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Validation of an Intermediate Care Unit Severity Score (ImCUSS) to a portuguese cohort population
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Introdução: Quando se procura uma definição para Unidades de Cuidados Intermédios pela literatura médica existente, deparamo-nos com uma grande diversidade de formatos e conceitos, o que torna difícil a comparação de dados. Dito isto, é comum ocorrer a adaptação de scores de Cuidados Intensivos, apesar de tal ter resultados contraditórios, no contexto de Cuidados Intermédios. Em 2015, surgiu um novo score, especificamente feito a pensar em Cuidados Intermédios, chamado de ImCUSS, cujo valor preditivo tem vindo a ser posto em causa.
Objetivos: Validação do ImCUSS, explorando o valor preditivo para outcome desfavorável (mortalidade hospitalar). Adicionalmente, propõe-se um endpoint composto (mortalidade e necessidade de ventilação mecânica invasiva).
Métodos: Realizou-se um estudo retrospetivo de Junho a Novembro de 2018, numa Unidade de Cuidados Intermédios no Hospital Santa Maria. Com esse intuito, foram colhidos dados clínicos, o SAPSII e SOFA à admissão e calculado o ImCUSS. Para avaliar a performance de cada score, foi determinada a discriminação e a calibração, através da área sob a curva de ROC e o teste de Hosmer-Lemeshow, respetivamente e ainda a taxa de mortalidade normalizada.
Resultados: Foram incluídos 244 doentes. Em suma, o SAPS II foi o score com melhor discriminação, embora subestime significativamente a mortalidade. O ImCUSS, apesar de também subestimar, foi o score que obteve a mortalidade prevista mais próxima da observada. Estes resultados ficaram aquém dos estudos prévios, sendo uma justificação para tal diferença a variabilidade populacional. Salientar que o ImCUSS com o endpoint composto proposto pelo grupo conseguiu a menor diferença entre os valores esperado e observado. Conclusão: Em suma, atualmente, é prematura a inclusão do ImCUSS como preditor de mortalidade intra-hospitalar nas Unidades de Cuidados Intermédios. Contudo, achados promissores foram encontrados ao analisar o ImCUSS com um endpoint composto, algo a investigar no futuro por outros centros hospitalares
Background: When in search of a definition of Intermediate Care Units (ImCUs) throughout medical literature, high diversity in formats and concepts renders it difficult to compare data. Commonly, adaptation from typical Intensive Care Unit scores occurs, although this has presented conflicting results in ImCU patients. In 2015, a new score, specifically designed for ImCUs, was presented, the Intermediate Care Unit Severity Score (ImCUSS). Since then, its predictive value has been questioned. Objectives: We sought to validate ImCUSS and also defined a composite endpoint (death or need for mechanical ventilation) to further validate its predictive value for poor outcome. Methods: We conducted a retrospective study from June to November of 2018, on an ImCU, in Hospital Santa Maria. With that aim in mind, we collected clinical data, SAPS II and SOFA scores, and calculated ImCUSS. To assess the performance of each score we evaluated the discrimination and calibration, using the area under the receiver operating characteristic (AUROC) and the Hosmer-Lemeshow goodness-of-fit test, respectively and also calculated the standardized mortality ratio (SMR). Results: The cohort included 244 patients. Overall, SAPS II was the score that showed better discrimination, even though markedly underestimated mortality. ImCUSS also underestimated, but its predicted mortality was closest to the observed. Still, these results fall short, comparing to previous studies. The group explores variability in the population as the basis of this discrepancy. It is important to mention that ImCUSS with a composite endpoint had interesting results, as it had the best ratio of observed/expected from all the scores studied. Conclusion: At this time, is still premature to use ImCUSS as a broad predictor of in-hospital mortality for ImCUs. However, new and promising findings were found for ImCUSS with a composite endpoint, that should be assessed in other centers.
Background: When in search of a definition of Intermediate Care Units (ImCUs) throughout medical literature, high diversity in formats and concepts renders it difficult to compare data. Commonly, adaptation from typical Intensive Care Unit scores occurs, although this has presented conflicting results in ImCU patients. In 2015, a new score, specifically designed for ImCUs, was presented, the Intermediate Care Unit Severity Score (ImCUSS). Since then, its predictive value has been questioned. Objectives: We sought to validate ImCUSS and also defined a composite endpoint (death or need for mechanical ventilation) to further validate its predictive value for poor outcome. Methods: We conducted a retrospective study from June to November of 2018, on an ImCU, in Hospital Santa Maria. With that aim in mind, we collected clinical data, SAPS II and SOFA scores, and calculated ImCUSS. To assess the performance of each score we evaluated the discrimination and calibration, using the area under the receiver operating characteristic (AUROC) and the Hosmer-Lemeshow goodness-of-fit test, respectively and also calculated the standardized mortality ratio (SMR). Results: The cohort included 244 patients. Overall, SAPS II was the score that showed better discrimination, even though markedly underestimated mortality. ImCUSS also underestimated, but its predicted mortality was closest to the observed. Still, these results fall short, comparing to previous studies. The group explores variability in the population as the basis of this discrepancy. It is important to mention that ImCUSS with a composite endpoint had interesting results, as it had the best ratio of observed/expected from all the scores studied. Conclusion: At this time, is still premature to use ImCUSS as a broad predictor of in-hospital mortality for ImCUs. However, new and promising findings were found for ImCUSS with a composite endpoint, that should be assessed in other centers.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2021
Palavras-chave
Cuidados intermédios Intermediate Care Unit Severity Score (ImCUSS) Risco de mortalidade Risco de necessidade de escalada de cuidados