The case against using the APACHE system to predict intensive care unit outcome in trauma patients

M. J. Vassar, James W Holcroft, D. Teres, C. M. Watts, W. A. Knaus

Research output: Contribution to journalArticle

21 Scopus citations

Abstract

The use of outcome indices as a means of evaluating institutional performance for delivery of medical care is at the forefront of federal health policy reforms. Because an enormous number of clinical and financial data are generated by ICU patients, it is inevitable that integrated bedside computers will be necessary to supply the type of information that is being sought by governmental and private insurance agencies involved in assessment of hospital performance. The Health Care Financing Administration already has adopted the APACHE data collection protocols and predictive models for the severity of illness adjustments that were used in assessing the 1986 hospital-specific death rate for acute myocardial infarction, congestive heart failure, stroke, and pneumonia. In our opinion, however, it is unlikely that any single system will be developed that can accurately estimate more than 50% of ICU deaths. The intention of the APACHE III system to include 78 diagnostic categories seems unrealistic. Furthermore, the number of data needed to document outcomes for both low- and high-risk admissions is impractical. We are evaluating APACHE III to determine whether the revisions to the definition for head trauma will represent a significant improvement in predicting outcomes for trauma patients. In the interim, the financial investment in the APACHE III automated bedside data collection system cannot be justified for trauma patients. Neither should it be used in ICUs that admit a large number of trauma patients as a tool for monitoring unit efficiency, guiding triage decisions, allocating staff and ICU beds, identifying risks of iatrogenic or other potential complications, or assessing quality of life, in spite of marketing efforts by the APACHE Corporation. We believe that using any of the APACHE systems for these purposes, at best, is premature, and potentially misrepresents the trauma patient population. Standards for patient classification already are in place for use in making determinations for institutional reimbursement from governmental and insurance agencies. The inequities for certain subgroups of patients, including trauma patients, could create situations in which care is rationed rather than allocated according to a plan that distributes resources efficiently. The APACHE system has several shortcomings and adds little, if anything, to the potential solutions for trauma quality assurance and resource allocation. Nor has the APACHE system established procedures for documenting institutional review of unexpected trauma deaths that would be equivalent, for example, to the type of audit filters applied by the American College of Surgeons in conjunction with the TRISS methodology. Unexpected outcomes using data from illness severity systems should serve as a trigger for implementing peer review audits based on predetermined criteria. The APACHE systems, to the best of our knowledge, have no such criteria. Control over the computer technology and data abstracted for quality assurance currently favors the policy makers and hospital administrators. The hospital 'industry' is under pressure to accommodate fiscal constraints associated with increasing costs of ICU care. Clinicians responsible for the care of critically injured patients need to continue to work on solutions to the problems of rising hospital costs, allocation of hospital resources, and evaluation of physician performance. We do not believe that the APACHE III system is likely to be of much more value than the APACHE II system in solving the problems related to trauma care delivery. Until further independent evaluations have been completed, we will remain doubtful about the usefulness of the APACHE system.

Original languageEnglish (US)
Pages (from-to)117-134
Number of pages18
JournalCritical Care Clinics
Volume10
Issue number1
StatePublished - 1994

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine

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