INTERMACS profiles and modifiers: Heterogeneity of patient classification and the impact of modifiers on predicting patient outcome.
INTERMACS profiles and modifiers: Heterogeneity of patient classification and the impact of modifiers on predicting patient outcome.
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DOI：
10.1016/j.healun.2015.10.037
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发表时间：
2016-04
期刊：
影响因子：
--
通讯作者：
Salerno C
中科院分区：
文献类型：
--
作者：
Cowger J;Shah P;Stulak J;Maltais S;Aaronson KD;Kirklin JK;Pagani FD;Salerno C
INTERMACS患者特征和修饰符是在植入耐久性VAD之前患者疾病严重程度的描述符。目前尚不清楚个别美国机构和从业人员如何分配配置文件，以及修改是否改善了风险区分。基于网络的调查受访者（n=212）回答了有关INTERMACS配置文件分配过程中，他们的机构。对于五个假设的临床场景，受访者分配了最佳配置文件。然后查询INTERMACS登记研究（2009-2014），并计算了两种配置文件之间以及基于临时循环支持（TCS）、频繁飞行（FF）或心律失常调节剂的死亡率的风险比（HR，95%置信区间）。受访者包括131名（62%）心脏病专家，30名（14%）外科医生和51名（24%）医生扩展员/协调员。机构概况分配是可变的（63%由心脏病专家/外科医生分配; 10%由研究协调员分配; 27%由医生扩展器分配）。假设患者情景中的配置文件分配是异质的，特别是对于连续配置文件。剖面1、2和3的1年生存率分别为77± 1.2%、80± 0.7%和84± 0.7%（p<0.001）。虽然曲线1患者的校正生存期低于曲线3（p=0.001），但曲线1与曲线2的生存期相似（校正HR 1.01 [0.88-1.12]）。TCS（校正HR 1.1 [0.94-1.2]）和心律失常（校正HR 1.1 [0.97-1.2]）修饰因子不能预测死亡率，但FF修饰因子可以预测死亡率（HR 1.3 [1.02-1.63]）。在INTERMACS图谱的过程和分配中存在大量异质性。这种异质性可能影响用于风险分层的死亡率估计。只有FF修饰符似乎可以提高风险识别能力，超出已知风险因素的识别能力。添加客观描述符可以减少Profile异质性。
INTERMACS patient Profiles and Modifiers are descriptors of patient illness severity prior to durable VAD implant. It is unknown how individual U.S. institutions and practitioners assign Profiles and if Modifiers improve on risk discrimination. Web-based survey respondents (n=212) answered questions about the INTERMACS Profile assignment process within their institution. For five hypothetical clinical scenarios, respondents assigned the best Profile. The INTERMACS registry (2009–2014) was then queried and hazard ratios (HR, 95% confidence interval) for mortality between Profiles and based on the presence of temporary circulatory support (TCS), Frequent Flyer (FF), or Arrhythmia Modifiers were calculated. Respondents included 131 (62%) cardiologists, 30 (14%) surgeons, and 51 (24%) physician extenders/coordinators. Institutional Profile assignment was variable (63% assigned by cardiologists/surgeons; 10% by research coordinators; 27% by physician extenders). Profile assignments within hypothetical patient scenarios were heterogeneous, especially for contiguous Profiles. One year survivals for Profiles 1, 2, and 3 were 77±1.2%, 80±0.7%, and 84±0.7%, respectively (p<0.001). While Profile 1 patients had worse adjusted survival than Profiles 3 (p=0.001), survival for Profiles 1 vs. 2 was similar (adjusted HR 1.01 [0.88–1.12]). The TCS (adjusted HR 1.1 [0.94–1.2]) and Arrhythmia (adjusted HR 1.1 [0.97–1.2]) modifiers were not predictive of mortality but the FF modifier was (HR 1.3 [1.02–1.63]). Substantial heterogeneity exists in the process and assignment of INTERMACS Profiles. This heterogeneity could impact mortality estimates used for risk stratification. Only the FF modifier appears to improve risk discrimination beyond that of known risk factors. Adding objective descriptors may reduce Profile heterogeneity.
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