Identification of high-risk subgroups in very elderly intensive care unit patients

INTRODUCTION: Current prognostic models for intensive care unit (ICU) patients have not been specifically developed or validated in the very elderly. The aim of this study was to develop a prognostic model for ICU patients 80 years old or older to predict in-hospital mortality by means of data obtained within 24 hours after ICU admission. Aside from having good overall performance, the model was designed to reliably and specifically identify subgroups at very high risk of dying. METHODS: A total of 6,867 consecutive patients 80 years old or older from 21 Dutch ICUs were studied. Data necessary to calculate the Glasgow Coma Scale, Acute Physiology and Chronic Health Evaluation II, Simplified Acute Physiology Score II (SAPS II), Mortality Probability Models II scores, and ICU and hospital survival were recorded. Data were randomly divided into a developmental (n = 4,587) and a validation (n = 2,289) set. By means of recursive partitioning analysis, a classification tree predicting in-hospital mortality was developed. This model was compared with the original SAPS II model and with the SAPS II model after recalibration for very elderly ICU patients in the Netherlands. RESULTS: Overall performance measured by the area under the receiver operating characteristic curve and by the Brier score was similar for the classification tree, the original SAPS II model, and the recalibrated SAPS II model. The tree identified most patients with very high risk of mortality (9.2% of patients versus 8.9% for the original SAPS II and 5.9% for the recalibrated SAPS II had a risk of more than 80%). With a cut-point at a risk of 80%, the positive predictive values were 0.88 for the tree, 0.83 for the original SAPS II, and 0.87 for the recalibrated SAPS II. CONCLUSION: Prognostic models with good overall performance may also reliably identify subgroups of very elderly ICU patients who have a very high risk of dying before hospital discharge. The classification tree has the advantage of identifying the separate factors contributing to bad outcome and of using few variables. Up to 9.5% of patients were found to have a risk to die of more than 85%.