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Clinical Investigations in Critical Care |

Comparison of Outcome From Intensive Care Admission After Adjustment for Case Mix by the APACHE III Prognostic System*

John V. Pappachan, FRCA; Brian Millar, BA, RGN; E. David Bennett, FRCP; Gary B. Smith, FRCA
Author and Funding Information

*From the Department of Intensive Care Medicine (Drs. Pappachan and Smith), Queen Alexandra Hospital, Portsmouth, UK; Critical Audit, Ltd. (Mr. Millar), St. George’s Hospital Medical School, London, UK; and Department of Intensive Care Medicine (Dr. Bennett), St. George’s Hospital, London, UK.



Chest. 1999;115(3):802-810. doi:10.1378/chest.115.3.802
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Study objectives: To evaluate the acute physiology, age, chronic health evaluation III (APACHE III) scoring system in the context of general adult ICUs in the United Kingdom.

Design: Prospective, noninterventional, cohort study.

Setting: Seventeen general adult ICUs in a discrete area of southwest England.

Patients: 12,793 patients admitted between April 1, 1993 and December 31, 1995.

Measurements: Sociodemographic and severity-of-illness data were collected for all patients admitted to the study units. Formal goodness-of-fit tests were applied and observed mortality was compared with that predicted by using the APACHE III system.

Results: For the group of ICUs as a whole, the risk-adjusted standardized mortality ratio (SMR) was 1.23 (95% confidence intervals, 1.12–1.25). For 11 out of 17 ICUs, the SMR was significantly greater than unity (p < 0.05). Calibration, as tested by Hosmer-Lemeshow statistics, was poor (H2 = 312.54; C2 = 332.85; df = 8; p < 0.01); however, model discrimination was good with a total correct classification rate of 82.9% and an area under the receiver operating characteristic curve of 0.89.

Conclusions: The excess mortality observed after case-mix adjustment using the APACHE III system in this study may be the result of either poor intensive care performance as compared with the United States or a failure of the APACHE III equation to fit the UK data.

Abbreviations: A&E = accident and emergency; APACHE = acute physiology, age, chronic health evaluation; CI = confidence interval; ROC = receiver operating characteristic; SMR = standardized mortality ratio; TCCR = total correct classification rate

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