosis groups.
• To recalibrate PIM-2, in the broad-spectrum patients and to specific diagnosis group.
• To evaluate the new model concerning calibration and discrimination
• To understand clinicians awareness of the purpose and use of prognostic mortality scores in Portuguese PICUs.
Specific aims
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Aims
References
Acknowledgements
Methods
Introduction
State of the Art
Background
Research Questions
Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
References
Methods
State of the Art
Background
Research Questions
Aims
Acknowledgements
Results
Introduction
PICUs – Pediatric Intensive Care Units; PIM – Pediatric Index of Mortality
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References
Acknowledgements
Methods
Introduction
State of the Art
Background
Research Questions
Aims
Target Population
Methods
23Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
References
Methods
State of the Art
Background
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Acknowledgements
Results
Introduction
The target population will be all children admitted in Portuguese PICUs.
PICUs – Pediatric Intensive Care Units
References
Acknowledgements
Methods
Introduction
State of the Art
Background
Research Questions
Aims
Sample
Methods
24Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
References
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Acknowledgements
Results
Introduction
Sources: PICUs from Hospital de Santa Maria, Hospital de D. Estefânia, Hospital Fernando da Fonseca, Hospital Geral de S. João, Hospital Pediátrico de Coimbra, Hospital Garcia de Orta, Hospital Geral de Santo António, Hospital da Misericórdia de Paredes and Hospital de Faro.
Children were included in different groups of diagnosis.
PICUs – Pediatric Intensive Care Units
References
Acknowledgements
Methods
Introduction
State of the Art
Background
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Aims
Sample
Methods
25Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
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Introduction
Age(mean) : 2005-2006: 6 y 1 m; 2007-2008: 6 y 1 m.
Lenght of stay(mean): 2005-2006: 182h; 2007-2008: 127h.
43%
57%
Admission Period2005/2006 2007/2008
Male Female
55.8 56.356.343.7
Gender
Planed Unplaned
36.5
63.5
39.6 60,4
Admission Type
References
Acknowledgements
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Introduction
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Background
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Sample
Methods
26Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
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Accidents/
External C
auses
Cardiovascu
lar
Neurological
Respira
toryRenal
Gastrointesti
nal
Oncological
Metabolic/E
ndocrinal/E
lectrolyti
c
Post-proce
dure
Post-operatory
Others
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2.1
9.5
22.8
0.6 0.3 1.5 2.4 2.7
32.3
9.8
17.8
1.1
9.7
18
0.7 0.9 0.4 1.3 0.2
41.1
8.8
Groups Diagnosis
2005/20062007/2008
References
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Methods
Introduction
State of the Art
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Validation
Calibration Discrimination
Methods
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Standardized Mortality Ratio (SMR)
Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
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Validation
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Methods
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Standardized Mortality Ratio (SMR)
Observed deaths / expected deaths
SMR<1.00 SMR=1 SMR>1.00“we are
doing better than
expected”
“we are doing as
expected”
“we are doing worse than expected”
Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
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Validation
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Methods
29Case-mix and Optimization in Mortality Prognostic Scores in Portuguese PICUs
Standardized Mortality Ratio (SMR)
Hosmer-Lemeshow Test
Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
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Validation
Calibration Discrimination
Methods
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Standardized Mortality Ratio (SMR)
Relative Operating Characteristic (ROC)
Curves
Sensitivity vs. 1-Specificity for every
value of the score
Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
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31Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
References
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Introduction
Validation
Calibration DiscriminationStandardized Mortality Ratio
Sensitivity vs. 1-Specificity for every
value of the score
Area under the (AUC)ROC Curve
Relative Operating Characteristic (ROC)
Curves
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Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
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Acknowledgements
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Introduction
AUC – Area Under the ROC Curve
0,70≤AUC<0,80 0,80≤AUC<0,90 0,90≤AUC<1,00 AUC=1,00Acceptable Good Execlent Perfect
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Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
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Introduction
Main study
Surveys of use
Grounding of conclusions
https://docs.google.com/spreadsheet/viewform?pli=1&formkey=dHZpbU9hX1h6cFEyWExnTzNzRHplcnc6MQ#gid=0
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ResultsAgreement* (%)
Clinicians… 1 2 3 4 5 NAwereness of Mortality Prognostic Scores :- Concept 0 0 16,7 55,6 2,78 18
- Use in Portuguese PICUs 0 0 10,5 21,1 47,4 19
- Use in the their specific PICU 0 10,5 21,1 47,4 21,1 19
Access to the scores 0 26,3 10,5 47,4 15,8 19
Idea of scores Calibration to Portuguese reality 5,3 10,5 42,1 36,8 5,3 19
Idea of scores usefulness in Portuguese PICUs 0 0 5,3 89,5 5,3 19
*1 - Total disagreement, …, 5 - Total agreement
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ResultsAgreement* (%)
Clinicians… 1 2 3 4 5 NAwereness of Mortality Prognostic Scores :- Concept 0 0 16,7 55,6 2,78 18
- Use in Portuguese PICUs 0 0 10,5 21,1 47,4 19
- Use in the their specific PICU 0 10,5 21,1 47,4 21,1 19
Access to the scores 0 26,3 10,5 47,4 15,8 19
Idea of scores Calibration to Portuguese reality 5,3 10,5 42,1 36,8 5,3 19
Idea of scores usefulness in Portuguese PICUs 0 0 5,3 89,5 5,3 19
*1 - Total disagreement, …, 5 - Total agreement
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ResultsAgreement* (%)
Clinicians opinion … 1 2 3 4 5 NImpact of:the score use in the their specific PICU 0 0 15,8 78,9 5,3 19
recommended score (in their decision) 57,9 36,8 0 5,3 0 19
a recalibrated score (in their decision) 10,5 26,3 21,1 36,8 5,3 19scores usefulness in clinical practice or PICU structure 5,6 38,9 44,4 11,2 0 18
Of scores abillity todiscriminate the quality of the health care 0 0 21,1 68,4 10,5 19
provide patient stratification 0 0 36,8 57,3 5,3 19
*1 - Total disagreement, …, 5 - Total agreement
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Methods
State of the Art
Background
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Introduction
References
ResultsAgreement* (%)
Clinicians opinion … 1 2 3 4 5 NImpact of:the score use in the their specific PICU 0 0 15,8 78,9 5,3 19
recommended score (in their decision) 57,9 36,8 0 5,3 0 19
a recalibrated score (in their decision) 10,5 26,3 21,1 36,8 5,3 19scores usefulness in clinical practice or PICU structure 5,6 38,9 44,4 11,2 0 18
Of scores abillity todiscriminate the quality of the health care 0 0 21,1 68,4 10,5 19
provide patient stratification 0 0 36,8 57,3 5,3 19
*1 - Total disagreement, …, 5 - Total agreement
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Introduction
References
Results
Clinicians … Yes (%) No(%) NKnowledge of a model 94,7 5,3 19Opinion on the necessity of recalibration in each country 57,9 42,1 19
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Clinicians … Yes (%) No(%) NKnowledge of a model 94,7 5,3 19Opinion on the necessity of recalibration in each country 57,9 42,1 19
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PIM-2 AUC
2002 0,639
2006 0,644
2008 0,647
2005/2006
AUC – Area Under the Curve; PIM – Pediatric Index of Mortality
1-Specificity
Sen
sitiv
ity
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Background
Research Questions
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Acknowledgements
Introduction
References
Results
PIM-2 AUC
2002 0,633
2006 0,632
2008 0,645
2007/2008
AUC – Area Under the Curve; PIM – Pediatric Index of Mortality
1-Specificity
Sens
itivi
ty
42
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Introduction
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Results
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Results
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Results
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Results
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Results
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AUC
PIM2
2002 2006 2008
2005/2006
2007/2008
2005/2006
2007/2008
2005/2006
2007/2008
Accidents/External Causes
0,422 0,498 0,432 0,525 0,405 0,506
Cardiovascular 0,917 0,667 0,833 0,667 0,833 0,667
Neurologic 0,603 0,399 0,609 0,413 0,596 0,406
Respiratory 0,661 0,688 0,657 0,695 0,665 0,693
Postoperative 0,770 0,747 0,755 0,747 0,758 0,699
Others 0,657 0,745 0,674 0,725 0,661 0,716
AUC – Area Under the Curve; PIM – Pediatric Index of Mortality
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Results
AUC
PIM2
2002 2006 2008
2005/2006
2007/2008
2005/2006
2007/2008
2005/2006
2007/2008
Accidents/External Causes
0,422 0,498 0,432 0,525 0,405 0,506
Cardiovascular 0,917 0,667 0,833 0,667 0,833 0,667
Neurologic 0,603 0,399 0,609 0,413 0,596 0,406
Respiratory 0,661 0,688 0,657 0,695 0,665 0,693
Postoperative 0,770 0,747 0,755 0,747 0,758 0,699
Others 0,657 0,745 0,674 0,725 0,661 0,716
AUC – Area Under the Curve; PIM – Pediatric Index of Mortality
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Introduction
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Results
AUC
PIM2
2002 2006 2008
2005/2006
2007/2008
2005/2006
2007/2008
2005/2006
2007/2008
Accidents/External Causes
0,422 0,498 0,432 0,525 0,405 0,506
Cardiovascular 0,917 0,667 0,833 0,667 0,833 0,667
Neurologic 0,603 0,399 0,609 0,413 0,596 0,406
Respiratory 0,661 0,688 0,657 0,695 0,665 0,693
Postoperative 0,770 0,747 0,755 0,747 0,758 0,699
Others 0,657 0,745 0,674 0,725 0,661 0,716
AUC – Area Under the Curve; PIM – Pediatric Index of Mortality
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Results
• New Algorithm:
o PIM-2 IM=(-0.015 x SBP)+(4.270 x PUPIL REACTION)+ - 0.011 x mm)+(0.040 x BASE EXCESS)+(- 0.695 x VENTILATION)+(- 3.019 x PLANED ADMISSION)+(-1.099 x POST OPERATORY)+(19.805 x CARDIAC SURGERY)+(0.702 x RECOVERY)+(0.426 x DIGESTIVE) + 2.779
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Results
PIM-2 AUC
2002 0,633
2006 0,632
2008 0,645
2007/2008
AUC – Area Under the Curve; PIM – Pediatric Index of Mortality
1-Specificity
Sens
itivi
ty
PIM-2 AUC
IM 0,875
50
Results
Methods
State of the Art
Background
Research Questions
Aims
Acknowledgements
Introduction
References
Results
51
Results
Methods
State of the Art
Background
Research Questions
Aims
Acknowledgements
Introduction
References
ResultsGroup AUC Chi-square p-value
Accidents/External Causes
0,848 19,336 0,013
Cardiovascular 0,500 5,000 0,172
Neurologic 0,865 7,326 0,502
Respiratory 0,674 10,329 0,243
Postoperative 0,731 7,816 0,452
Others 0,745 8,787 0,361
Group AUC Chi-square p-value
Accidents/External Causes
0,525 11,043 0,199
Cardiovascular 0,667 4,841 0,184
Neurologic 0,413 7,469 0,487
Respiratory 0,695 9,219 0,324
Postoperative 0,747 8,815 0,358
Others 0,725 12,430 0,133
PIM-2 IM
PIM-2 2006
52
Results
Methods
State of the Art
Background
Research Questions
Aims
Acknowledgements
Introduction
References
ResultsGroup AUC Chi-square p-value
Accidents/External Causes
0,848 19,336 0,013
Cardiovascular 0,500 5,000 0,172
Neurologic 0,865 7,326 0,502
Respiratory 0,674 10,329 0,243
Postoperative 0,731 7,816 0,452
Others 0,745 8,787 0,361
Group AUC Chi-square p-value
Accidents/External Causes
0,525 11,043 0,199
Cardiovascular 0,667 4,841 0,184
Neurologic 0,413 7,469 0,487
Respiratory 0,695 9,219 0,324
Postoperative 0,747 8,815 0,358
Others 0,725 12,430 0,133
PIM-2 IM
PIM-2 2006
53
Results
Methods
State of the Art
Background
Research Questions
Aims
Acknowledgements
Introduction
References
Conclusions and Discussion
PIM-2 showed acceptable discrimination but poor calibration in specific diagnosis groups and in general Portuguese PICUs.
Recalibrated version of PIM-2 showed better discrimination and calibration either in specific diagnosis groups either general Portuguese PICUs than the ones used nowadays.
Mortality Prognostic Scores’ importance is recognized in Portuguese PICUs, however:
Clinicians don’t feel the need of a recalibration Scores don’t frequently lead to a change in clinical practice.
54
Results
Methods
State of the Art
Background
Research Questions
Aims
Acknowledgements
Introduction
References
Conclusions and Discussion
PIM-2 showed acceptable discrimination but poor calibration in specific diagnosis groups and in general Portuguese PICUs.
Recalibrated version of PIM-2 showed better discrimination and calibration either in specific diagnosis groups either general Portuguese PICUs than the ones used nowadays.
Mortality Prognostic Scores’ importance is recognized in Portuguese PICUs, however:
Clinicians don’t feel the need of a recalibration Scores don’t frequently lead to a change in clinical
practice.
55
Results
Methods
State of the Art
Background
Research Questions
Aims
Acknowledgements
Introduction
References
Conclusions and Discussion
PIM-2 showed acceptable discrimination but poor calibration in specific diagnosis groups, and in general Portuguese PICUs.
Recalibrated version of PIM-2 showed better discrimination and calibration either in specific diagnosis groups and general Portuguese PICUs than the ones used nowadays.
Mortality Prognostic Scores’ importance is recognized in Portuguese PICUs, however:
Clinicians don’t feel the need of a recalibration Scores don’t frequently lead to a change in clinical
practice.
• Anthony R. Brady, D.H., Stephanie Black, Sam Jones, Kathy Rowan, Gale Pearson, Jane Ratcliffe and Gareth J. Parry, Assessment and Optimization of Mortality Prediction Tools for Admissions to Pediatric Intensive Care in the United Kingdom. Pediatrics, 2006. 117;
• Carmen Ferández, J.L.-H., Jose C. Flores, Dolores Galaviz, Marta Rupérez, Kay B. Brandstrup, Amaya Bustinza, Prognosis in critically ill children requiring continuous renal replacement therapy. IPNA, 2005;
• César Sánchez, J.L.-H., Santiago Mencía, Javier Urbano, Angel Carrillo and José María Bellón, Clinical severity scores do not predict tolerance to enteral nutrition in critically ill children. British Journal of Nutrition, 2009. 102: p. 191–194;
• Esra Arun Ozer, A.K., Berrak Sarioglu, Oya Halicioglu, Sumer Sutcuoglu, and Isin Yaprak, The Comparison of PRISM and PIM Scoring Systems for Mortality Risk in Infantile Intensive Care. Journal of Tropical Pediatrics, 2004. 50;
References
56Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
References
Methods
State of the Art
Background
Research Questions
Aims
Acknowledgements
Results
Introduction
• Ganapathy Balakrishnan, T.A., David Hallworth, Neil S Morton, Prospective evaluation of the Paediatric Risk of Mortality (PRISM) score. Archives ofDisease in Childhood, 1992. 67: p. 196-200.
• Okay, G.A.C.A.F.D.A.F.T.S., Application of the pediatric risk of mortality (PRISM) score and determination of mortality risk factors in a tertiary pediatric intensive care unit. Clinics, 2010. 65.
• Pollack MM, R.U., Getson PR, Pediatric risk of mortality (PRISM) score. Crit Care Med, 1998. 16(11): p. 1110-6.
• Slater, A.M.B., FRACP, FJFICM; Shann, Frank MB, BS, MD, FRACP, FJFICM; the ANZICS Paediatric Study Group, The suitability of the Pediatric Index of Mortality (PIM), PIM2, the Pediatric Risk of Mortality (PRISM), and PRISM III for monitoring the quality of pediatric intensive care in Australia and New Zealand. Pediatric Critical Care Medicine, 2004. 5(5): p. 447-453.
• S. Prieto Espuñes, J.L.-H.C., C. Rey Galán, A. Medina Villanueva, A. Concha Torre y P. Martínez Camblor, Índices pronósticos de mortalidad en cuidados intensivos pediátricos. An Pediatr (Barc), 2007. 66: p. 345-50.
References
57Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
References
Methods
State of the Art
Background
Research Questions
Aims
Acknowledgements
Expected results
Introduction
• S M Tibby, D.T., M Festa, S Hanna, M Hatherill, G Jones, P Habibi, A Durward, I A Murdoch, A comparison of three scoring systems for mortality risk among retrieved intensive care patients. Arch Dis Child, 2002. 87: p. 421-425;
• Vanessa Feller Martha, P.C.R.G., Jefferson Pedro Piva, Paulo Roberto Einloft, Francisco Bruno, Viviane Rampon, Comparação entre dois escores de prognóstico (PRISM e PIM) em unidade de terapia intensiva pediátrica. Jornal de Pediatria, 2005. 81(3): p. 259-64.
References
58Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
References
Methods
State of the Art
Background
Research Questions
Aims
Acknowledgements
Expected results
Introduction
We gratefully acknowledge :• Professor Altamiro Costa Pereira;• Phd Armando Teixeira-Pinto;• Msc Rosa Oliveira;• Daniel Martins;
for their guidance and time
• And you;
For your attention.
PICUs – Pediatric Intensive Care Units
Acknowledgments
59Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units
Methods
State of the Art
Background
Research Questions
Aims
Acknowledgements
Expected results
Introduction
References
The End
60
Introdução à Medicina II
2011/2012Class 121
Advisors: Rosa Oliveira2 and Daniel Martins3
2. [email protected]; 3. [email protected];
Questions?