Comparison of the APACHE III, APACHE II and Glasgow Coma Scale in acute head injury for prediction of mortality and functional outcome |
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Authors: | D-Y Cho Y-C Wang |
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Affiliation: | (1) Division of Neurosurgery, China Medical College Hospital, 75 Yuh Der Rd., Taichung, Taiwan, ROC FAX: +886 (4) 203 0639, TW;(2) Division of Neurosurgery, Taichung Veterans General Hospital, 160 Section 3 Taichung Harbor Road, Taichung, Taiwan, ROC FAX: +886 (4) 3741323, TW |
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Abstract: | Objectives: This study examines the efficacy of the predicting power for hospital mortality and functional outcome of three different
scoring systems for head injury in a neurosurgical intensive care unit (NICU).
Design: On the day of admission, data were collected from each patient to compute the Acute Physiology, Age, and Chronic Health
Evaluation (APACHE) II and III, and Glasgow Coma Scale (GCS) scores. Hospital mortality was defined as the deaths of patients
before discharge from hospital. Early mortality was defined as death before the 14th day after admission. Late mortality was
defined as death after the 15th day from admission. Functional outcome was evaluated by Index of Independence in Activities
of Daily Living (Index of ADL).
Setting: An 8-bed NICU in a 1270-bed medical center in Taichung Veterans General Hospital.
Patients and participants: Two hundred non-selected patients with acute head injury were included in our study in a consecutive period of 2 years.
Patients less than 14 years old were not included.
Interventions: None.
Measurements and results: Sensitivity, specificity and correct prediction outcome were measured by the chi-square method in three scoring systems.
The Youden index was also obtained. The best cut-off point in each scoring system was determined by the Youden index. The
difference in Youden index was calculated by Z score. A difference was also considered if the probability value was less than
0.05. The area under Receiver Operating Characteristic (ROC) curve was computed. Then the area under ROC of each scoring system
was compared by Z score. There was statistical significance if p was less than 0.05. For prediction of hospital mortality, the best cut-off points are 55 for APACHE III, 17 for APACHE II
and 5 for GCS. The correct prediction outcome is 82.4% in APACHE III, 78.4% in APACHE II and 81.9% in the GCS. The Youden
index has best cut-off points at 0.68 for APACHE III, 0.59 for APACHE II, and 0.56 for GCS. The area under Receiver Operating
Characteristic (ROC) curve is 0.90 in the APACHE III, 0.84 in the APACHE II and 0.86 in the GCS. There are no statistical
differences among APACHE III and II, and GCS in terms of correct prediction outcome, Youden Index and the area under the ROC
curve. Other physiological variables excluding GCS in APACHE III and II (AP III-GCS, AP II-GCS) have less statistical value
in the determination of mortality for acute head injury. For the prediction of late mortality, APACHE III and II yield significantly
better results in the area under the ROC curve, correct prediction and Youden index than those of GCS. Other physiological
variables (AP III-GCS and AP II-GCS) play an important role in the prediction of late mortality in APACHE scores. For prediction
of the functional outcome of surviving patients with acute head injury, the APACHE III yields the best results of correct
prediction outcome, Youden index and the area under the ROC curve.
Conclusion: The APACHE III and II may not replace the role of GCS in cases of acute head injury for hospital or early mortality assessment.
But for prediction of the late mortality, the APACHE III and II have better accuracy than GCS. Other physiological variables
excluding GCS in the APACHE system play a crucial contribution for late mortality. GCS is simple, less time-consuming and
economical for patients with acute head injury for the prediction of hospital and early mortality. The APACHE III provides
better prediction for severe morbidity than GCS and APACHE II. Therefore, the APACHE III provides a good assessment not only
for hospital and late mortality, but also for functional outcome.
Received: 22 May 1995 Accepted: 2 September 1996 |
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Keywords: | Acute physiology Age and Chronic Health Evaluation (APACHE) Glasgow Coma Scale (GCS) Index of Independence in Activities of Daily Living (Index of ADL) Receiver Operating Characteristic (ROC) Mortality |
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