Risk-Adjusting Mortality in the Nationwide Veterans Affairs Healthcare System.
Risk-Adjusting Mortality in the Nationwide Veterans Affairs Healthcare System.
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DOI：
10.1007/s11606-021-07377-1
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发表时间：
2022-11
影响因子：
5.7
通讯作者：
Hasselbeck, Rachael
中科院分区：
文献类型：
--
作者：
Prescott, Hallie C.;Kadel, Rajendra P.;Eyman, Julie R.;Freyberg, Ron;Quarrick, Matthew;Brewer, David;Hasselbeck, Rachael
美国退伍军人事务部（VA）医疗保健系统于2005年开始报告重症监护（ICU）入院的风险调整死亡率。然而，尽管VA的死亡率模型已经更新并适应于所有住院患者的风险调整，但最近的模型性能尚未公布。我们试图评估VA的4个标准化死亡率模型的当前性能：急性护理30天死亡率（急性护理SMR-30）; ICU 30天死亡率（ICU SMR-30）;急性护理住院死亡率（急性护理SMR）;和ICU住院死亡率（ICU SMR）。采用分离推导和验证样本的回顾性队列研究。使用衍生数据拟合标准化死亡率模型，并将系数应用于验证样本。纳入了2017-2018财年（推导）和2019财年（验证）期间符合模型入选标准的全国VA住院病例。使用c-统计量评价模型性能，以评估观察到的死亡与预测的死亡的区别和比较，以评估校准。在2017-2019年符合急性护理SMR-30的1，143，351例住院患者中，住院死亡率为1.8%，30天死亡率为4.3%。验证数据中SMR模型的C统计量为0.870（急性护理SMR-30）; 0.864（ICU SMR-30）; 0.914（急性护理SMR）;和0.887（ICU SMR）。SMR-30验证队列中有16，036例死亡（4.29%死亡率），而预测死亡为17，458例（4.67%），反映了0.38%的过度预测。在预测风险的十分位数中，观察到的死亡率与预测的死亡率百分比的绝对差异平均为0.38%，在最高风险的十分位数中观察到的最大误差为1.81%。VA的SMR模型，其中包括患者的生理表现，具有高度的预测性，并表现出良好的校准整体和跨风险十分位数。当前SMR模型的性能与初始ICU SMR模型相似，表明进行了适当的调整和重新校准。在线版本包含补充材料，可通过10.1007/s11606-021-07377-1获得。
The US Veterans Affairs (VA) healthcare system began reporting risk-adjusted mortality for intensive care (ICU) admissions in 2005. However, while the VA’s mortality model has been updated and adapted for risk-adjustment of all inpatient hospitalizations, recent model performance has not been published. We sought to assess the current performance of VA’s 4 standardized mortality models: acute care 30-day mortality (acute care SMR-30); ICU 30-day mortality (ICU SMR-30); acute care in-hospital mortality (acute care SMR); and ICU in-hospital mortality (ICU SMR). Retrospective cohort study with split derivation and validation samples. Standardized mortality models were fit using derivation data, with coefficients applied to the validation sample. Nationwide VA hospitalizations that met model inclusion criteria during fiscal years 2017–2018(derivation) and 2019 (validation) were included. Model performance was evaluated using c-statistics to assess discrimination and comparison of observed versus predicted deaths to assess calibration. Among 1,143,351 hospitalizations eligible for the acute care SMR-30 during 2017–2019, in-hospital mortality was 1.8%, and 30-day mortality was 4.3%. C-statistics for the SMR models in validation data were 0.870 (acute care SMR-30); 0.864 (ICU SMR-30); 0.914 (acute care SMR); and 0.887 (ICU SMR). There were 16,036 deaths (4.29% mortality) in the SMR-30 validation cohort versus 17,458 predicted deaths (4.67%), reflecting 0.38% over-prediction. Across deciles of predicted risk, the absolute difference in observed versus predicted percent mortality was a mean of 0.38%, with a maximum error of 1.81% seen in the highest-risk decile. The VA’s SMR models, which incorporate patient physiology on presentation, are highly predictive and demonstrate good calibration both overall and across risk deciles. The current SMR models perform similarly to the initial ICU SMR model, indicating appropriate adaption and re-calibration. The online version contains supplementary material available at 10.1007/s11606-021-07377-1.
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