injury severity scores
TRANSCRIPT
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Injury Severity Scores
The document contains a thorough review of different injury
severity scores employed in trauma care, their classificationbased on anatomic and physiologic scales and a collection of
abstracts from research papers highlighting
their advantages and shortcomings.
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Injury severity scores are simply a way to describe and quantify the severity of traumatic
injury. They aid in assessment of injury, provide a more objective measure of injury
severity that results in more efficient and accurate communication with other trauma
care providers, give a comparison of trauma outcomes of different institutions (qualitycontrol), and also provide some sense of the probability of survival of the victims. They
are essential to quality control evaluation and trauma research efforts because, in
theory, they permit valid comparison of trauma populations with differing baseline risk.
There are several injury severity indices that are typically based on anatomic or
physiologic parameters, or a combination of both.
ANATOMIC CLASSIFICATION
Two coding systems are available for classifying anatomic injuries: the Abbreviated
Injury Scale (AIS) and the International Classification of Diseases (ICD). The AIS wasdeveloped in 1971 uniquely for the classification of injuries and includes a severity score
that was developed and is updated by consensus among a group of clinical experts. The
severity score varies from 1 (minor injury) to 6 (theoretically nonsurvivable injury) and is
based principally on threat to life, though energy dissipation, permanent impairment,
and treatment period required are also taken into consideration.1The ICD, in contrast,
is a coding system designed for use with all diagnoses, is coded systematically in hospital
discharge databases, and is not accompanied by a severity score. (Moore et al)
As already stated, there are two major anatomic systems for quantifying injury severity:
the Abbreviated Injury Scale and the International Classification of Disease Clinical (ICD-
9CM) score. There are also several scoring severity systems that are derivatives orfunctions of these two fundamental methods, such as the Anatomic Profile (AP), the
Injury Severity Scale (ISS) and the New Injury Severity Scale (NISS), all based on the AIS,
and the ICISS based on ICD-9CM scores. The predictive validity and reliability of the AIS
and its derivatives have been demonstrated, but their widespread use in population-
based research and evaluation is constrained because of the cost of AIS coding.6Studies
have shown that it takes, on average, between 10 and 20 minutes to review the medical
record and assign AIS codes; coding time depends on the complexity of the case and the
training of the coder. The study by Sacco et al. was designed to evaluate the relative
performance among both AIS- and ICD-based scoring systems. Results support the
integrity of the AIS and argue for its continued use in research and evaluation. The studyconcluded that the modified Anatomic Profile, Anatomic Profile, and New Injury Severity
Score, however, should be used in preference to the Injury Severity Score as an overall
measure of severity.
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1. Abbreviated Injury Scale (AIS)
The Abbreviated Injury Scale (AIS), developed in 1971, is a guideline of anatomical
descriptors of wounds from trauma victims, which supplies for each lesion description
an identifying number made up by 7 digits: the first digit identifies body region; thesecond represents type of anatomical structure; the third and fourth digits identify
specific anatomical structure, or in cases of external surface lesions, the specific nature
of the lesion; the fifth and sixth digits identify the level of lesion in a specific body region
and anatomical structure; and the seventh digit to the right of decimal point is the AIS
severity score identifier. This number may vary from 1 (minimal severity) to 6 (maximum
severity, almost always fatal)(1)
. AIS is the basis for the calculation of other injury
indices, including the Injury Severity Score (ISS) and the New Injury Severity Score (NISS).
(See AIS 2005: A contemporary injury scale).
2. Injury Severity Score
Among anatomical severity scores, the Injury Severity Score (ISS), created by Baker et al.
in 1974 has been considered for over 20 years to be the gold standard to classify trauma
victims, both blunt and penetrating. The ISS is based upon the Abbreviated Injury Scale
AIS. ISS is obtained by summing the square value of the 3 highest AIS scores, identifying
severity of patients and enabling stratification of them. A polytrauma is defined as an ISS
>= 16. The greater the score value, the greater the severity of patient, and,
consequently greater mortality. The ISS does have significant limitations, most notably,
the ISS does not account for multiple injuries to a single body region nor for differences
in severity across body regions. For instance, an AIS 5 injury is given equal weight in the
ISS calculation, despite the fact that an abdomen AIS 5 injury is associated with a
significantly higher probability of survival than a AIS 5 head injury.
In 1997, authors of ISS changed this indicator because there was a flaw identified
in its calculation, which considered a single lesion per body lesion, underestimating the
severity of patients. In patients with multiple lesions located in the same body region,
ISS considers only the most severe, ignoring the second most severe lesion that many
times, is in the same body segment of the first. To correct these limitations the New
Injury Severity Score (NISS) was created considering the three most severe lesions in the
calculation, regardless of the body region(3)
. This change from ISS to NISS aimed at
increasing predictive value of the index and simplifying its calculation. The predictive
value of NISS vs. ISS has been assessed with regard to several outcomes, including
survival, rate of hospital stay, admission to ICU, sepsis, multiple organ dysfunctionsyndrome, nosocomial infection, postoperative complications, post trauma
complications, results/functional skill, transference to other hospitals and situation at
discharge (whether or not resources and/or specific medical care were needed after
hospital discharge), and it has generally been found that NISS outperforms or is
equivalent to ISS in predicting these outcomes.
3. Anatomic Profile (AP)
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The AP is an alternative index created because of the limitation of ISS. AP was proposed
in 1990 and considers all body lesions of the victim for its calculation, but in spite of
that, the improvement in AP performance compared to ISS was only modest, and the
complexity of AP application discourage broad acceptance of this index. The study by
Frankema et al. comparing ISS with AP and NISS presents conclusions that point out
better performance of these two indexes compared with ISS.
4. International Classification of Diseases 9th Edition Injury Severity Score (ICISS)
An ICD-9 Injury Severity Score (ICISS) is defined as the product of all survival risk ratios
for an individual patient's traumatic ICD-9 codes. A survival risk ratio (SRR) is XXXXX.The ICISS method differs from the other methods in that its building blocks are not the AIS
scores for each ICD-9-CM trauma diagnosis, but rather the survival proportion for each ICD-9-
CM diagnosis based on some reference database. A study by Rutledge et al. (J Trauma 1998)
concluded that ICISS-derived predictions of survival, hospital charges, and hospital
length of stay consistently outperformed those of ISS and TRISS. (see Osler et al. J
Trauma 1996)
5. Survival Risk Ratios (SRRs)
A study by Clark et al concluded the following regarding SRRs: Predictions of survival
based on anatomic injury alone can be performed using ICD-9 codes, with no advantage
from extra coding of AIS diagnoses. Predictions based on the single worst SRR were
closer to actual outcomes than those based on multiplying SRRs.
6. Trauma Mortality Prediction Model (TMPM)
A study by Osler et al. (Ann Surg 2008) concluded that trauma mortality models based
on empirical estimates of individual injury severity better discriminate between
survivors and nonsurvivors than does the current standard, ISS. One such model, theTMPM, has both superior discrimination and calibration when compared with the ISS.
The TMPM should replace the ISS as the standard measure of overall injury severity.
- TMPM-ICD9: a trauma mortality prediction model based on ICD-9-CM codes.
Glance LG, Osler TM, Mukamel DB, Meredith W, Wagner J, Dick AW.
Department of Anesthesiology, University of Rochester School of Medicine, Rochester, New York 14642,
USA.
Abstract
OBJECTIVE: To develop and validate a new ICD-9 injury model that uses regressionmodeling, as opposed to a simple ratio measurement, to estimate empiric injury
severities for each of the injuries in the ICD-9-CM lexicon. BACKGROUND: The American
College of Surgeons now requires International Classification of diseases ninth Edition
(ICD-9-CM) codes for injury coding in the National Trauma Databank. International
Classification of diseases ninth Edition Injury Severity Score (ICISS) is the best-known
risk-adjustment model when injuries are recorded using ICD-9-CM coding, and would
http://www.ncbi.nlm.nih.gov/pubmed?term=%22Glance%20LG%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Osler%20TM%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Mukamel%20DB%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Meredith%20W%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Wagner%20J%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Dick%20AW%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Dick%20AW%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Wagner%20J%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Meredith%20W%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Mukamel%20DB%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Osler%20TM%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Glance%20LG%22%5BAuthor%5D -
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likely be used to risk-adjust outcome measures for hospital trauma report cards. ICISS,
however, has been criticized for its poor calibration. METHODS: We developed and
validated a new ICD-9 injury model using data on 749,374 patients admitted to 359
hospitals in the National Trauma Databank (version 7.0). Empiric measures of injury
severity for each of the trauma ICD-9-CM codes were estimated using a regression-
based approach, and then used as the basis for a new Trauma Mortality PredictionModel (TMPM-ICD9). ICISS and the Single-Worst Injury (SWI) model were also re-
estimated. The performance of each of these models was compared using the area
under the receiver operating characteristic (ROC), the Hosmer-Lemeshow statistic, and
the Akaike information criterion statistic. RESULTS: TMPM-ICD9 exhibits significantly
better discrimination (ROCTMPM = 0.880 [0.876-0.883]; ROCICISS = 0.850 [0.846-0.855];
ROCSWI = 0.862 [0.858-0.867]) and calibration (HLTMPM = 29.3 [12.1-44.1]; HLICISS =
231 [176-279]; HLSWI = 462 [380-548]) compared with both ICISS and the Single Worst
Injury model. All models were improved with the addition of age, gender, and
mechanism of injury, but TMPM-ICD9 continued to demonstrate superior model
performance. CONCLUSIONS: Because TMPM-ICD9 uniformly out-performs ICISS and
the SWI model, it should be used in preference to ICISS for risk-adjusting trauma
outcomes when injuries are recorded using ICD9-CM codes.
- A Trauma Mortality Prediction Model Based on the Anatomic Injury ScaleOsler, Turner MD, MSc; Glance, Laurent MD; Buzas, Jeffery S. PhD; Mukamel, Dana PhD; Wagner, Jacob
MD, PhD; Dick, Andrew PhD
Abstract
Objective: To develop a statistically rigorous trauma mortality prediction model based
on empiric estimates of severity for each injury in the abbreviated injury scale (AIS) andcompare the performance of this new model with the injury severity score (ISS).
Summary Background Data: Mortality rates at trauma centers should only be compared
after adjusting for differences in injury severity, but no reliable measure of injury
severity currently exists. The ISS has served as the standard measure of anatomic injury
for 30 years. However, it relies on the individual injury severities assigned by experts in
the AIS, is nonmonotonic with respect to mortality, and fails to perform even as well as
a far simpler model based on the single worst injury a patient has sustained.
Methods: This study is based on data from 702,229 injured patients in the National
Trauma Data Bank (NTDB 6.1) hospitalized between 2001 and 2005. Sixty percent of the
data was used to derive an empiric measure of severity of each of the 1322 injuries in
the AIS lexicon by taking the weighted average of coefficients estimated using 2
separate regression models. The remaining 40% of the data was use to create 3
exploratory mortality prediction models and compare their performance with the ISS
using measures of discrimination (C statistic), calibration (Hosmer Lemeshow statistic
and calibration curves), and the Akaike information criterion.
Results: Three new models based on empiric AIS injury severities were developed. All of
these new models discriminated survivors from nonsurvivors better than the ISS, but
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one, the trauma mortality prediction model (TMPM), had both better discrimination
[ROCTMPM = 0.901 (0.898-0.905), ROCISS = 0.871 (0.866-0.877)] and better calibration
[HLTMPM = 58 (35-91), HLISS = 296 (228-357)] than the ISS. The addition of age, gender,
and mechanism of injury improved all models, but the augmented TMPM dominated ISS
by every measure [ROCTMPM = 0.925(0.921-0.928), ROCISS = 0.904(0.901-0.909), HLTMPM =
18 (12-31), HLISS = 54 (30-64)].Conclusions: Trauma mortality models based on empirical estimates of individual injury
severity better discriminate between survivors and nonsurvivors than does the current
standard, ISS. One such model, the TMPM, has both superior discrimination and
calibration when compared with the ISS. The TMPM should replace the ISS as the
standard measure of overall injury severity.
7. Trauma Registry Abbreviated Injury Scale Score (TRAIS)
Worse Injury: Kilgo et al. (J Trauma 2003) showed regardless of scoring type (ICD/AIS
SRRs or AIS severity), a patient's worst injury discriminates survival better, fits better,
and explains more variance than currently used multiple injury scores.
PHYSIOLOGIC SEVERITY SCORES
Prediction of outcomes after injury has traditionally incorporated measures of injury
severity, but recent studies suggest that including physiologic and shock measures can
improve accuracy of anatomic-based models. A recent study by Guzzo et al. found that
the predictive ability of a novel physiologic model is superior to anatomic-based models
such as Injury Severity Score, but comparable with other physiologic-based models such
as Revised Trauma Score, Physiologic Trauma Score and Trauma, and Injury Severity
Score.
1. Revised Trauma Score (RTS)The Revised Trauma Score is made up of a combination of results from three categories:
Glascow coma scale, systolic blood pressure, and respiratory rate.
2. Physiologic Trauma Score (PTS)
A study by Kuhls et al. (J Am Coll Surg 2002) concluded that a new statistical model
(Physiologic Trauma Score), including only physiologic variables (admission SIRS score
combined with Glasgow Coma Score and age) and easily calculated at the patient
bedside, accurately predicts mortality in trauma patients. The predictive ability of thismodel is comparable to other complex models that use both anatomic and physiologic
data (TRISS, ISS, and ICISS).
COMBINED ANATOMIC/PHYSIOLOGIC SCORES
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So far, the studies suggest that predictive power of TRISS and ASCOT are roughly equal,
with the advantage of TRISS being that is much easier to calculate.
1. TRISS (Trauma and Injury Severity Score)
The TRISS is a composite of the ISS, Revised Trauma Score (RTS), and age. It has greatpredictive value but its widespread applicability is limited because it is difficult for many
trauma facilities to compute because it requires 8 to 10 variables and ISS depends on
the specialized Abbreviated Injury Scale (AIS) scale rather than the International
Classification of Diseases scale (ICD-9). Recent advances in anatomic and physiologic
scoring markedly simplify TRISS-type models at no cost to prediction. This approach uses
routinely available data, requires up to seven fewer terms, and predicts at least as well
as the original TRISS. These findings could increase the availability of accurate trauma
scoring tools to smaller trauma facilities (Incorporating recent advances to make the
TRISS approach universally available.Kilgo PD,Meredith JW,Osler TM..)
2. American College of Surgeons' Committee on Trauma (ASCOT)
a predictive measure of outcome that incorporates AIS injury descriptions, age, and
physiologic data into a single score. ASCOT has not been generally adopted, probably
because of it provided only slightly improved predictive power over Trauma and Injury
Severity Score (TRISS) at the price of substantially increased complexity of calculation.
(Champion et al, J Trauma) Moreover, a recent comparison of ASCOT and TRISS scoring
found no significant difference between the Receiver Operator Characteristic Curve
(ROC) areas of these two approaches to outcome prediction, confirming that the
predictive power of the two methods is equal.[9]
List Severity Score IndicesAbbreviated Injury Scale max (AISmax), Trauma and Injury Severity Score (TRISS), A
Severity Characterization of Trauma (ASCOT), Abdominal Trauma Index (ATI), Glasgow
Coma Scale (GCS), and Pediatric Trauma Score (PTS), four AIS-based algorithms (Injury
Severity Score [ISS], New Injury Severity Score, Anatomic Profile Score [APS], and
maximum AIS [maxAIS]), their four ICD to AIS mapped counterparts, and the ICD-9
based ISS (ICISS) .
Measuring injury severity: time for a change?
J Trauma. 1998
Brenneman FD, Boulanger BR, McLellan BA, Redelmeier DA.Department of Surgery, Sunnybrook Health Science Centre, University of Toronto, Ontario, Canada.
Abstract:
BACKGROUND: The Injury Severity Score (ISS) does not take into account multiple
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Kilgo%20PD%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Kilgo%20PD%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Kilgo%20PD%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Meredith%20JW%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Meredith%20JW%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Meredith%20JW%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Osler%20TM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Osler%20TM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Osler%20TM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://ovidsp.tx.ovid.com/spb/ovidweb.cgi?Link+Set+Ref=00005373-200210000-00001|00005373_1996_41_380_osler_classification_%7c00005373-200210000-00001%23xpointer%28id%28R7-1%29%29%7c10%7chttp%3a%2f%2facs.tx.ovid.com%2facs%2f.5c103e04ef61e5550ce593f7adca05af0334ad3d6d38a1f400230673b342cfb54bea84c4ae6dba622ed2fc4eb4096d3967.gif%7covftdb%7c00005373-199609000-00002&P=84&S=BHMPFPEJLLDDKKEFNCHLLBJLIOPPAA00&WebLinkReturn=Full+Text%3dL%7cS.sh.15.16%7c0%7c00005373-200210000-00001#106#106http://ovidsp.tx.ovid.com/spb/ovidweb.cgi?Link+Set+Ref=00005373-200210000-00001|00005373_1996_41_380_osler_classification_%7c00005373-200210000-00001%23xpointer%28id%28R7-1%29%29%7c10%7chttp%3a%2f%2facs.tx.ovid.com%2facs%2f.5c103e04ef61e5550ce593f7adca05af0334ad3d6d38a1f400230673b342cfb54bea84c4ae6dba622ed2fc4eb4096d3967.gif%7covftdb%7c00005373-199609000-00002&P=84&S=BHMPFPEJLLDDKKEFNCHLLBJLIOPPAA00&WebLinkReturn=Full+Text%3dL%7cS.sh.15.16%7c0%7c00005373-200210000-00001#106#106http://ovidsp.tx.ovid.com/spb/ovidweb.cgi?Link+Set+Ref=00005373-200210000-00001|00005373_1996_41_380_osler_classification_%7c00005373-200210000-00001%23xpointer%28id%28R7-1%29%29%7c10%7chttp%3a%2f%2facs.tx.ovid.com%2facs%2f.5c103e04ef61e5550ce593f7adca05af0334ad3d6d38a1f400230673b342cfb54bea84c4ae6dba622ed2fc4eb4096d3967.gif%7covftdb%7c00005373-199609000-00002&P=84&S=BHMPFPEJLLDDKKEFNCHLLBJLIOPPAA00&WebLinkReturn=Full+Text%3dL%7cS.sh.15.16%7c0%7c00005373-200210000-00001#106#106http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Brenneman%20FD%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Boulanger%20BR%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22McLellan%20BA%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Redelmeier%20DA%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Redelmeier%20DA%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22McLellan%20BA%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Boulanger%20BR%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Brenneman%20FD%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://ovidsp.tx.ovid.com/spb/ovidweb.cgi?Link+Set+Ref=00005373-200210000-00001|00005373_1996_41_380_osler_classification_%7c00005373-200210000-00001%23xpointer%28id%28R7-1%29%29%7c10%7chttp%3a%2f%2facs.tx.ovid.com%2facs%2f.5c103e04ef61e5550ce593f7adca05af0334ad3d6d38a1f400230673b342cfb54bea84c4ae6dba622ed2fc4eb4096d3967.gif%7covftdb%7c00005373-199609000-00002&P=84&S=BHMPFPEJLLDDKKEFNCHLLBJLIOPPAA00&WebLinkReturn=Full+Text%3dL%7cS.sh.15.16%7c0%7c00005373-200210000-00001#106#106http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Osler%20TM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Meredith%20JW%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Kilgo%20PD%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract 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injuries in the same body region, whereas a New ISS (NISS) may provide a more accurate
measure of trauma severity by considering the patient's three greatest injuries
regardless of body region. The purpose of this study was to evaluate the ISS and NISS in
patients with blunt trauma. METHODS: Consecutive individuals treated from January of
1992 to September of 1996 at one institution were included if they had sustained blunt
trauma and satisfied triage standards (n = 2,328). For each patient, we computed the ISSand the NISS to determine how often the two scores were identical or discrepant.
Discrepant cases were then further analyzed using receiver operating characteristic
curves to determine which score better predicted short-term mortality. RESULTS: The
mean ISS was 25 +/- 13, and the mean NISS was 33 +/- 18. The two predictive scores
were identical in 32% of patients and discrepant in 68% of patients. Patients with
identical scores had a lower mortality rate than patients with discrepant scores (10% vs.
13%; p < 0.02). In patients with discrepant scores, the area under the receiver operating
characteristic curves was greater for the NISS than the ISS (0.852 vs. 0.799; p < 0.001),
and greater amounts of discrepancy were associated with increasing rates of mortality
(p < 0.001). CONCLUSIONS: The NISS often increases the apparent severity of injury and
provides a more accurate prediction of short-term mortality. The benefit associated
with using the NISS rather than the ISS must be weighed against the disadvantages of
changing a scoring system and the potential for still greater improvements.
A new characterization of injury severity.
J Trauma. 1990
Champion HR, Copes WS, Sacco WJ, Lawnick MM, Bain LW, Gann DS, Gennarelli T, Mackenzie E,
Schwaitzberg S.
Washington Hospital Center, DC 20010.
ASCOT (A Severity Characterization of Trauma) is a physiologic and anatomic
characterization of injury severity which combines emergency department admission
values of Glasgow Coma Scale, systolic blood pressure, respiratory rate, patient age, and
AIS-85 anatomic injury scores in a way that obviates ISS shortcomings. ASCOT values are
related to survival probability using the logistic function and regression weights reaffirm
the importance of head injury and coma to the prediction of patient outcome. The
ability of TRISS and ASCOT to discriminate survivors from non-survivors and the
reliability of their predictions, as measured by the Hosmer-Lemeshow statistic, were
compared using Major Trauma Outcome Study (MTOS) patient data. ASCOT
performance matched or exceeded TRISS's for blunt-injured patients and for
penetrating-injured patients. ASCOT performance gains were modest for blunt-injured
patients. The Hosmer-Lemeshow statistics suggest that ASCOT reliably predicts patient
outcome for penetrating-injured patients and nearly so for blunt-injured patients.
Statistically reliable predictions were not achieved by TRISS for either set. ASCOT
provides a more precise description of patient physiologic status and injury number,
location, and severity than TRISS. The ASCOT patient description may be useful in
relating to other important outcomes not highly correlated with TRISS or the Injury
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Champion%20HR%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Copes%20WS%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Sacco%20WJ%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Lawnick%20MM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Bain%20LW%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Gann%20DS%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Gennarelli%20T%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Mackenzie%20E%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Schwaitzberg%20S%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Schwaitzberg%20S%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Mackenzie%20E%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Gennarelli%20T%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Gann%20DS%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Bain%20LW%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Lawnick%20MM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Sacco%20WJ%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Copes%20WS%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Champion%20HR%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract -
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Severity Score (ISS) such as disability, length of stay, and resources required for
treatment.
NISS predicts post injury multiple organ failure better than the ISS.
J Trauma. 2000
Balogh Z, Offner PJ, Moore EE, Biffl WL.Department of Surgery, Denver Health Medical Center, University of Colorado Health Sciences Center,
80204, USA.
Abstract:
BACKGROUND: The Injury Severity Score (ISS) has been observed consistently to be a
robust predictor of postinjury multiple organ failure (MOF). However, the ISS fails to
account for multiple injuries to the same body region. Recently, the "new" ISS (NISS) has
been proposed to address this shortcoming. Preliminary studies suggest the NISS is
superior to the ISS in predicting trauma mortality. Our purpose was to determine
whether the NISS is a better predictor of postinjury MOF than the ISS. METHODS: A total
of 558 patients admitted to our Level I trauma center with ISS > 15, age > 15 years, andsurvival > 48 hours were prospectively identified; 101 (18%) developed postinjury MOF.
Data characterizing postinjury MOF were collected, and the NISS was calculated
retrospectively. The ISS and NISS were compared as univariate predictors of MOF.
Multivariate analysis was used to determine whether substitution of NISS for ISS
resulted in a superior predictive model. RESULTS: In 295 patients (53%), the NISS was
greater than the ISS. This subgroup of patients experienced a greater frequency of MOF
(26.7% vs. 8.3%, p < 0.0001), a higher mortality (12.8% vs. 4.9%, p < 0.001), and a higher
early transfusion requirement (6.7 U vs. 3.6 U, p < 0.0001) compared with the group in
which NISS equaled ISS. Moreover, the NISS yielded better separation between patients
with and without MOF reflected by the greater difference in median NISS scorescompared with ISS scores. The multivariate predictive model, including NISS, showed a
better goodness of fit compared with the same model that included ISS. CONCLUSIONS:
The NISS is superior to the ISS in the prediction of postinjury MOF. This measure of
tissue injury severity should replace the ISS in trauma
Comparison of alternative methods for assessing injury severity based on
anatomic descriptors.
J Trauma. 1999
Sacco WJ, MacKenzie EJ, Champion HR, Davis EG, Buckman RF.
ThinkSharp, Inc., Bel Air, Maryland, USA.
Abstract:
BACKGROUND: There is mounting confusion as to which anatomic scoring systems can
be used to adequately control for trauma case mix when predicting patient survival.
METHODS: Several Abbreviated Injury Scale (AIS) and International Classification of
Disease Clinical (ICD-9CM)-based methods of scoring severity were compared by using
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Balogh%20Z%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Offner%20PJ%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Moore%20EE%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Biffl%20WL%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Sacco%20WJ%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22MacKenzie%20EJ%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Champion%20HR%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Davis%20EG%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Buckman%20RF%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Buckman%20RF%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Davis%20EG%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Champion%20HR%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22MacKenzie%20EJ%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Sacco%20WJ%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Biffl%20WL%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Moore%20EE%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Offner%20PJ%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Balogh%20Z%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract -
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data from the Pennsylvania Trauma Outcome Study. By using a design dataset, the
probability of survival was modeled as a function of each score or profile. Resulting
coefficients were used to derive expected probabilities in a test dataset; expected and
observed probabilities were then compared by using standard measures of
discrimination and calibration. RESULTS: The modified Anatomic Profile, Anatomic
Profile, and New Injury Severity Score outperformed the International Classification ofDisease-based Injury Severity Score. This finding remains true when AIS values are
obtained by means of a conversion from International Classification of Disease to AIS.
CONCLUSION: Results support the integrity of the AIS and argue for its continued use in
research and evaluation. The modified Anatomic Profile, Anatomic Profile, and New
Injury Severity Score, however, should be used in preference to the Injury Severity Score
as an overall measure of severity.
Consensus or data-derived anatomic injury severity scoring?
J Trauma. 2008
Moore L, Lavoie A, Le Sage N, Bergeron E, Emond M, Abdous B.
Trauma and Emergency Medicine Research Unit, Department of Social and Preventative Medicne, Centre
Hospitalier Affili Universitaire Qubec (Enfant-Jsus Hospital), Laval University, Quebec City, Quebec,
Canada.
Abstract:
BACKGROUND: Anatomic injury severity scores can be grouped into two classes;
consensus-derived and data-derived. The former, including the Injury Severity Score
(ISS), the New Injury Severity Score (NISS), and the Anatomic Profile Score (APS), are
based on the severity score of the Abbreviated Injury Scale (AIS), assigned by clinical
experts. The latter, including the International Classification of Disease Injury Severity
Score (ICISS) and the Trauma Registry Abbreviated Injury Scale Score (TRAIS) are based
on survival probabilities calculated in large trauma databases. We aimed to compare the
predictive accuracy of consensus-derived and data-derived severity scores when
considered alone and in combination with age and physiologic status. METHODS:
Analyses were based on 25,111 patients from the trauma registries of the four Level I
trauma centers in the province of Quebec, Canada, abstracted between April 1998 and
March 2005. The predictive validity of each severity score was evaluated in logistic
regression models predicting hospital mortality using measures of discrimination (Area
Under the Receiver Operating Characteristics curve [AUC]) and calibration (Hosmer-
Lemeshow statistic [HL]). RESULTS: Data-derived scores had consistently better
predictive accuracy than consensus-derived scores in univariate models (p < 0.0001) butvery little difference between scores was observed in models including information on
age and physiologic status. The difference in AUC between the least accurate severity
score (ISS) and the most accurate severity score (TRAIS) was 15% in anatomic-only
models but fell to 2% in models including age and physiologic status. CONCLUSIONS:
Data-derived scores provide more accurate mortality prediction than consensus-derived
scores do when only anatomic injury severity is considered but offer little advantage if
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Moore%20L%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Lavoie%20A%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Le%20Sage%20N%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Bergeron%20E%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Emond%20M%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Abdous%20B%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Abdous%20B%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Emond%20M%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Bergeron%20E%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Le%20Sage%20N%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Lavoie%20A%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Moore%20L%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract -
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age and physiologic status are taken into account. This may be because of the fact that
data-derived scores are not an independent measure of anatomic injury severity.
The New Injury Severity Score: a more accurate predictor of in-hospital
mortality than the Injury Severity Score.
J Trauma. 2004
Lavoie A, Moore L, LeSage N, Liberman M, Sampalis JS.
Centre hospitalier affili universitaire de Qubec, Enfant-Jsus Hospital, Quebec City, Quebec, Canada.
Abstract:
OBJECTIVE: The purpose of this study was to determine whether the New Injury Severity
Score (NISS) is a better predictor of mortality than the Injury Severity Score (ISS) in
general and in subgroups according to age, penetrating trauma, and body region
injured. METHODS: The study population consisted of 24,263 patients from three urban
Level I trauma centers in the province of Quebec, Canada. Discrimination and calibration
of NISS and ISS models were compared using receiver operator characteristic (ROC)curves and Hosmer-Lemeshow statistics. RESULTS: NISS showed better discrimination
than ISS (area under the ROC curve = 0.827 vs. 0.819; p = 0.0006) and improved
calibration (Hosmer-Leme-show = 62 vs. 112). The advantage of the NISS over the ISS
was particularly evident among patients with head/neck injuries (area under the ROC
curve = 0.819 vs. 0.784; p < 0.0001; Hosmer-Lemeshow = 59 vs. 350). CONCLUSION: The
NISS is a more accurate predictor of in-hospital death than the ISS and should be chosen
over the ISS for case-mix control in trauma research, especially in certain
subpopulations such as head/neck-injured patients.
Prediction of outcomes in trauma: anatomic or physiologic parameters?
J Am Coll Surg. 2005
Guzzo JL, Bochicchio GV, Napolitano LM, Malone DL, Meyer W, Scalea TM.
Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of
Medicine, Baltimore, MD 21201, USA.
Abstract:
BACKGROUND: Prediction of outcomes after injury has traditionally incorporated
measures of injury severity, but recent studies suggest that including physiologic and
shock measures can improve accuracy of anatomic-based models. A recent single-
institution study described a mortality predictive equation [f(x) = 3.48 - .22 (GCS) - .08
(BE) + .08 (Tx) + .05 (ISS) + .04 (Age)], where GSC is Glasgow Coma Score, BE is base
excess, Tx is transfusion requirement, and ISS is Injury Severity Score, which had 63%
sensitivity, 94% specificity, (receiver operating characteristic [ROC] 0.96), but did not
provide comparative data for other models. We have previously documented that the
Physiologic Trauma Score, including only physiologic variables (systemic inflammatory
response syndrome, Glasgow Coma Score, age) also accurately predicts mortality in
trauma. The objective of this study was to compare the predictive abilities of these
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Lavoie%20A%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Moore%20L%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22LeSage%20N%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Liberman%20M%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Sampalis%20JS%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Guzzo%20JL%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Bochicchio%20GV%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Napolitano%20LM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Malone%20DL%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Meyer%20W%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Scalea%20TM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Scalea%20TM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Meyer%20W%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Malone%20DL%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Napolitano%20LM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Bochicchio%20GV%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Guzzo%20JL%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Sampalis%20JS%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Liberman%20M%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22LeSage%20N%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Moore%20L%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Lavoie%20A%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract -
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statistical models in trauma outcomes. METHODS: Area under the ROC curve of
sensitivity versus 1-specificity was used to assess predictive ability and measured
discrimination of the models. RESULTS: The study cohort consisted of 15,534 trauma
patients (80% blunt mechanism) admitted to a Level I trauma center over a 3-year
period (mean age 37 +/- 18 years; mean Injury Severity Score 10 +/- 10; mortality 4%).
Sensitivity of the new predictive model was 45%, specificity was 96%, ROC was 0.91,validating this new trauma outcomes model in our institution. This was comparable with
area under the ROC for Revised Trauma Score (ROC 0.88), Trauma and Injury Severity
Score (ROC 0.97), and Physiologic Trauma Score (ROC 0.95), but superior compared with
admission Glasgow Coma Score (ROC 0.79), Injury Severity Score (ROC 0.79), and age
(ROC 0.60). CONCLUSIONS: The predictive ability of this new model is superior to
anatomic-based models such as Injury Severity Score, but comparable with other
physiologic-based models such as Revised Trauma Score, Physiologic Trauma Score and
Trauma, and Injury Severity Score.
Trauma registry injury coding is superfluous: a comparison of outcomeprediction based on trauma registry International Classification of Diseases-
Ninth Revision (ICD-9) and hospital information system ICD-9 codes.
J Trauma. 1997
Osler TM, Cohen M, Rogers FB, Camp L, Rutledge R, Shackford SR.
Department of Surgery, College of Medicine, University of Vermont, Burlington 05405, USA.
BACKGROUND: Trauma registries are an essential but expensive tool for monitoring
trauma system performance. The time required to catalog patients' injuries is the source
of much of this expense. Typically, 15 minutes of chart review per patient are required,
which in a busy trauma center may represent 25% of a full-time employee. Wehypothesized that International Classification of Disease-Ninth Revision (ICD-9) codes
generated by the hospital information system (HI) would be similar to those coded by a
dedicated trauma registrar (TR) and would be as accurate as TR ICD-9 codes in
predicting outcome. METHODS: One thousand eight hundred twelve patients admitted
to a Level I trauma center during 2 years had International Classification of Disease
Injury Severity Scores (ICISS) calculated based on HI and TR ICD-9 codes. The relative
predictive powers of these two ICISSs were then compared for every patient using
Receiver Operator Characteristic Curve Area (ROC) and Hosmer Lemeshow Statistics.
RESULTS: Eighty-nine percent of patients (1,608 of 1,812) had identical HI and TR ICISSs.
Eleven patients' ICISSs differed by >0.1, and only two patients' scores differed by >0.2.
ICISS proved to be a powerful predictor of outcome whether derived from HI (ROC =
0.884; 95% confidence interval (CI) = 0.850-0.917) or TR (ROC = 0.872; 95% CI = 0.837-
0.908). Although these predictive powers were not significantly different (p = 0.076), the
trend was for HI to perform better than TR. ISS calculated for the same data set using
the MacKenzie dictionary proved significantly less predictive of outcome than either
ICISS (ROC(MacKenzie) = 0.843; 95% CI = 0.792-0.884; p = 0.034). CONCLUSION: We
conclude that in our hospital TR data on individual injuries can be replaced by HI data
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Osler%20TM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Cohen%20M%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Rogers%20FB%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Camp%20L%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Rutledge%20R%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Shackford%20SR%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Shackford%20SR%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Rutledge%20R%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Camp%20L%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Rogers%20FB%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Cohen%20M%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Osler%20TM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract -
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without loss of predictive power. ISS based on the MacKenzie dictionary should be
abandoned because it is much less predictive of outcome than ICISS.
Incorporating recent advances to make the TRISS approach universally
available.
J Trauma. 2006
Kilgo PD, Meredith JW, Osler TM.
Department of Biostatistics, Emory University School of Public Health, GA 30322, USA.
BACKGROUND: The Trauma and Injury Severity Score (TRISS), used to garner predictions
of survival from the Injury Severity Score (ISS), the Revised Trauma Score (RTS, for
physiologic reserve), and age is difficult for many trauma facilities to compute because it
requires 8 to 10 variables and ISS depends on the specialized Abbreviated Injury Scale
(AIS) scale rather than the International Classification of Diseases scale (ICD-9). It has
been shown that metrics describing a patient's worst injury (WORSTSRR) are a powerful
predictor of survival (regardless of coding type, AIS versus ICD-9) and that the Glasgow
Coma Scale (GCS) motor component contains the majority of the information found in
the full GCS score. This study hypothesized that the TRISS approach could be made more
predictive and efficient with fewer variables by incorporating these advances.
METHODS: A total of 310,958 patients with nonmissing TRISS variables were subset
from the National Trauma Data Bank (NTDB). Logistic regression was used to model
mortality as a function of anatomic, physiologic and age variables. A traditional TRISS
model was computed (with NTDB-derived coefficients) that uses ISS, RTS, age index, and
mechanism to predict survival. Four smaller three- or four-variable models employed
the ICD-9 WORSTSRR, the GCS motor component, and age (both continuously and
dichotomously). Two of the four models also use mechanism. These models werecompared using the concordance index (c-index, a measure of model discrimination)
and the pseudo-R statistic (estimates proportion of variance explained). RESULTS: Each
experimental model (two models with 3 variables and two models with 4 variables) have
superior discrimination and explain more variance than the traditional TRISS model that
employs 8-10 variables. CONCLUSIONS: Recent advances in anatomic and physiologic
scoring markedly simplify TRISS-type models at no cost to prediction. This approach uses
routinely available data, requires up to seven fewer terms, and predicts at least as well
as the original TRISS. These findings could increase the availability of accurate trauma
scoring tools to smaller trauma facilities.
A modification of the injury severity score that both improves accuracy and
simplifies scoring.
J Trauma. 1997
Osler T, Baker SP, Long W.
Department of Surgery, University of Vermont, Burlington 05405, USA. turner.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Kilgo%20PD%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Meredith%20JW%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Osler%20TM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Osler%20T%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Baker%20SP%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Long%20W%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Long%20W%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Baker%20SP%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Osler%20T%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Osler%20TM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Meredith%20JW%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Kilgo%20PD%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract -
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OBJECTIVES: The Injury Severity Score (ISS) has served as the standard summary
measure of anatomic injury for more than 20 years. Nevertheless, the ISS has an
idiosyncrasy that both impairs its predictive power and complicates its calculation. We
present here a simple modification of the ISS called the New Injury Severity Score (NISS),
which significantly outperforms the venerable but dated ISS as a predictor of mortality.DESIGN: Retrospective calculation of NISS and comparison of NISS with prospectively
calculated ISS. MATERIALS AND METHODS: The NISS is defined as the sum of the
squares of the Abbreviated Injury Scale scores of each of a patient's three most severe
Abbreviated Injury Scale injuries regardless of the body region in which they occur. NISS
values were calculated for every patient in two large independent data sets: 3,136
patients treated during a 4-year period at the American College of Surgeons' Level I
trauma center in Albuquerque, New Mexico, and 3,449 patients treated during a 4-year
period at the American College of Surgeons' Level I trauma center at the Emanuel
Hospital in Portland, Oregon. The power of NISS to predict mortality was then compared
with previously calculated ISS values for the same patients in each of the two data sets.
MEASUREMENTS AND MAIN RESULTS: We find that NISS is not only simple to calculate
but more predictive of survival as well (Albuquerque: receiver operating characteristic
(ROC) ISS = 0.869, ROC NISS = 0.896, p < 0.001; Portland: ROC ISS = 0.896, ROC NISS =
0.907,p < 0.004). Moreover, NISS provides a better fit throughout its entire range of
prediction (Hosmer Lemeshow statistic for Albuquerque ISS = 29.12, NISS = 8.88;
Hosmer Lemeshow statistic for Portland ISS = 83.48, NISS = 19.86). CONCLUSION: NISS
should replace ISS as the standard summary measure of human trauma.
A comparison of the abilities of nine scoring algorithms in predicting
mortality.
J Trauma. 2002
Meredith JW, Evans G, Kilgo PD, MacKenzie E, Osler T, McGwin G, Cohn S, Esposito T, Gennarelli T,
Hawkins M, Lucas C, Mock C, Rotondo M, Rue L, Champion HR.
Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
27157, USA.
OBJECTIVE: The purpose of this study was to compare the abilities of nine Abbreviated
Injury Scale (AIS)- and (ICD-9)-based scoring algorithms in predicting mortality.
METHODS: The scores collected on 76,871 incidents consist of four AIS-based algorithms
(Injury Severity Score [ISS], New Injury Severity Score, Anatomic Profile Score [APS], and
maximum AIS [maxAIS]), their four ICD to AIS mapped counterparts, and the ICD-9-based ISS (ICISS). A 10-fold cross-validation was performed and area under the receiver
operating characteristic curve was used to determine algorithm discrimination. Hosmer-
Lemeshow statistics were computed to gauge goodness-of-fit, and model refinement
measured variance of predicted probabilities. RESULTS: Overall, the ICISS has the best
discrimination and model refinement, whereas the APS has the best Hosmer-Lemeshow
performance. ICD-9 to AIS mapped scores have worse discrimination than their AIS-
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Meredith%20JW%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Evans%20G%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Kilgo%20PD%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22MacKenzie%20E%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Osler%20T%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22McGwin%20G%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Cohn%20S%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Esposito%20T%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Gennarelli%20T%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Hawkins%20M%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Lucas%20C%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Mock%20C%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Rotondo%20M%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Rue%20L%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Champion%20HR%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Champion%20HR%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Rue%20L%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Rotondo%20M%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Mock%20C%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Lucas%20C%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Hawkins%20M%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Gennarelli%20T%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Esposito%20T%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Cohn%20S%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22McGwin%20G%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Osler%20T%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22MacKenzie%20E%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Kilgo%20PD%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Evans%20G%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Meredith%20JW%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract 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based counterparts, but still show moderate performance. CONCLUSION: Differences in
performance were relatively small. Complex scores such as the ICISS and the APS
provide improvement in discrimination relative to the maxAIS and the ISS. Trauma
registries should move to include the ICISS and the APS. The ISS and maxAIS perform
moderately well and have bedside benefits.
Comparing measures of injury severity for use with large databases.
J Trauma. 2002
Stephenson SC, Langley JD, Civil ID.
Injury Prevention Research Unit, Department of Preventive and Social Medicine, Dunedin School of
Medicine, University of Otago, New Zealand.
BACKGROUND: After recent debate about the best measure of anatomic injury severity,
this study aimed to compare four measures based on Abbreviated Injury Scale scores
derived using ICDMAP-90-the Modified Anatomic Profile (ICD/mAP), Anatomic Profile
Score (ICD/APS), Injury Severity Score (ICD/ISS), and New Injury Severity Score(ICD/NISS)-with the International Classification of Diseases-based Injury Severity Score
(ICISS). METHODS: Data were selected from New Zealand public hospital discharges
from 1989 to 1998. There were 349,409 patients in the dataset, of whom 3,871 had
died. Models were compared in terms of their discrimination and calibration using
logistic regression. Age was included as a covariate. RESULTS: The ICISS and ICD/mAP
were the best performing measures. Adding age significantly improved the
discrimination and calibration of almost all the models. CONCLUSION: The ICISS is a
viable alternative to ICDMAP-based measures for coding anatomic injury severity on
large datasets.
Predictors of mortality in adult trauma patients: the physiologic trauma
score is equivalent to the Trauma and Injury Severity Score.
J Am Coll Surg. 2002
Kuhls DA, Malone DL, McCarter RJ, Napolitano LM.
Department of Surgery, University of Nevada School of Medicine, Las Vegas, USA.
BACKGROUND: Several statistical models (Trauma and Injury Severity Score [TRISS], New
Injury Severity Score [NISS], and the International Classification of Disease, Ninth
Revision-based Injury Severity Score [ICISS]) have been developed over the recent
decades in an attempt to accurately predict outcomes in trauma patients. The anatomicportion of these models makes them difficult to use when performing a rapid initial
trauma assessment. We sought to determine if a Physiologic Trauma Score, using the
systemic inflammatory response syndrome (SIRS) score in combination with other
commonly used indices, could accurately predict mortality in trauma. STUDY DESIGN:
Prospective data were analyzed in 9,539 trauma patients evaluated at a Level I Trauma
Center over a 30-month period (January 1997 to July 1999). A SIRS score (1 to 4) was
calculated on admission (1 point for each: temperature > 38 degrees C or < 36 degrees
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Stephenson%20SC%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Langley%20JD%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Civil%20ID%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Kuhls%20DA%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Malone%20DL%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22McCarter%20RJ%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Napolitano%20LM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Napolitano%20LM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22McCarter%20RJ%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Malone%20DL%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Kuhls%20DA%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Civil%20ID%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Langley%20JD%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Stephenson%20SC%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract -
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C, heart rate > 90 beats per minute, respiratory rate > 20 breaths per minute, neutrophil
count > 12,000 or < 4,000. SIRS score, Injury Severity Score (ISS), Revised Trauma Score
(RTS), TRISS, Glasgow Coma Score, age, gender, and race were used in logistic regression
models to predict trauma patients' risk of death. The area under the receiver-operating
characteristic curves of sensitivity versus 1-specificity was used to assess the predictive
ability of the models. RESULTS: The study cohort of 9,539 trauma patients (of which7,602 patients had complete data for trauma score calculations) had a mean ISS of 9 +/-
9 (SD) and mean age of 37 +/- 17 years. SIRS (SIRS score > or = 2) was present in 2,165 of
7,602 patients (28.5%). In single-variable models, TRISS and ISS were most predictive of
outcomes. A multiple-variable model, Physiologic Trauma Score combining SIRS score
with Glasgow Coma Score and age (Hosmer-Lemenshow chi-square = 4.74) was similar
to TRISS and superior to ISS in predicting mortality. The addition of ISS to this model did
not significantly improve its predictive ability. CONCLUSIONS: A new statistical model
(Physiologic Trauma Score), including only physiologic variables (admission SIRS score
combined with Glasgow Coma Score and age) and easily calculated at the patient
bedside, accurately predicts mortality in trauma patients. The predictive ability of this
model is comparable to other complex models that use both anatomic and physiologic
data (TRISS, ISS, and ICISS).
ICISS: an international classification of disease-9 based injury severity score.
J Trauma. 1996
Osler T, Rutledge R, Deis J, Bedrick E.
Department of Surgery, University of Vermont College of Medicine, Burlington, USA.
BACKGROUND: The Injury Severity Score (ISS) has served as the standard summary
measure of human trauma for 20 years. Despite its stalwart service, the ISS has twoweaknesses: it relies upon the consensus derived severity estimates for each
Abbreviated Injury Scale (AIS) injury and considers, at most, only three of an individual
patient's injuries, three injuries that often are not even the patient's most severe
injuries. Additionally, the ISS requires that all patients have their injuries described in
the AIS lexicon, an expensive step that is currently taken only at hospitals with a zealous
commitment to trauma care. We hypothesized that a data driven alternative to ISS that
used empirically derived injury severities and considered all of an individual patient's
injuries would more accurately predict survival. METHODS: Survival risk ratios were
derived for every International Classification of Disease 9th Edition (ICD-9) injury
category (800-959.9) using the North Carolina State Discharge Database experience with
300,000 trauma patients over 5 years. An ICD-9 Injury Severity Score (ICISS) was then
defined as the product of all survival risk ratios for an individual patient's traumatic ICD-
9 codes. We compared the performance of ISS and ICISS in a group of 3,142 patients
accrued at the University of New Mexico Trauma Center over 4 years. These patients
had both AIS and ICD-9 descriptors meticulously assigned prospectively by designated
trauma data base personnel. RESULTS: ICISS outperformed ISS at a level that was highly
statistically significant (p < 0.0001) and may be clinically important: ISS misclassification
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Osler%20T%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Rutledge%20R%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Deis%20J%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Bedrick%20E%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Bedrick%20E%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Deis%20J%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Rutledge%20R%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Osler%20T%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract -
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rate 7.67%, ISS Receiver Operator Characteristic Curve area = 0.872; ICISS
misclassification rate 5.95%, ICISS Receiver Operator Characteristic Curve area = 0.921.
Moreover, these improvements are largely preserved when ICISS is used in a probability
of survival model that includes age, mechanism, and revised trauma score. About half of
ICISS's improvement in predictive power is because of its use of an individual patient's
worst three injuries regardless of body region. The remainder is because of bettermodeling of individual injuries and allowing all injuries to contribute to the final score.
CONCLUSIONS: We conclude that ICISS is a much better predictor of survival than ISS in
injured patients. The use of the ICD-9 lexicon may avoid the need for AIS coding, and
thus may add an economic incentive to the statistical appeal of ICISS. It is possible that a
similar data driven revision of ISS using the AIS vocabulary might perform as well or
better than ICISS. Indeed, the actual lexicon used to divide up the injury "landscape"
into individual injuries may be of little consequence so long as all injuries are considered
and empirically derived SRRs are used to calculate the final injury measure.
Comparison of the Injury Severity Score and ICD-9 diagnosis codes aspredictors of outcome in injury: analysis of 44,032 patients.
J Trauma. 1997
Rutledge R, Hoyt DB, Eastman AB, Sise MJ, Velky T, Canty T, Wachtel T, Osler TM.
Department of Surgery, University of North Carolina at Chapel Hill 27599-7210, USA.
INTRODUCTION: Appropriate stratification of injury severity is a critical tool in the
assessment of the treatment and the prevention of injury. Since its inception, the Injury
Severity Score (ISS) has been the generally recognized "gold standard" for anatomic
injury severity assessment. However, there is considerable time and expense involved in
the collection of the information required to calculate an accurate ISS. In addition, thepredictive power of the ISS has been shown to be limited. Previous work has
demonstrated that the anatomic information about injury contained in the International
Classification of Diseases Version 9 (ICD-9) can be a significant predictor of survival in
trauma patients. The goal of this study was to utilize the San Diego County Trauma
Registry (SDTR), one of the nation's leading trauma registries, to compare the predictive
power of the ISS with the predictive power of the information contained in the injured
patients' ICD-9 diagnoses codes. It was our primary hypothesis that survival risk ratios
derived from patients' ICD-9 diagnoses codes would be equal or better predictors of
survival than the Injury Severity Score. The implications of such a finding would have the
potential for significant cost savings in the care of injured patients. METHODS: Data for
the test population were obtained from the SDTR, which contains data from 1985
through 1993 from five participating hospitals. Four data sources were utilized to
estimate the expected survival rate/mortality rate for each ICD-9 code in the SDTR.
These were (1) the SDTR patients themselves, (2) the North Carolina State Hospital
Discharge Database, (3) the North Carolina Trauma Registry Database, and (4) the
Agency for Health Care Policy Research's Health Care Utilization Project Database. Each
of these data sources was separately utilized to develop a survival risk ratio (SRR) for
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Rutledge%20R%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=