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Biomedical subjects

D P Wagner

Publications and source records attributed to D P Wagner.

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↗
PubMed1992

An initial comparison of intensive care in Japan and the United States.

OBJECTIVE: The objective of this study was to compare the utilization of, and outcome from, critical care services in selected medical centers providing secondary and tertiary care in the United States and Japan. DESIGN: Prospective data collection on 1,292 patients from each of the participating Japanese study hospitals in 1987 to 1989 and compared with the 5,030 patients in the United States 1982 Acute Physiology and Chronic Health Evaluation (APACHE II) database used to develop the APACHE II equation. Detailed organizational characteristics of the participating ICUs and hospitals were also obtained. SETTING: Data collection took place in the ICUs of 13 U.S. hospitals and six Japanese hospitals. PATIENTS: Data were collected on consecutive, unselected patients from medical, surgical, and mixed medical/surgical critical care units, with a spectrum of medical and surgical diagnoses. MEASUREMENTS AND MAIN RESULTS: U.S. and Japanese ICUs have a similar array of diagnostic and therapeutic modalities. Only 2% (range 0.6 to 3.5) of beds in Japanese hospitals were designated to intensive care. The organization of the Japanese and U.S. ICUs varied by hospital. There were significantly fewer women admitted to Japanese ICUs and a substantially lower proportion of low-risk-of-death patients. Despite a rapidly aging population, there were relatively fewer elderly patients with chronic health ailments in the Japanese ICU population (8%) compared with the U.S. cohort (18%). CONCLUSIONS: In this sample of hospitals, similar high-technology critical care is available in the United States and Japan. Variations in utilization between the two countries represent differences in case mix and bed availability. The APACHE II equation stratified patients in the Japanese patient cohort across the full spectrum of increasing severity of illness.

Chi-Square Distribution↗
PubMed1992

Evaluation of definitions for sepsis.

OBJECTIVE: To evaluate the current definitions for sepsis and clarify and quantify the risk for intensive care unit (ICU) patients with sepsis. DESIGN: A prospective cohort analysis of 519 patients with a primary clinical diagnosis of sepsis treated in the ICUs of 40 US hospitals drawn from a nationally representative sample of 17,440 admissions. MEASUREMENTS: Patient's age, treatment location prior to ICU admission, comorbidities, origin of sepsis, daily physiologic measurements, therapeutic intensity, and subsequent hospital mortality rate. INTERVENTION: Patients were categorized into subgroups by important risk factors and into current clinical definitions of sepsis. Patients also were provided an individual risk of hospital mortality based on their individual predicted risk by using the first ICU day APACHE III score, treatment location prior to ICU admission, and etiology of sepsis. RESULTS: Patients with a designated urinary source of sepsis had a significantly lower baseline risk of death (30 percent) than patients with other causes (54 percent, p less than 0.01). Patients admitted to the ICU from the emergency department also had significantly lower mortality (37 percent) than patients admitted from hospital wards, other units within the hospital, or transferred from other hospitals (55 percent, p less than 0.01). Recognized definitions such as "sepsis syndrome" and "septic shock" identified groups of patients with significantly different mortality rates, 40 percent and 64 percent, respectively (p less than 0.01), but the range of individual patient risks within these groups were indistinguishable from the 211 patients (41 percent) that did not meet these definitions during the initial seven days of ICU treatment. Multivariate analysis using initial APACHE III score, etiology (urosepsis or other), and treatment location prior to ICU admission provided the greatest degree of discrimination (ROC = 0.82) of patients by risk of hospital death. CONCLUSIONS: Sepsis is a complex clinical entity and could be viewed as a continuum with substantial variation in initial severity and risk of hospital death. One accurate description of sepsis is the continuous measure of hospital mortality risk estimated primarily from physiologic abnormalities.

Bacteremia↗
PubMed1991

Short-term mortality predictions for critically ill hospitalized adults: science and ethics.

Modern life-sustaining therapy often succeeds in postponing death but may be ineffective at restoring health. Decisions that influence the time and circumstances of an individual's death are now common and require an accurate and comprehensive characterization of likely outcome. Evaluation of alternative outcomes requires acknowledgement that most patients find some outcomes to be worse than death. Improved understanding of major predictors of patient outcome, combined with rapidly expanding technical abilities to collect and manipulate large amounts of detailed clinical data, have created a new intellectual and technical basis for estimating outcomes from intensive medical care. Such objective probability estimates, such as the system described here, can reduce uncertainty about difficult clinical decisions and can be used by physicians, patients, and society to reorient health care toward more scientifically and ethically defensible approaches.

Adult↗
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↗
PubMed1990

Statistical methods in SUPPORT.

The analysis and interpretation of the data collected in SUPPORT provide great potential for understanding the relationships among treatment choices, patient and physician values and preferences, perceptions about the risks and benefits of treatments, institutional characteristics, and outcomes (as measured by quality of life, survival, and satisfaction). The complicated analyses required to elucidate these relationships will pose many technical challenges in dealing with longitudinal observational data collected from seriously ill patients at multiple sites. Major challenges include the handling of incomplete data, proper parameterization of treatment effects, strategies to avoid various potential biases, validating predictive models, and constructing endpoints that combine survival with quality of life. Within the structure of the SUPPORT study, mechanisms have been established to guide the analyses and to ensure their quality and validity.

Confounding Factors, Epidemiologic↗
PubMed1989

Multiple systems organ failure: epidemiology and prognosis.

This article reviews the basic epidemiologic and prognostic data for the syndrome of MSOF. When MSOF is defined as severe physiologic abnormalities, it occurs following a wide variety of diseases. The distinguishing feature of MSOF appears not to be the underlying etiology, but the uniform and frequently fatal outcome once it develops. This suggests that MSOF may represent a final common pathway to death rather than a clinical syndrome with a single underlying etiology. Regardless of cause, evaluating the incremental impact of new therapy on MSOF will be assisted by the adoption of uniform definitions as well as by the explicit measurement of severity of disease and calculation of individual probabilities of death.

Cross-Sectional Studies↗
PubMed1988

Interlist equivalence of the word intelligibility by picture identification test administered in broad-band noise.

The effect of broad-band noise on the interlist equivalence of the Word Intelligibility by Picture Identification Test (WIPI) was examined. Subjects were 24 normally hearing children aged 6:7-9:1 years (years:months) who were assigned in equal numbers to one of three signal-to-noise ratio (S/N) conditions (S/N = 0, +2, +4dBSPL). Each child was administered all four lists of the WIPI under one of these noise conditions. No significant order, gender or ear effects were observed. Performance increased linearly with increasing S/N. Statistically significant mean differences were seen between lists, and individual interlist pairwise comparisons revealed differences exceeding chance occurrence. Pooled correlations of interlist equivalence were of moderate strength. Caveats regarding clinical application of the WIPI administered in noise are discussed.

Child↗