injury severity scores

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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=

injury severity scores

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