Hindawi Publishing Corporation Current Gerontology and Geriatrics Research Volume 2014, Article ID 934852, 9 pages http://dx.doi.org/10.1155/2014/934852 Review Article The Simplified Acute Physiology Score III Is Superior to the Simplified Acute Physiology Score II and Acute Physiology and Chronic Health Evaluation II in Predicting Surgical and ICU Mortality in the ‘‘Oldest Old’’ Aftab Haq,1 Sachin Patil,2 Alexis Lanteri Parcells,1 and Ronald S. Chamberlain1,2,3 1 Saint George’s University School of Medicine, West Indies, Grenada 2 Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, USA 3 Department of Surgery, University of Medicine and Dentistry of New Jersey (UMDNJ), 94 Old Short Hills Road Livingston, Newark, NJ 07039, USA Correspondence should be addressed to Ronald S. Chamberlain; [email protected] Received 25 August 2013; Revised 3 November 2013; Accepted 2 December 2013; Published 17 February 2014 Academic Editor: Giuseppe Zuccala Copyright © 2014 Aftab Haq et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Elderly patients in the USA account for 26–50% of all intensive care unit (ICU) admissions. The applicability of validated ICU scoring systems to predict outcomes in the “Oldest Old” is poorly documented. We evaluated the utility of three commonly used ICU scoring systems (SAPS II, SAPS III, and APACHE II) to predict clinical outcomes in patients > 90 years. 1,189 surgical procedures performed upon 951 patients > 90 years (between 2000 and 2010) were analyzed. SAPS II, SAPS III, and Acute APACHE II were calculated for all patients admitted to the SICU. Differences between survivors and nonsurvivors were analyzed using the Student’s t-test and binary logistic regression analysis. A receiver operating characteristic (ROC) curve was constructed for each scoring system studied. The area under the ROC curve (aROC) for the SAPS III was 0.81 at a cut-off value of 57, whereas theaROCfor SAPS II was 0.75 at a cut-off score of 44 and the aROC for APACHE II was 0.74 at a cut-off score of 13. The SAPS III ROC curve for prediction of hospital mortality exhibited the greatest sensitivity (84%) and specificity (66%) with a score of 57 for the “Oldest Old” population. 1. Introduction important role in guiding physician decision making and may facilitate evidence-based rationing of limited healthcare Life expectancy has increased substantially in the past half resources in the future. century due to significant advances in healthcare preven- To date, numerous studies have documented the negative tion alongside improvements in diagnosis and treatment impact of advanced age on ICU outcomes [2–7]. Although approaches. As a result, the most rapidly growing segment of older age is clearly associated with increased mortality, other the US population is the elderly, defined as individuals older age-related factors signifying severity of illness have been than 65 years [1].The“OldestOld”inthepopulationarethose shown to be better at predicting ICU outcomes in elderly over 85, which currently represents 2% of the US census— patients than age alone [8, 9]. These factors include the afigure,thatis,expectedtoincreaseover200%by2050[1]. admitting diagnosis [8, 10–13], comorbidities [14–18], and These changing demographics have already had a dramatic the functional status of the patient prior to ICU admission effectonICUadmissions,withmeanageofpatientsadmitted [19–22]. Commonly used ICU prognostic scoring models and total number of ICU admissions increasing faster than include the Simplified Acute Physiologic Score II (SAPS healthcare resources can keep pace [2]. Information derivable II), Acute Physiology and Chronic Health Evaluation II from validated ICU scales will likely play an increasingly (APACHE II), and the newly developed SAPS III. These 2 Current Gerontology and Geriatrics Research scoring systems incorporate physiologic parameters, co- 3. Results morbidities, admitting diagnoses, Glasgow coma scales, and age to provide a numerical score that can in turn predict ICU See Table 2. mortality. Sakr et al. compared the utility of SAPS III against 3.1. Age and Sex. The mean overall patient age was 93.2 years APACHE II and SAPS II in 1851 surgical ICU patients (91–100); the mean age among male patients was 92.9 years, (mean age of 62 years). They noted that in-hospital mortality while the mean age among female patients was 93.4 years. wassubstantiallygreaterinpatientswithhigherSAPSIII The M : F ratio was 1 : 1.02. On SICU admission, the survivor score, and that a score greater than 80 was associated group’s mean age was 93.2, whereas the mortality group’s with a 70% mortality rate whereas a score less than 40 mean age was 92.8 years, < 0.5. was associated with a less than 3% mortality. The authors concluded that the SAPS II and SAPS III predict mortal- 3.2. Length of Stay and Discharge Status. The mean stay for ity better than the APACHE II model in elderly patients all patients admitted to the SICU was 6±8days and the mean [23]. hospital stay was 16.6 ± 10 days. The majority of discharged Healthcare advancements in recent decades have permit- patients were sent to a nursing facility (=30; 33.7%) or tedmoreelectivesurgeriesinpatientswithveryadvancedage. home without assisted living (=29; 32.6%). The remainder However, suitable literature documenting the ICU outcomes of the patients were discharged to a cancer center (=8; of this age group is lacking. This study sought to evaluate 9%), or rehabilitation center (=4; 4.4%), while 14 patients the utility of the SAPS II, SAPS III, and APACHE II scoring (15.7%) suffered mortality. systems in nonagenarians (>90 years) admitted to the surgical ICU. 3.3. Comorbidities. The co-morbidities most prevalent in our study population were cardiac diseases. These include congestive heart failure (CHF) in 38.2% (=34)patients, 2. Materials and Methods hypertension in 34.8% (=31) patients, atrial fibrillation in 29.2% (=26) patients, and coronary artery disease in 21.3% A retrospective review of all nonagenarians admitted to Saint (=19)patients. Barnabas Medical Center (SBMC) in Livingston, NJ, over a 10-year period (between 2000 and 2010) was performed. 951 unique nonagenarian patients were admitted who underwent 3.4. Anesthesia. The preoperative American Society of Anes- 1189 surgical procedures. 117 (9.8%) of those patients were thesiologists (ASA) score was available for 64 patients, and admitted to the Surgical Intensive Care Unit (SICU) postop- themeanASAscorewas3.31(range:2–5).ThemeanASA eratively. Pertinent data was collected using a standard data score for male patients was 3.33 (range: 2–5) compared to 3.15 (range: 2–4) in female patients, = 0.4. Twenty-eight percent collection sheet after approval from the institutional review =18 =36 board (IRB: 10–25). Data abstracted included age, gender, ( )ofpatientshadanASAscoreoftwo,56.2%( ) hadanASAscoreofthree,12.5%(=8)hadanASAscoreof comorbidities, procedure type, ASA status, operative time, =2 hospital length of stay, ICU length of stay, ICU admission, four while only 3.1% ( )ofpatientshadanASAscoreof and outcome. SAPS II, SAPS III, and APACHE II scores and five. General anesthesia was provided to 74.2% of the patients (=66), cardiac anesthesia to 10.1% (=9), and regional predicted mortality were calculated by retrospective chart =7 =7 review for 89 patients (28 were excluded due to insufficient anesthesia to 7.9% ( ). The remaining 7.9% ( ) chart data). Two study populations were grouped into a of cases were performed under Monitored Anesthesia Care mortality group and a survivor group. The mortality group (MAC). included all patients who died within the SICU and the survivor group consisted of all patients who were discharged. 3.5. Surgery. Among the surgical procedures performed =34 Receiver Operator Characteristic (ROC) Curves were plotted 38.2% ( ) had general surgery, orthopedic surgery =12 =9 to determine the sensitivity and specificity in the aforemen- 13.5% ( ), cardiac surgery 10.1% ( ), urologic =8 =7 tioned ICU scoring models to predict in-hospital mortality in surgery 9% ( ), neurosurgery 7.9% ( ), vascular =6 =13 this population. surgery 6.7% ( ), and 14.6% ( )ofpatientshad The outcomes of ICU patients, especially mortality, invasive procedures (endoscopy, cystoscopy, and biopsy). The 152 ± 112 depend on several factors. Based on these factors, several meanoperativetimewas minutes. severity scoring systems have been developed. The severity sores usually comprise two parts: the score itself (higher 3.6. SAPS II, SAPS III, and APACHE II Scores. The overall number indicates higher severity) and a probability model mortality in the studied group was 15.7% (14 of 89). The mean (an equation giving the probability of in-hospital death). SAPS II, score (predicted mortality) for patients who died The most commonly used severity scoring systems include was 57.4 ± 20.0 (55.2% ± 29.7%) compared to 41.7 ± 14.9 APACHE II, SAPS II, and SAPS III. The APACHE II was (30.5% ± 23.7%) for survivors, < 0.001.ThemeanSAPS developed by a panel of experts based on their personal III score (predicted mortality), for patients who died, was opinion whereas SAPS II and SAPS III were developed by 74.6 ± 14.2 (60.7% ± 22.1%) compared to 57.8 ± 14.5 (32.4% ± prospective multi-institutional studies. Differences between 23.6%) for survivors, < 0.001.ThemeanAPACHEIIscore