Recalibration of the Delirium Prediction Model for ICU Patients (PRE-DELIRIC); an international multicenter observational study
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1 Recalibration of the Delirium Prediction Model for ICU Patients (PRE-DELIRIC); an international multicenter observational study M. van den Boogaard, L. Schoonhoven, E. Maseda, C. Plowright, C. Jones, A. Luetz, P.V. Sackey, P.G. Jorens, L.M. Aitken, F.M.P. van Haren, J.G. van der Hoeven, P. Pickkers Radboud University Nijmegen Medical Center Department of Intensive Care Medicine Nijmegen, The Netherlands
2 Background 25-50% of ICU patients develop delirium during ICU stay Prolonged duration of: Mechanical ventilation LOS-ICU LOS in-hospital More re-intubations and re-admissions Associated with increased mortality rate
3 DELIRIUM IS BAD, AND PREVENTION IS BETTER THAN CURE
4 BUT,.. It is unnecessary to apply preventive measures in all patients: - Less effective (dilution effect) - Labor intensive - Exposure to side-effects Need for a delirium prediction model to identify high risk patients
5 Background PREdiction DELIRium in ICu patients consists of 10 predictors to predict delirium within 24 hours after ICU admission High predictive value in 3,054 patients (development, internal and external validation) of 0.85 (AUROC)
6 PRE-DELIRIC-model Variables Odds ratio 95% CI Coefficient 1. Age per year APACHE-II score per point Coma: - Medication induced - Miscellaneous - Combination RC RC Diagnose group - Surgery - Medical - Trauma - Neurological/neurosurgery RC RC Infection Metabolic acidosis (yes/no) Morphine use mg/day mg/day - >18.6mg/day RC RC Sedation Urea increased per mmol/l Urgent admission
7 Aim of study Unknown what the international performance is of the model Aim To determine the performance of the PRE-DELIRIC model, internationally
8 Measures of Model Performance Discrimination Ability to correctly separate two outcome measures; expressed in AU(RO)C Calibration How closely are the predicted probabilities agree with the actual outcomes; expressed by Hosmer-Lemeshow test and Calibration plot (more informative)
9 Participants 1. Australia-Princess Alexandra Hospital, Brisbane; Leanne Aitken 2. Australia-Canberra Hospital, Canberra; Frank van Haren 3. Belgium-Academical hospital Antwerp; Philippe Jorens 4. Germany-Charité Universitaetsmedizin Berlin, Claudia Spies, Alawi Lütz 5. Spain- Hospital Universitario La Paz, Madrid; Emilio Maseda 6. Sweden-Karolinska University Hospital Solna, Stockholm; Anna Schandl, Peter Sackey 7. UK-Medway Maritime Hospital, Kent ; Catherine Plowright 8. UK-Whiston Hospital, Prescot; Christina Jones
10 Methods Data collection period 3 months (E-CRF) Ten predictors within 24hours after ICU admission: age, APACHE-II score, urgent admission, admission category, infection, coma, sedation, morphine use, urea level, and metabolic acidosis Delirium diagnose during complete ICU stay using CAM-ICU Quality measurements: CAM-ICU compliance and inter rater reliability
11 Inclusion and exclusion Total : 2,852 patients Excluded: 1,028 patients Included: 1,824 patients - CAM-ICU compliance: 82±16% - IRR: 0.87±0.17
12 Results Significant differences on predictors between the centers
13 Results
14 Recalibration Stepwise approach to optimize calibration (intercept of -0- and slope of -1-) New intercept and use of fixed calibration slope of 1 New intercept and new slope calculation New intercept for each center and use of fixed slope General Over linear estimation mixed method fit using mean estimated intercept and mean estimated calibration slope Resulting in adjusted intercept and adjusted linear predictors
15 Recalibration Stepwise approach to optimize calibration (intercept of -0- and slope of -1-) New intercept and use of fixed calibration slope of 1 New intercept and new slope calculation New intercept for each center and use of fixed slope General linear mixed method fit using mean estimated intercept and mean estimated calibration slope Resulting in adjusted intercept and adjusted linear predictors
16 Recalibration
17 Conclusion In this study we recalibrated the PREDELIRIC-model internationally Despite differences in predictors between the centers in the different countries the discriminative power of the PREDELIRIC-model remained good The PREDELIRIC model may facilitate implementation of strategies to prevent delirium, also in other countries
18 Many thanks to: 1. Leanne Aitken and Frank van Haren: Australia 2. Philippe Jorens: Belgium 3. Claudia Spies, Alawi Lütz: Germany 4. Emilio Maseda: Spain 5. Anna Schandl, Peter Sackey: Sweden 6. Catherine Plowright and Christina Jones: UK
City, University of London Institutional Repository
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