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[JAMA在线发表]:医生与护士判断ICU患者6个月后生存及功能预后的预测准确性
2017年06月07日 时讯速递, 进展交流 暂无评论

Original Investigation

Caring for the Critically Ill Patient

Discriminative Accuracy of Physician and Nurse Predictions for Survival and Functional Outcomes 6 Months After an ICU Admission

Michael E. Detsky, Michael O. Harhay, Dominique F. Bayard, et al

JAMA. Published online May 21, 2017. doi:10.1001/jama.2017.4078

Abstract

Importance 背景

Predictions of long-term survival and functional outcomes influence decision making for critically ill patients, yet little is known regarding their accuracy.

预测远期生存率及功能状态能够影响危重病患者的医疗决策,但有关预测准确性知之甚少。

Objective 目的

To determine the discriminative accuracy of intensive care unit (ICU) physicians and nurses in predicting 6-month patient mortality and morbidity, including ambulation, toileting, and cognition.

确定ICU医生与护士预测患者6个月后病死率及罹患率(包括活动,如厕及认知能力)的鉴别准确性。

Design, Setting, and Participants 设计,场景及研究人群

Prospective cohort study conducted in 5 ICUs in 3 hospitals in Philadelphia, Pennsylvania, and enrolling patients who spent at least 3 days in the ICU from October 2013 until May 2014 and required mechanical ventilation, vasopressors, or both. These patients’ attending physicians and bedside nurses were also enrolled. Follow-up was completed in December 2014.

在宾州费城3所医院的5个ICU进行的前瞻性队列研究,入选患者为2013年10月至2014年5月期间住ICU至少3天且需要机械通气和(或)升压药物。这些患者的主治医生与床旁护士也同时入选。2014年12月完成随访。

Main Outcomes and Measures 主要预后指标

ICU physicians’ and nurses’ binary predictions of in-hospital mortality and 6-month outcomes, including mortality, return to original residence, ability to toilet independently, ability to ambulate up 10 stairs independently, and ability to remember most things, think clearly, and solve day-to-day problems (ie, normal cognition). For each outcome, physicians and nurses provided a dichotomous prediction and rated their confidence in that prediction on a 5-point Likert scale. Outcomes were assessed via interviews with surviving patients or their surrogates at 6 months. Discriminative accuracy was measured using positive and negative likelihood ratios (LRs), C statistics, and other operating characteristics.

ICU医生与护士对住院病死率,6个月预后(包括病死率,回到住所,独立如厕能力,独立走10阶台阶的能力,以及记忆、思考与解决日常问题能力)作出预测。对上述每个预后指标,医生与护士均作出二分变量预测,并根据5分Likert评分评价其预测的可靠性。在6个月时对于存活患者或其亲属进行随访以评估预后。辨别准确性采用阳性与阴性似然比(LRs)、C统计变量及其他指标进行评估。

Results 结果

Among 340 patients approached, 303 (89%) consented (median age, 62 years [interquartile range, 53-71]; 57% men; 32% African American); 6-month follow-up was completed for 299 (99%), of whom 169 (57%) were alive. Predictions were made by 47 physicians and 128 nurses. Physicians most accurately predicted 6-month mortality (positive LR, 5.91 [95% CI, 3.74-9.32]; negative LR, 0.41 [95% CI, 0.33-0.52]; C statistic, 0.76 [95% CI, 0.72-0.81]) and least accurately predicted cognition (positive LR, 2.36 [95% CI, 1.36-4.12]; negative LR, 0.75 [95% CI, 0.61-0.92]; C statistic, 0.61 [95% CI, 0.54-0.68]). Nurses most accurately predicted in-hospital mortality (positive LR, 4.71 [95% CI, 2.94-7.56]; negative LR, 0.61 [95% CI, 0.49-0.75]; C statistic, 0.68 [95% CI, 0.62-0.74]) and least accurately predicted cognition (positive LR, 1.50 [95% CI, 0.86-2.60]; negative LR, 0.88 [95% CI, 0.73-1.06]; C statistic, 0.55 [95% CI, 0.48-0.62]). Discriminative accuracy was higher when physicians and nurses were confident about their predictions (eg, for physicians’ confident predictions of 6-month mortality: positive LR, 33.00 [95% CI, 8.34-130.63]; negative LR, 0.18 [95% CI, 0.09-0.35]; C statistic, 0.90 [95% CI, 0.84-0.96]). Compared with a predictive model including objective clinical variables, a model that also included physician and nurse predictions had significantly higher discriminative accuracy for in-hospital mortality, 6-month mortality, and return to original residence (P < .01 for all).

在接受筛选的340名患者中,303名(89%)签署知情同意(中位年龄62 岁 [四分位区间,53-71]; 57% 为男性;32% 为美国黑人);299 名患者 (99%) 完成6个月随访,其中 169 名患者 (57%) 存活。47名医生与128名护士对患者预后进行了预测。医生对6个月病死率的预测最为准确(阳性LR, 5.91 [95% CI, 3.74-9.32];阴性LR, 0.41 [95% CI, 0.33-0.52];C统计变量,0.76 [95% CI, 0.72-0.81]),而对认知能力的预测准确性最差(阳性LR, 2.36 [95% CI, 1.36-4.12]; 阴性LR, 0.75 [95% CI, 0.61-0.92]; C统计变量,0.61 [95% CI, 0.54-0.68])。护士对住院病死率的预测最准确(阳性LR, 4.71 [95% CI, 2.94-7.56]; 阴性LR, 0.61 [95% CI, 0.49-0.75]; C统计变量, 0.68 [95% CI, 0.62-0.74]),但对认知能力的预测准确性最低(阳性 LR, 1.50 [95% CI, 0.86-2.60];阴性 LR, 0.88 [95% CI, 0.73-1.06];C统计变量, 0.55 [95% CI, 0.48-0.62])。当医生及护士对其预测结果非常有信心时,辨别准确性最高 (如,医生对6个月病死率的预测有信息时:阳性LR, 33.00 [95% CI, 8.34-130.63]; 阴性 LR, 0.18 [95% CI, 0.09-0.35]; C统计变量, 0.90 [95% CI, 0.84-0.96])。与包括客观临床指标在内的预测模型相比,同时包括医生和护士预测的模型对住院病死率,6个月病死率及回到住所的辨别准确性更高(所有P 值< .01)。

Conclusions and Relevance 结论及意义

ICU physicians’ and nurses’ discriminative accuracy in predicting 6-month outcomes of critically ill patients varied depending on the outcome being predicted and confidence of the predictors. Further research is needed to better understand how clinicians derive prognostic estimates of long-term outcomes.

ICU医生和护士对危重病患者6个月预后的预测准确性依赖于预测指标及预测者的信心。需要进一步的研究以更好理解医务人员如何对远期预后作出预测。

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