PubMed Health⌕ Search

Biomedical subjects

E A Draper

Publications and source records attributed to E A Draper.

At least 19 recordsLinked to original sources
PubMed1992

Reliability of a measure of severity of illness: acute physiology of chronic health evaluation--II.

This study examines how reliably the components of the APACHE II score (Acute Physiology Score (APS), age and chronic health) are abstracted from the medical record in terms of inter-rater reproducibility (Intraclass Correlation Coefficient [ICC], kappa). In the sample studied, assignment of the APS is highly reproducible (ICC = 0.90). Reproducibility of the age variable (ICC = 0.998) suggests that age is accurately abstracted. Chronic health data does not fare as well as the APS and age (kappa = 0.66). This study suggests that the components of the APACHE II score can be collected reliably.

Abstracting and Indexing↗
PubMed1991

The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults.

The objective of this study was to refine the APACHE (Acute Physiology, Age, Chronic Health Evaluation) methodology in order to more accurately predict hospital mortality risk for critically ill hospitalized adults. We prospectively collected data on 17,440 unselected adult medical/surgical intensive care unit (ICU) admissions at 40 US hospitals (14 volunteer tertiary-care institutions and 26 hospitals randomly chosen to represent intensive care services nationwide). We analyzed the relationship between the patient's likelihood of surviving to hospital discharge and the following predictive variables: major medical and surgical disease categories, acute physiologic abnormalities, age, preexisting functional limitations, major comorbidities, and treatment location immediately prior to ICU admission. The APACHE III prognostic system consists of two options: (1) an APACHE III score, which can provide initial risk stratification for severely ill hospitalized patients within independently defined patient groups; and (2) an APACHE III predictive equation, which uses APACHE III score and reference data on major disease categories and treatment location immediately prior to ICU admission to provide risk estimates for hospital mortality for individual ICU patients. A five-point increase in APACHE III score (range, 0 to 299) is independently associated with a statistically significant increase in the relative risk of hospital death (odds ratio, 1.10 to 1.78) within each of 78 major medical and surgical disease categories. The overall predictive accuracy of the first-day APACHE III equation was such that, within 24 h of ICU admission, 95 percent of ICU admissions could be given a risk estimate for hospital death that was within 3 percent of that actually observed (r2 = 0.41; receiver operating characteristic = 0.90). Recording changes in the APACHE III score on each subsequent day of ICU therapy provided daily updates in these risk estimates. When applied across the individual ICUs, the first-day APACHE III equation accounted for the majority of variation in observed death rates (r2 = 0.90, p less than 0.0001).

Age Factors↗
PubMed1991

Utilizing findings from the APACHE III research to develop operational information system for the ICU--the APACHE III ICU Management System.

The APACHE III data base reflects the disease, physiologic status, and outcome data from 17,400 ICU patients at 40 hospitals, 26 of which were randomly selected from representative geographic regions, bed size, and teaching status. This provides a nationally representative standard for measuring several important aspects of ICU performance. Results from the study have now been used to develop an automated information system to provide real time information about expected ICU patient outcome, length of stay, production cost, and ICU performance. The information system provides several new capabilities to ICU clinicians, clinic, and hospital administrators. Among the system's capabilities are: the ability to compare local ICU performance against predetermined criteria; the ability to forecast nursing requirements; and, the ability to make both individual and group patient outcome predictions. The system also provides improved administrative support by tracking ICU charges at the point of origin and reduces staff workload eliminating the requirement for several manually maintained logs and patient lists. APACHE III has the capability to electronically interface with and utilize data already captured in existing hospital information systems, automated laboratory information systems, and patient monitoring systems. APACHE III will also be completely integrated with several CIS vendors' products.

Databases, Factual↗
PubMed1988

Patient selection for intensive care: a comparison of New Zealand and United States hospitals.

To examine how the use of intensive care varies, we compared 5,030 adult ICU admissions in 13 U.S. hospitals with 1,005 patients in two New Zealand (N.Z.) hospitals. Despite similar national demographic and hospital patient characteristics, there were substantial differences in the use of intensive care. The N.Z. hospitals designated 1.7% of their total beds for intensive care compared to 5.6% in the U.S. hospitals. The average age for N.Z. admissions was 42 compared to 55 in the U.S. (p less than .0001). The N.Z. ICUs admitted fewer patients with severe chronic failing health (N.Z. 8.7%, U.S. 18%) and following elective surgery (N.Z. 8%, U.S. 40%). Approximately half the N.Z. admissions were for trauma, drug overdose, and asthma while these diagnoses accounted for 11% of U.S. admissions. When controlled for differences in case mix and severity of illness, hospital mortality rates in N.Z. were comparable to the U.S. This study demonstrates substantial differences in patient selection among these U.S. and N.Z. ICUs that have equal technical and manpower capabilities and provide similar high-quality intensive care. Physicians from both countries justify the differences on medical criteria; however, both approaches to patient selection cannot be optimal. Additional outcome comparisons between acutely ill patients treated in the U.S. and N.Z. could help refine ICU selection criteria and improve the precision of clinical decision-making.

Adult↗
PubMed1987

Identification of low-risk monitor admissions to medical-surgical ICUs.

A total of 5,790 intensive care unit (ICU) admissions from 13 tertiary care institutions were studied to identify patients who were at such low risk of receiving unique ICU therapies that admission might have been avoided or the length of ICU stay reduced. We used acute severity of disease on admission to the ICU along with the type of disease or surgery to risk stratify individual ICU patients. Among 1,941 patients who only received monitoring services on admission to the ICU, 1,358 (70 percent) were predicted to have less than a 10 percent risk of requiring subsequent active ICU treatment. Only 58 (4.3 percent) of these low-risk patients actually received active treatment. The identification of low-risk patients was equally accurate in estimation and validation data sets. Our methods should allow physicians and hospitals to assess their current ICU utilization and, if appropriate, guide reductions in use.

Diagnosis-Related Groups↗
PubMed1986

The use and implications of do not resuscitate orders in intensive care units.

To describe current "do not resuscitate" (DNR) order writing practices, we studied 7,265 intensive care unit (ICU) admissions at 13 hospitals. All of the ICUs used DNR orders and 39% of all in-unit deaths were preceded by them. Patients with DNR orders were often elderly and in severely failing health. They were more severely ill than other patients in ICUs, and often had multiple organ failure. Most patients with DNR orders (94%) died in the hospital, and 86% died or were discharged from the ICU three days after a DNR order. The frequency of DNR orders ranged from 0.4% to 13.5%, and the mean interval from ICU admission to DNR order was from 5.4 to 24 days. These variations could not be explained by differences in patient characteristics, and may reflect varying physician attitudes. Do not resuscitate orders are now an accepted practice in ICUs and their use follows basic ethical and scientific guidelines. The brief interval between writing a DNR order and death or ICU discharge suggests that they often represent a decision point for placing broader limits on therapy.

Adult↗
PubMed1986

An evaluation of outcome from intensive care in major medical centers.

We prospectively studied treatment and outcome in 5030 patients in intensive care units at 13 tertiary care hospitals. We stratified each hospital's patients by individual risk of death using diagnosis, indication for treatment, and Acute Physiology and Chronic Health Evaluation (APACHE) II score. We then compared actual and predicted death rates using group results as the standard. One hospital had significantly better results with 69 predicted but 41 observed deaths (p less than 0.0001). Another hospital had significantly inferior results with 58% more deaths than expected (p less than 0.0001). These differences occurred within specific diagnostic categories, for medical patients alone and for medical and surgical patients combined, and were related more to the interaction and coordination of each hospital's intensive care unit staff than to the unit's administrative structure, amount of specialized treatment used, or the hospital's teaching status. Our findings support the hypothesis that the degree of coordination of intensive care significantly influences its effectiveness.

Critical Care↗
PubMed1986

Physiologic abnormalities and outcome from acute disease. Evidence for a predictable relationship.

Initial physiologic data from 1625 nonoperative patients with 18 acute life-threatening diseases treated in an intensive care unit suggest a uniform predictable relationship between acute changes in normal physiologic balance and a patient's risk of death. We found that incremental deviations from normal physiologic balance represent equivalent and predictable incremental risks to survival, regardless of the disease initiating the physiologic disturbance. The relative impact of these physiologic abnormalities on outcome may depend on our understanding of the disease's mechanism of action. Diseases for which there is good understanding of underlying pathophysiology and precise treatment appear to have lower death rates throughout the range of physiologic imbalance compared with those for which pathophysiologic knowledge is limited or unknown. These results document the importance of pathophysiologic understanding to improving survival from acute disease. More importantly, they suggest a predictable relationship between risk of death and physiologic abnormalities for a wide range of diseases. The existence of such a relationship could greatly expand our prognostic ability and permit improved evaluation of new therapeutic discoveries.

Acute Disease↗
PubMed1985

Relationship between acute physiologic derangement and risk of death.

Initial evidence from 481 acutely ill patients with 12 major life-threatening diseases suggests a consistent relationship between the magnitude of physiologic derangement and the patient's risk of death. These results were found in postoperative and nonoperative diseases, including gastrointestinal bleeding, intracranial bleeding, pneumonia, congestive heart failure, trauma and hemorrhagic shock. There appear to be substantial differences in the inherent risk of these diseases, but within each diagnosis, the impact of incremental increases in physiologic derangement on mortality appears to be similar. The existence of a uniform relationship in a variety of diagnoses could have important implications for the researcher and clinician wishing to evaluate outcome from intense medical care. It would allow more reproducible and precise stratification of patients by risk of death prior to therapy, thereby improving our understanding of the efficacy of new and existing treatments.

Death↗
PubMed1985

Prognosis in acute organ-system failure.

This prospective study describes the current prognosis of patients in acute Organ System Failure (OSF). Objective definitions were developed for five OSFs, and then 5677 ICU admissions from 13 hospitals were monitored. The number and duration of OSF were linked to outcome at hospital discharge for each of the 2719 ICU patients (48%) who developed OSF. For all medical and most surgical admissions, a single OSF lasting more than 1 day resulted in a mortality rate approaching 40%. Among both medical and surgical patients, two OSFs for more than 1 day increased death rates to 60%. Advanced chronologic age increased both the probability of developing OSF and the probability of death once OSF occurred. Mortality for 99 patients with three or more OSFs persisting after 3 days was 98%. The two patients who survived were both young, in prior excellent health, and had severe but limited primary diseases. These results emphasize the high death rates associated with acute OSF and the rapidity with which mortality increases over time. The prognostic estimates provide reference data for physicians treating similar patients.

Acute Disease↗
PubMed1985

APACHE II: a severity of disease classification system.

This paper presents the form and validation results of APACHE II, a severity of disease classification system. APACHE II uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status to provide a general measure of severity of disease. An increasing score (range 0 to 71) was closely correlated with the subsequent risk of hospital death for 5815 intensive care admissions from 13 hospitals. This relationship was also found for many common diseases. When APACHE II scores are combined with an accurate description of disease, they can prognostically stratify acutely ill patients and assist investigators comparing the success of new or differing forms of therapy. This scoring index can be used to evaluate the use of hospital resources and compare the efficacy of intensive care in different hospitals or over time.

Acute Disease↗
PubMed1984

The value of measuring severity of disease in clinical research on acutely ill patients.

There are five major factors that determine outcome from disease: (1) disease type, (2) the severity of the disease, (3) the patient's age, (4) his prior health status, and (5) the therapy available. Evaluation of new treatments for various diseases is often done with little information on individual patients' severity. The most widely used method of controlling for acute severity fails to account for interaction among major organ systems and for important threshold effects found within physiologic measurements. To illustrate, we simulated a clinical trial comparing severity and outcome for two groups randomly chosen from 50 consecutive respiratory failure patients. Mean values for a variety of clinical, demographic, and physiologic measures were similar. A severity of disease classification, however, predicted differential mortality (25% vs 37%) that matched actual death rates. Uniform and accurate measurement of acute severity of disease in individual patients could improve the precision of clinical research.

Acute Disease↗
PubMed1984

Initial international use of APACHE. An acute severity of disease measure.

We need objective and reliable ways of measuring the severity of disease of hospitalized patients. This paper demonstrates the international predictive accuracy of a severity of disease measure on 1504 consecutive, unscheduled intensive care admissions to 14 hospitals in the United States, France, Spain, and Finland. Using laboratory data gathered within 24 hours of ICU admission, the Acute Physiology Score of APACHE (Acute Physiology and Chronic Health Evaluation) was a strong and stable predictor of hospital survival and concurrent therapeutic effort. In ordinary least squares and logistic multiple regression analysis, the impact of the Acute Physiology Score (APS) was highly significant (p less than 0.001) and of virtually identical magnitude in the United States and European hospitals. The use of this severity of disease measure should help researchers gain insights concerning the efficacy of medical services and the characteristics of physician decision making by permitting more precise prognostic stratification of severely ill patients.

Costs and Cost Analysis↗