Introduction
Methods
Search strategy
Study selection
Quality assessment
Data extraction
Results
Study characteristics
Study | Setting | Study period | Number of patients | Age (years) | Female (%) | Surgical admission (%) | Hospital mortality (%) |
---|---|---|---|---|---|---|---|
Soares, 2006 [15] | 1 ICU, Brazil | Jan 2003 to Dec 2005 | 952 | Mean: 58.3 | 45.3 | 63.5 | 33.5 |
Serrato, 2007 [16] | 1 ICU, Mexico | Jan 2006 to May 2006 | 95 | Mean: 59 | 49.0 | 28.0 | 20.0 |
Ledoux, 2008 [34] | 1 ICU, Belgium | Dec 2005 to Jul 2006 | 802 | Median: 66 | 39.4 | 71.1 | 17.5 |
Duke, 2008 [26] | 1 ICU, Australia | Oct 2005 to Dec 2007 | 1,741 | Median: 66 | 47.4 | 39.4 | 11.3 |
Tsai, 2008 [31] | 1 ICU, Taiwan | Jan 2002 to Dec 2006 | 104 | Mean: 51 | 42.3 | 61.4 | 76 |
Sakr, 2008 [35] | 1 ICU, Germany | Aug 2004 to Dec 2005 | 1,851 | Mean: 61.6 | 36.6 | 85.8 | 9.0 |
Metnitz, 2009 [36] | 22 ICU, Austria | Oct 2006 to Feb 2007 | 2,060 | Mean: 64.9 | 42.0 | 57.5 | 21.7 |
Capuzzo, 2009 [39] | 2 ICU, Italy | Jan 2006 to Sep 2007 | 684 | Median: 73 | 37.0 | 81.8 | 19.6 |
Strand, 2009 [37] | 2 ICU, Norway | Jun 2006 to Dec 2007 | 1,862 | Median: 63 | 36.0 | 29.4 | 23.6 |
Alves, 2009 [17] | 1 ICU, Brazil | Jan 2006 to Dec 2006 | 350 | Mean: 73.4a | 48.0 | 31.1 | 30.6 |
Mbongo, 2009 [40] | 1 ICU, Spain | Jan 2006 to Dec 2006 | 864 | Mean: 60.7 | 34.7 | 86.3 | 8.2 |
Poole, 2009 [41] | 147 ICU, Italy | Feb 2007 to Dec 2007 | 28,357 | Mean: 65.8 | 40.7 | 53.5 | 29.6 |
Median: 70 | |||||||
Maccariello, 2010 [18] | 11 ICU, Brazil | Jan 2007 to Jul 2008 | 244 | Mean: 69.5 | 43.0 | 19.0 | 68.0 |
Silva Junior, 2010 [19] | 2 ICU, Brazil | Mar 2008 to Mar 2009 | 1,310 | Mean: 67.1 | 60.5 | 100 | 10.8 |
Khwannimit, 2010 [27] | 1 ICU, Thailand | Jan 2005 to Dec 2010 | 1,873 | Median: 62 | 41.1 | 0 | 28.6 |
Soares, 2010 [20] | 28 ICU, Brazil | Aug 2007 to Sep 2009 | 717 | Mean: 61.2 | 51.0 | 64.0 | 30.0 |
Khwannimit, 2011 [28] | 1 ICU, Thailand | Mar 2007 to Aug 2009 | 2,022 | Median: 62 | 40.0 | 0 | 26.1 |
Lim, 2011 [32] | 1 ICU, South Korea | Mar 2008 to Feb 2009 | 633 | Mean: 60 | 37.0 | 0 | 31.0 |
Costa e Silva, 2011 [21] | 6 ICU, Brazil | Nov 2003 to Jun 2005 | 366 | Mean: 57.1 | 41.0 | 23.5 | 67.8 |
Christensen, 2011 [38] | 1 ICU, Denmark | Jan 2007 to Dec 2007 | 469 | NR | 66.3 | 63.5 | 17.7 |
Juneja, 2012 [29] | 1 ICU, India | Jul 2008 to Sep 2009 | 653 | Mean: 58.5 | 42.1 | 0 | 15.8 |
Nassar Junior, 2012 [22] | 3 ICU, Brazil | Jul 2008 to Dec 2009 | 5,780 | Median: 66 | 52.7 | 20.9 | 9.1 |
Keegan, 2012 [25] | 3 ICU, USA | Jan 2006 to Dec 2006 | 2,596 | Mean: 63.2 | 45.2 | 19.8 | 10.9 |
Nassar Junior, 2013 [23] | 3 ICU, Brazil | Jul 2008 to Dec 2009 | 1,015 | Median: 61 | 40.4 | 0 | 2.1 |
De Oliveira, 2013 [24] | 1 ICU, Brazil | May 2006 to Jan 2007 | 501 | Mean: 46 | 34.5 | 100 | 7.8 |
Khwannimit, 2013 [30] | 1 ICU, Thailand | Jan 2005 to Dec 2010 | 880 | Median: 59 | 42.4 | 30.6 | 57.4 |
Lim, 2013 [33] | 22 ICU, South Korea | Jul 2010 to Jan 2011 | 2,309b | Median: 62 | 35.3 | 39.8 | 20.1 |
López-Caler, 2013 [42] | 6 ICU, Spain | Jan 2006 to Oct 2007 | 2,171 | Mean: 61.4 | NR | 37.2 | 16.0 |
Study quality
Study | Study participation | Prognostic factor measurement | Analysis |
---|---|---|---|
Soares, 2006 [15] | Yes | Yes | Yes |
Serrato, 2007 [16] | Yes | Yes | Yes |
Ledoux, 2008 [34] | Yes | Yes | Yes |
Duke, 2008 [26] | Yes | Yes | Yes |
Tsai, 2008 [31] | Yes | No | Yes |
Sakr, 2008 [35] | Yes | Yes | Yes |
Metnitz, 2009 [36] | Yes | Yes | Yes |
Capuzzo, 2009 [39] | Yes | Yes | Yes |
Strand, 2009 [37] | Yes | Yes | Yes |
Alves, 2009 [17] | Yes | Yes | Yes |
Mbongo, 2009 [40] | Yes | Yes | Yes |
Poole, 2009 [41] | Yes | Yes | Yes |
Maccariello, 2010 [18] | Yes | No | Yes |
Silva Junior, 2010 [19] | Yes | Yes | Yes |
Khwannimit, 2010 [27] | Yes | Yes | Yes |
Soares, 2010 [20] | Yes | Yes | Yes |
Khwannimit, 2011 [28] | Yes | Yes | Yes |
Lim, 2011 [32] | Yes | Yes | Yes |
Costa e Silva, 2011 [21] | Yes | No | Yes |
Christensen, 2011 [38] | Yes | NR | Yes |
Juneja, 2012 [29] | Yes | Yes | Yes |
Nassar Junior, 2012 [22] | Yes | Yes | Yes |
Keegan, 2012 [25] | Yes | Yes | Yes |
Nassar Junior, 2013 [23] | Yes | Yes | Yes |
De Oliveira, 2013 [24] | Yes | Yes | Yes |
Khwannimit, 2013 [30] | Yes | Yes | Yes |
Lim, 2013 [33] | Yes | Yes | Yes |
López-Caler, 2013 [42] | No | Yes | Yes |
Calibration and discrimination
Study | Calibration for general SAPS III | Calibration for customized SAPS III | aROC (95% CI) | SMR (95% CI) for general SAPS III | SMR (95% CI) for customized SAPS III |
---|---|---|---|---|---|
Central and South America
| |||||
Soares, 2006 [15] | C: 13.637 (P = 0.092) | C: 9.132 (P = 0.331) | 0.87 (0.85 to 0.90) | 1.19 (1.04 to 1.37) | 0.95 (0.84 to 1.07) |
Serrato, 2007 [16] | C: 6.64 (P >0.1) | NR | 0.86 (0.825 to 0.895) | 0.81 | NR |
Alves, 2009 [17] | H: 16.42 (P = 0.037) | H: 16.66 (P = 0.034) | 0.881 (0.843 to 0.913) | 1.10 (0.90 to 1.33) | 0.86 (0.70 to 1.04) |
C: 17.57 (P = 0.025) | C: 15.95 (P = 0.047) | ||||
Maccariello, 2010 [18] | C: 10.16 (P = 0.254) | C: 9.33 (P = 0.315) | 0.82 (0.76 to 0.88) | 1.26 (1.10 to 1.46) | 1.04 (0.92 to 1.18) |
Silva Junior, 2010 [19] | C: 10.47 (P = 0.234) | NR | 0.86 (0.83 to 0.88) | 1.04 (1.03 to 1.07) | NR |
Soares, 2010 [20] | C: 15.804 (P = 0.045) | C: 12.607 (P = 0.126) | 0.84 (0.81 to 0.87) | 1.29 (1.09 to 1.53) | 1.02 (0.87 to 1.19) |
Costa e Silva, 2011 [21] | H (DD): 6.86 (P = 0.551) | H (DD): 6.33 (P = 0.610) | DD: 0.73 (0.67 to 0.78) | DD: 1.35 (1.07 to 1.63) | DD: 1.09 (0.83 to 1.35) |
H (NCD): 10.47 (P = 0.163) | H (NCD): 13.22 (P = 0.113) | NCD: 0.80 (0.73 to 0.86) | NCD: 1.15 (0.75 to 1.55) | NCD: 1.00 (0.61 to 1.39) | |
Nassar Junior, 2012 [22] | C: 226.6 (P <0.001) | NR | 0.855 (0.846 to 0.864) | 0.46 (0.37 to 0.54) | NR |
Nassar Junior, 2013 [23] | C: 51.8 (P <0.001) | NR | 0.804 (0.779 to 0.828) | 0.31 (0.11 to 0.50) | NR |
De Oliveira, 2013 [24] | H: 59.41 (P <0.001) | C: 123.49 (P <0.001) | 0.696 (0.607 to 0.786) | 1.94 (1.38 to 2.64) | 1.88 (1.34 to 2.56) |
C: 155.57 (P <0.001) | H: 45.6 (P <0.001) | ||||
North America
| |||||
Keegan, 2012 [25] | C: 36.6 (P <0.05) | NR | 0.801 (0.785 to 0.816) | 0.66 (0.69 to 0.75) | NR |
Australasia
| |||||
Duke, 2008 [26] | H: 36.15 (P = 0.009) | H: 27.37 (P = 0,06) | 0.88 (0.85 to 0.90) | 0.84 (0.724 to 0.969) | 0.92 (0.80 to 1.06) |
C: ? (P = 0.019) | |||||
Tsai, 2008 [31] | H: 5.445 (P = 0.71) | NR | 0.73 | NR | NR |
Khwannimit, 2010 [27] | H: 106.7 (P <0.001) | H: 98.2 (P <0.001) | 0.933 (0.921 to 0.944) | 0.86 (0.79 to 0.93) | 0.92 (0.85 to 0.99) |
C: 101.2 (P <0.001) | C: 96.2 (P <0.001) | ||||
Khwannimit, 2011 [28] | H: 101.6 (P <0.001) | H: 79.9 (P <0.001) | 0.916 (0.902 to 0.929) | 0.81 (0.74 to 0.88) | 0.88 (0.80 to 0.96) |
C: 176.3 (P <0.001) | C: 170 (P <0.001) | ||||
Lim, 2011 [32] | C: 3.174 (P = 0.923) | C: 3.286 (P = 0.915) | 0.78 (0.75 to 0.81) | 0.72 (0.62 to 0.83) | 0.78 (0.67 to 0.89) |
Juneja, 2012 [29] | HL(?): 13.12 (P = 0.108) | NR | 0.901 (0.871 to 0.932) | 0.763 (0.628 to 0.918) | NR |
Khwannimit, 2013 [30] | H: 39.4 (P <0.001) | NR | 0.817 (0.790 to 0.845) | 0.97 (0.89 to 1.06) | NR |
C: 49.6 (P <0.001) | |||||
Lim, 2013 [33] | H: 123.06 (P <0.001) | H: 73.53 (P <0.001) | 0.829 (0.82 to 0.86) | 0.72 (0.65 to 0.78) | 0.78 (0.71 to 0.85) |
C: 118.45 (P <0.001) | C: 70.52 (P <0.001) | ||||
Central and Western Europe
| |||||
Ledoux, 2008 [34] | C: 16.59 (P = 0.035) | C: 8.30 (P = 0.405) | 0.85 (0.82 to 0.89) | 0.82 (0.70 to 0.93) | 0.96 (0.84 to 1.08) |
Sakr, 2008 [35] | H: 211.84 (P <0.001) | H: 177.37 (P <0.001) | 0.84 (0.81 to 0.88) | NR | NR |
C: 208.49 (P <0.001) | C: 126.79 (P <0.001) | ||||
Metnitz, 2009 [36] | H: 100.18 (P <0.001) | H: 51.56 (P <0.001) | 0.82 | 0.79 (0.74 to 0.85) | 0.86 (0.80 to 0.92) |
C: 90.29 (P <0.001) | C: 45.61 (P <0.001) | ||||
Northern Europe
| |||||
Strand, 2009 [37] | C: 17.40 (P = 0.066) | C: 18.25 (P = 0.051) | 0.81 (0.79 to 0.93) | 0.71 (0.65 to 0.78) | 0.74 (0.68 to 0.81) |
Christensen, 2011 [38] | HL(?): 9.23 (P = 0.51) | NR | 0.69 (0.63 to 0.75) | NR | NR |
Southern Europe and Mediterranean countries
| |||||
Capuzzo, 2009 [39] | H: 23.36 (P = 0.002) | H: 25.73 (P = 0.001) | 0.835 (0.794 to 0.876) | 0.83 (0.77 to 0.89) | 0.81 (0.75 to 0.87) |
C: 22.47 (P = 0.004) | C: 26.19 (P = 0.001) | ||||
Mbongo, 2009 [40] | C: 8.57 (P = 0.38) | C: 7.5 (P = 0.48) | 0.917 (0.880 to 0.954) | 0.71 (0.56 to 0.90) | 0.69 (0.55 to 0.87) |
Poole, 2009 [41] | Ua: 2,035,9 (P <0.001) | Ua: 1,929.2 (P <0.001) | 0.855 (0.851 to 0.860) | 0.73 (0.72 to 0.75) | 0.73 (0.72 to 0.75) |
López-Caler, 2013 [42] | HL(?): 20.05 (P <0.05) | 0.855 (0.851 to 0.860) | 0.845 (0.821 to 0.869) | 0.89 (0.80 to 0.98) | 0.86 (0.77 to 0.95) |
Mortality prediction
Discussion
Conclusions
Key messages
-
SAPS III showed significant departure from perfect calibration in most studies
-
There was a positive correlation between larger samples and higher H-L values for SAPS III. As calibration statistics are very sensitive to sample sizes, this is probably the best explanation for the significant departures from perfect calibration found in the larger studies
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SAPS III discrimination is very good
-
First-level customization improved SAPS III performance in all studies in which it was accomplished, although most of them were single-center studies
-
SAPS III is a reliable prognostic model to be used in clinical practice, but it should be customized before routine application in local settings.