Results from the national sepsis practice survey: predictions about mortality and morbidity and recommendations for limitation of care orders.
Results from the national sepsis practice survey: predictions about mortality and morbidity and recommendations for limitation of care orders.
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DOI：
10.1186/cc7926
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发表时间：
2009
期刊：
影响因子：
--
通讯作者：
Lemeshow S
中科院分区：
文献类型：
--
作者：
O'Brien JM Jr;Aberegg SK;Ali NA;Diette GB;Lemeshow S
重症患者和家属依赖医生提供预后估计和护理建议。关于影响这些预测的患者和临床医生因素知之甚少。这些预测与持续积极护理建议之间的关联也未得到充分研究。我们管理一个基于邮件的调查与模拟临床小插曲随机抽样的重症监护大会的美国胸科协会。插图代表了一名感染性休克伴多器官衰竭的患者，APACHE II评分相同，且脓毒症相关器官衰竭。Vignets因年龄（50或70岁）、体重指数（BMI）（正常或肥胖）和合并症（无或最近诊断的IIA期肺癌）而异。所有受试者都收到了试点测试中具有最高和最低死亡率预测的小插曲以及另外两个随机选择的小插曲。受访者估计的结果和选择的护理每个假设的病人。尽管疾病严重程度相同，但住院死亡率（第5至第95百分位数范围，17%至78%）和自我护理问题（第5至第95百分位数范围，2%至74%）的估计范围很宽。当临床因素（年龄、BMI和合并症）相同时，观察到类似的变化。估计医院死亡率和幸存者自我护理问题在肥胖BMI（分别高出4.3%和5.3%），年龄较大（分别高出8.2%和11.6%）和癌症诊断（分别高出5.9%和6.9%）的小插曲中显着更高。较高的死亡率估计值（预测死亡率每增加10%调整后的比值比为1.29）、自我护理感知问题（预测自我护理问题每增加10%调整后的比值比为1.26）和早期肺癌（调整后的比值比为5.82）与限制护理的建议独立相关。所研究的临床因素始终与较差的预后预测相关，但不能解释经验丰富的医生提供的诊断的变化。这些观察结果引起了人们的关注，即所提供的信息和由此产生的决定，继续积极的护理可能会受到个别医生的看法。为了提供更可靠和准确的结果估计，需要将患者特征和偏好与医生预测和实践相结合的工具。
Critically ill patients and families rely upon physicians to provide estimates of prognosis and recommendations for care. Little is known about patient and clinician factors which influence these predictions. The association between these predictions and recommendations for continued aggressive care is also understudied. We administered a mail-based survey with simulated clinical vignettes to a random sample of the Critical Care Assembly of the American Thoracic Society. Vignettes represented a patient with septic shock with multi-organ failure with identical APACHE II scores and sepsis-associated organ failures. Vignettes varied by age (50 or 70 years old), body mass index (BMI) (normal or obese) and co-morbidities (none or recently diagnosed stage IIA lung cancer). All subjects received the vignettes with the highest and lowest mortality predictions from pilot testing and two additional, randomly selected vignettes. Respondents estimated outcomes and selected care for each hypothetical patient. Despite identical severity of illness, the range of estimates for hospital mortality (5th to 95th percentile range, 17% to 78%) and for problems with self-care (5th to 95th percentile range, 2% to 74%) was wide. Similar variation was observed when clinical factors (age, BMI, and co-morbidities) were identical. Estimates of hospital mortality and problems with self-care among survivors were significantly higher in vignettes with obese BMIs (4.3% and 5.3% higher, respectively), older age (8.2% and 11.6% higher, respectively), and cancer diagnosis (5.9% and 6.9% higher, respectively). Higher estimates of mortality (adjusted odds ratio 1.29 per 10% increase in predicted mortality), perceived problems with self-care (adjusted odds ratio 1.26 per 10% increase in predicted problems with self-care), and early-stage lung cancer (adjusted odds ratio 5.82) were independently associated with recommendations to limit care. The studied clinical factors were consistently associated with poorer outcome predictions but did not explain the variation in prognoses offered by experienced physicians. These observations raise concern that provided information and the resulting decisions about continued aggressive care may be influenced by individual physician perception. To provide more reliable and accurate estimates of outcomes, tools are needed which incorporate patient characteristics and preferences with physician predictions and practices.
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影响因子：
7.2
作者：
Asch, DA;Jedrziewski, MK;Christakis, NA
通讯作者：
Christakis, NA
影响因子：
8.8
作者：
O'Brien, JM;Phillips, GS;Lemeshow, S
通讯作者：
Lemeshow, S
影响因子：
39.2
作者：
O'Brien, JM;Welsh, CH;Kramer, AM
通讯作者：
Kramer, AM
影响因子：
8.8
作者：
Akinnusi, Morohunfolu E.;Pineda, Lilibeth A.;El Solh, Ali A.
通讯作者：
El Solh, Ali A.
影响因子：
38.9
作者：
Sprung, Charles L.;Maia, Paulo;Thijs, Lambertius G.
通讯作者：
Thijs, Lambertius G.