SAPI : Score des Activités et des Pathologies en soins Intensifs ou intégration de la fonction intensive dans la fonction hospitalière
(2003)
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- Since about 10 years, the health care financing systems in the westerns countries encountered more and more difficulties. They are the consequences of the gradual rise in the health care costs together with a decrease in the resources. The tendency is to stop playing for what is performed and to replace this system by another one based on the allocation of resources corresponding to the real costs. This means that the real costs be estimated. The actual proportion is to link the allocations with the illness. But this method can be applied only to standardised patients with an unique standardised pathology without any other personal problems such as handicap, old age, social or economical problems. For on standard patients, the real costs will be greater than the estimates mean cost for the illness: such patients are called “outliers”. The hospitals who will accept to treat those patients will have important financial problems. The only way to avoid such risks is to measure the extracosts. This is especially important for the patients requiring Intensive Care because of the high costs of this type of care. <BR> Some tools are already used in Belgium. The first one is the classification of the hospitalised patients in APRDRGs. The second one is the registration of the real use of the intensive care resources within each hospital: number of days in Intensive Car Unit (ICU) and nursing activities. The last one is the registration of the number of application of some special cardiovascular techniques and of the mechanical ventilation. In this work we demonstrated that none of these tools is satisfactory. <BR> In the literature we find information about a lot of scores and index specially developed for intensive care. Two subjects of concern have leaded to the development of those scores or indexes : the importance of the measurement of severity of the illness and therapeutically workload. The first general severity scores appeared about 20 years ago. They xere progressively modified and reach nowadays their 3d generation which is based on mathematical models most often through the use of the logistic regression (APACHEIII, SAPSII, MPMII). They can be obtained by the measurement, at admission or during the first 24 hours, of some physiological parameters which evaluate the principal vital functions. They were built in order to predict an individual risk of death independently of the treatment administered as well as of the evolution during the ICU stay i.e. the apparition of expected and non-expected complications and the development of multiple organ failure (MOF). However, the so-called MOF syndrome is very important in that it is the most important cause of delayed death in ICU. These system organ failures are described by other specific scores such as the OSF score (Organ System Failure) and more recently the SOFA score (Severity Organ Failure Assessment score). The LODS (Logistic Organ Dysfunction System) score developed by Lemeshow is based on the logistic regression model but take into account only the data obtained during the first 24 hours in ICU. For the therapeutical workload evaluation, the most often used indexes are the OMEGA developed in France, the PRN (Project of Research Nursing) in Canada and the TISS (Therapeutical Intervention Scoring System) used in the northern America and In Europe. Only the TISS has been used widely and demonstrated its interest to define the needs in nursing staff as well as the costs in ICU. Nevertheless, even in his simplified version (TISS28), this score needs the registration of a lot of techniques which may be overused in case of financing decision based ion it and which must be brought up to date. Moreover, none of these scores and indexes consider together the physiologic situation of the patient and the treatment applied. In other words, they give little attention to the individual response to treatment, which is for us a central point in the discussion about intensive care. Finally, we found that none of the tools availed today is satisfactory (First part). <BR> We decide to built a new score based on a limited number of parameters which, as far as possible, cannot be overused, and that describes and quantifies, day by day and for each patient admitted in ICU, the type and importance of organ system failures and the applied therapeutical workload. This global score, called SAPI score, Scoring of Activity and Pathologies in Intensive care. By its specific capacity to evaluate the relation between the severity of the illness and the administered therapeutical workload, it should also be an interesting tool to evaluate the quality of care by the estimation of the expected death rates in ICU and by the analysis of the influence of the specific applied treatment as well as that of the total therapeutical workload on the patients evolution and outcome in ICU. Finally, we also want to use this new score to integrate the ICU stays within the whole hospital stays. <BR> At the end of the study, we demonstrated that we cannot use an unique score for the medical and the financial purposes: we obtained two components for the SAPI score, the SAPI-SEVERITY score correlated with the individual and collective risk of death in ICU, and the SAPI-ACTIVITY score mathematically linked with the estimated real costs in ICU These two components are based on the same set of 40 parameters which are considered separately or combined in clinically important associations. The parameters are 10 physiological measured variables that are always available, and 30 techniques. The selected techniques are very heavy ones as such as dialysis, EMCO are general anaesthesia and therefore will probably not be overused. In our database, they have been applied at 1 to 50% of the patients. The time needed to register those parameters ranges 1 to 2 minutes per patient and per day. A part of the selected parameters and associations are specifically associated to one of the 2 components of the SAPI score, the others are associated to both of them but with different weights. Consequently, the two components are mathematically independent and the relation between them can be analysed. This statistical methods used and the description of the SAPI score can be found in the second part chapter I. In the chapter II we detailed the observed relations nd the theoretical models between the 2 components of the SAPI score and the mortality rate on one hand, and the therapeutical costs on the other hand. <BR> Furthermore, the SAPI score is composed by the sum of the scores obtained for 7 different physiological systems : cardiovascular, respiratory, digestive, nephrological, neurological, metabolical, immuno-hematological, to which we add a so called general system which represents the parameters associated to all the others such as general anaesthesia. Thus, the SAPI score is also a Multiple Organ Failure (MOF) score which measure the number together with the degree of each system failure. Being measured daily, the SAPI score also provides information about the evolution of the MOF syndrome which are interesting at a physiopathological point of view (4th part chapter II°). <BR> Afterwards, we continue with 2 applications of the SAPI score to our database. First we analyse the pathological and therapeutical profile of the patients regarded their age (3d part chapter I). Interestingly, we find that no patients more than 85 years and admitted after an elective surgery developed severe MOF syndrome. In other words, it appears that the physician performed an intuitive and efficient selection for those very old patients. Second, we study the models based on the SAPI score within subgroups of patients based on the medical, surgical, cardiac or non cardiac admission pathologies, and for the emergency and elective admission groups (3d part chapter II). The conclusion is that the models are always reproducible. Moreover, we demonstrate in the 2 approaches that the severity of the MOF syndrome, measured with the SAPI-SEVERITY score, is the most important factor that explain both the risk of death in ICU and the therapeutical workload and costs. <BR> Finally, we demonstrate that the SAPI score may be considered as an estimator of the whole hospital intensive function and we proposed some practical applications to improve the financial system applied to the hospital intensive function and the management of the intensive care resources inside and outside the Intensive Care Units (4th part chapter I and II).We also demonstrate and illustrate that the SAPI score may be considered as one of the quality and efficiency of care indicator and therefore may be used in analyses such as Benckmarking (4th part chapter III). <BR> To conclude we can say that the SAPI score is a new score, obtained from a rigorous and objective selection of a limited number of parameters easy to obtained and difficult to overuse. The physiological parameters are associated to some important techniques so that the SAPI score can be considered as a measure of the response to the applied therapy. Moreover, the SAPI score results in the addition of the scores obtained for 8 physiological systems which can be measured daily. Thus, the SAPI score is a dynamic Multiple Organ Failure score. The theoretical models based on it are reproducible within different subgroups of patients. The SAPI score may be used for the medical application as well as for the estimation of the real costs in ICU. It may also be used as an estimator of the whole hospital intensive function, for the management of the hospital intensive care resources and as one of the quality and efficiency of care indicator
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Hanique, G. (2003). SAPI : Score des Activités et des Pathologies en soins Intensifs ou intégration de la fonction intensive dans la fonction hospitalière. https://hdl.handle.net/2078.5/110782