1 case-mix and optimization of mortality prognostic scores in portuguese pediatric intensive care...

1

Case-mix and Optimization of Mortality Prognostic

Scores in Portuguese Pediatric Intensive Care Units

Introdução à Medicina II

2011/2012Class 121

Advisors: Rosa Oliveira2 and Daniel Martins3

1. [email protected];

2. [email protected]; 3. [email protected];

Table of Contents

2Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units

• Introduction

• Contextualization

• State of the Art

• Background

• Are scores discriminative? And calibrated?

• Differences in calibration… Why?

• Should scores be recalibrated?

• Problems…

• Research Questions

• Aims

• Methods

• Expected results

• Results

• References

• Acknowledgments

PICUs – Pediatric Intensive Care Units

Introduction


Introduction

BackgroundBackground

Research QuestionsResearch Questions

AimsAims

ReferencesReferences

AcknowledgementsAcknowledgements

State of the ArtState of the Art

Contextualization

• A Pediatric Intensive Care Unit (PICU) is an area within a hospital specialized in the care of critically ill infants, children, and teenagers.

• The type and number of patients and the provided health care differs according to its location.

Frankel, Lorry R; DiCarlo, Joseph V (2003). “Pediatric Intensive Care”. In Bernstein, Daniel; Shelov, Steven P. Pediatrics for Medical Students (2nd ed.).

MethodsMethods





AimsAims


ResultsResults

Introduction

MethodsMethods

Introduction



AimsAims




MethodsMethods

Consume human and financial resources

Provide adequate treatment for severely ill children


Introduction

4PICUs – Pediatric Intensive Care Units

Portuguese PICUs

Case-mix and Optimization of Mortality Prognostic Scores in Portuguese Pediatric Intensive Care Units




AimsAims


ResultsResults

MethodsMethods


Introduction


Introduction



AimsAims




MethodsMethods


Introduction


Portuguese PICUs





AimsAims


ResultsResults

MethodsMethods


Introduction


Major health quality resource Pacient stratification

Evaluation

Mortality rate Assistance quality


Introduction



AimsAims




MethodsMethods


Introduction


Portuguese PICUs





AimsAims


ResultsResults

MethodsMethods


Introduction



Evaluation



Introduction



AimsAims




MethodsMethods


Introduction


Portuguese PICUs





AimsAims


ResultsResults

MethodsMethods


Introduction



Evaluation

Mortalit rate Assistance quality


Introduction



AimsAims




MethodsMethods

Consume human and financial resources


Introduction


Portuguese PICUs





AimsAims


ResultsResults

MethodsMethods


Introduction



Mortality Prognostic Scores

PIM PRISM

Introduction






AimsAims


ResultsResults

MethodsMethods


Introduction


PIM – Pediatric Index of Mortality; PRISM – Pediatric Risk of Mortality

Mortality Prognostic Scores

PIM PRISM

Introduction






AimsAims


ResultsResults

MethodsMethods


Introduction



Introduction






AimsAims


Expected resultsExpected results

MethodsMethods


Introduction



PIM PRISM

•Elective admission•Subjacent conditions•Pupil reaction to light•Mecânical ventilation

•Blood Pressure•Blood alcalemia•Oxigen in blood

•Sistolic blood presure•Diastolic blood presure

•Cardic and respiratory frequency•Partial pressure of oxygen in the blood (PaO2)•Partial pressure of carbon dioxide in the blood

(PaCO2)•Glasgow Coma scale

•Pupil reactionsTP/TTP•Total bilirubin

•Potassium and calcium concentrations•Glucose index•Bicarbonate

• Observation during 1h •Observation during 24h

• Parameters in admission and one hour after •The hightest parameter in the first 24 hours

• Amount of information;• Duration of the observation period;

• Moment in which the information is collected. 1

1. Slater, A.M.B., FRACP, FJFICM; Shann, Frank MB, BS, MD, FRACP, FJFICM; the ANZICS Paediatric Study Group, The suitability of the Pediatric Index of Mortality (PIM), PIM2, the Pediatric Risk of Mortality (PRISM), and PRISM III for monitoring the quality of pediatric intensive care in Australia and New Zealand. Pediatric Critical Care Medicine, 2004. 5(5): p. 447-453.

Logit = (-4.873) + (values * Beta) + (0.021 * (absolute(SBP-120))) + (0.071 * (absolute base excess)) + (0.415 * (FiO2/PaO2))

Mortality Prediction Value= eLogit/ (1+eLogit)


Carmen Ferández, J.L.-H., Jose C. Flores, Dolores Galaviz, Marta Rupérez, Kay B. Brandstrup, Amaya Bustinza, Prognosis in critically ill children requiring continuous renal replacement therapy. IPNA, 2005.

State of the Art

14



AimsAims



MethodsMethods

Introduction





AimsAims


ResultsResults

MethodsMethods


Introduction

Are scores discriminative? And calibrated?

“Both PRISM and PIM scores have a good discriminatory performance. The

calibration with PRISM score is good but the PIM score displays poor

calibration.”

Taori RN, L. K., Tullu MS (2010). "Performance of PRISM (Pediatric Risk of Mortality) score and PIM (Pediatric Index of Mortality) score in a tertiary care pediatric ICU." Indian J Pediatr 77(3): 267-271.

Background

15


AimsAims



MethodsMethods

Introduction







AimsAims


ResultsResults

MethodsMethods


Introduction


Diferences in calibration... Why?

Background

16


AimsAims



MethodsMethods

Introduction







AimsAims


ResultsResults

MethodsMethods


Introduction

Different regions

Missing values

Recalibrations

→ Population case-mix→ Type of PICU→ Admission policy→ …


Should scores be recalibrated?

“Subsequent validation of variables could improve the sensitivity and the

value of severity scoring in the future. Nevertheless, illness

severity scores will never be indicative of absolute irreversibility of disease or

impossibility of survival...” 2

“ In general, scoring systems should be used only in populations similar to

the reference population in which the prediction model was developed.” 1

Wells M, R.-F.J., Luyt DK, Dance M, Lipman J., Poor discriminatory performance of the Pediatric Risk of Mortality (PRISM) score in a South African intensive care unit. Crit Care Med., 1996. 24(9)

Unertl K, K.B., Prognostic scores in intensive care. Anaesthesist., 1997. 46(6): p. 471-80.

Background

17


AimsAims



MethodsMethods

Introduction







AimsAims


ResultsResults

MethodsMethods


Introduction

Problems...

Background

18


AimsAims



MethodsMethods

Introduction







AimsAims


ResultsResults

MethodsMethods


Introduction

→ Inclusion and exclusion criteria of the data-base;

→ Time of collection;

→ Human resources;

→ Algorithm descalibration through time; → …

Recalibration Background

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PIM

PRISM

PIM-2

PRISM III

Assessment and Optimization of Mortality Pronostic Scores in Portuguese Pediatric Intensive Care

“Are they doing a good job?”

MARTINS, D. A. A. 1; SANTOS, L. R.1; FIGUEIREDO, M. A. R. M.1; GUERRA, M. D. L.1; MAGALHÃES, R. S.1; FRANCISCO, R. M. H.1; REBELO, C. A. B. S. T.1; ABREU, C. A. M. L. M.1; LAIGINHAS, A. R. A.1; DIAS, M. O.1; CHAVES, J. G. A. C.1; OLIVEIRA, R. C. S.1,2;

Aim: To evaluate the Pediatric Risk of Mortality (…) and the Pediatric Index of Mortality (…) performance at Portuguese Pediatric Intensive Care Units, where PIM2-R is the recalibrated PIM2 model using the Australia and New Zealand Pediatric Intensive Care 2008 coefficients (which is for the first time applied and analyzed in Portuguese context).

Lack of calibration and discrimination in Portuguese reality


AimsAims



MethodsMethods

Introduction







AimsAims


ResultsResults

MethodsMethods


Introduction


PIM-3


20


MethodsMethods




AimsAims

Expected results


Carmen Ferández, J.L.-H., Jose C. Flores, Dolores Galaviz, Marta Rupérez, Kay B. Brandstrup, Amaya Bustinza, Prognosis in critically ill children requiring continuous renal replacement therapy. IPNA, 2005.

PIM AND PRISM underestimated the risk of death in other realities

Underestimated risk of death in Portugal

Optimize of the quality of the health care provided

We look forward to...


Introduction

We expect...


ResultsResults

• How do Pediatric Mortality Prognostic Scores (PIM-2) behave in Portuguese PICUs’ specific groups of diagnosis?

• Is it possible to enhance the performance of PIM-2 with a new recalibration?

• With what purpose are scores used in Portuguese PICUs’?

Research Questions

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AimsAims



MethodsMethods

Introduction






AimsAims


ResultsResults

MethodsMethods


Introduction


PICUs – Pediatric Intensive Care Units; PIM – Pediatric Index of Mortality

• To assess calibration and discrimination of Pediatric Mortality Prognostic Scores in Portuguese PICUs and in the specific diagnosis groups.

• To recalibrate PIM-2, in the broad-spectrum patients and to specific diagnosis group.

• To evaluate the new model concerning calibration and discrimination

• To understand clinicians awareness of the purpose and use of prognostic mortality scores in Portuguese PICUs.

Specific aims

22

AimsAims



MethodsMethods

Introduction






MethodsMethods




AimsAims


ResultsResults

Introduction

PICUs – Pediatric Intensive Care Units; PIM – Pediatric Index of Mortality

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MethodsMethods

Introduction




AimsAims

Target PopulationTarget Population

Methods



MethodsMethods




AimsAims


ResultsResults

Introduction

The target population will be all children admitted in Portuguese PICUs.




MethodsMethods

Introduction




AimsAims

SampleSample

Methods



MethodsMethods




AimsAims


ResultsResults

Introduction

Sources: PICUs from Hospital de Santa Maria, Hospital de D. Estefânia, Hospital Fernando da Fonseca, Hospital Geral de S. João, Hospital Pediátrico de Coimbra, Hospital Garcia de Orta, Hospital Geral de Santo António, Hospital da Misericórdia de Paredes and Hospital de Faro.

Children were included in different groups of diagnosis.




MethodsMethods

Introduction




AimsAims

SampleSample

Methods



MethodsMethods




AimsAims


ResultsResults

Introduction

Age(mean) : 2005-2006: 6 y 1 m; 2007-2008: 6 y 1 m.

Lenght of stay(mean): 2005-2006: 182h; 2007-2008: 127h.

43%

57%

Admission Period2005/2006 2007/2008

Male Female

55.8 56.356.343.7

Gender

Planed Unplaned

36.5

63.5

39.6 60,4

Admission Type



MethodsMethods

Introduction




AimsAims

SampleSample

Methods



MethodsMethods




AimsAims


ResultsResults

Introduction

Accidents/

External C

auses

Cardiovascu

lar

Neurological

Respira

toryRenal

Gastrointesti

nal

Oncologica

l

Metabolic/E

ndocrinal/E

lectrolyti

c

Post-proce

dure

Post-operatory

Others

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2.1

9.5

22.8

0.6 0.3 1.5 2.4 2.7

32.3

9.8

17.8

1.1

9.7

18

0.7 0.9 0.4 1.3 0.2

41.1

8.8

Groups Diagnosis

2005/20062007/2008



MethodsMethods

Introduction




AimsAims

ValidationValidation

Calibration Discrimination

Methods

27

Standardized Mortality Ratio (SMR)



MethodsMethods




AimsAims


ResultsResults

Introduction



MethodsMethods

Introduction




AimsAims



Methods

28


Observed deaths / expected deaths

SMR<1.00 SMR=1 SMR>1.00

“we are doing better

than expected”

“we are doing as

expected”

“we are doing worse than expected”



MethodsMethods




AimsAims


ResultsResults

Introduction



MethodsMethods

Introduction




AimsAims



Methods

29Case-mix and Optimization in Mortality Prognostic Scores in Portuguese PICUs


Hosmer-Lemeshow Test



MethodsMethods




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ResultsResults

Introduction



MethodsMethods

Introduction




AimsAims



Methods

30


Relative Operating Characteristic (ROC)

Curves

Sensitivity vs. 1-Specificity for every

value of the score



MethodsMethods




AimsAims


ResultsResults

Introduction



MethodsMethods

Introduction




AimsAims

Methods



MethodsMethods




AimsAims


ResultsResults

Introduction


Calibration DiscriminationStandardized Mortality Ratio

Sensitivity vs. 1-Specificity for every

value of the score

Area under the (AUC)ROC Curve

Relative Operating Characteristic (ROC)

Curves

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MethodsMethods




AimsAims

Methods



MethodsMethods




AimsAims


ResultsResults

Introduction

AUC – Area Under the ROC Curve

0,70≤AUC<0,80 0,80≤AUC<0,90 0,90≤AUC<1,00 AUC=1,00

Acceptable Good Execlent Perfect

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Methods



MethodsMethods




AimsAims


ResultsResults

Introduction

Main study

Surveys of use

Grounding of conclusions

https://docs.google.com/spreadsheet/viewform?pli=1&formkey=dHZpbU9hX1h6cFEyWExnTzNzRHplcnc6MQ#gid=0

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ResultsResults

MethodsMethods




AimsAims


Introduction


ResultsAgreement* (%)

Clinicians… 1 2 3 4 5 NAwereness of Mortality Prognostic Scores :- Concept 0 0 16,7 55,6 2,78 18

- Use in Portuguese PICUs 0 0 10,5 21,1 47,4 19

- Use in the their specific PICU 0 10,5 21,1 47,4 21,1 19

Access to the scores 0 26,3 10,5 47,4 15,8 19

Idea of scores Calibration to Portuguese reality 5,3 10,5 42,1 36,8 5,3 19

Idea of scores usefulness in Portuguese PICUs 0 0 5,3 89,5 5,3 19

*1 - Total disagreement, …, 5 - Total agreement

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ResultsResults

MethodsMethods




AimsAims


Introduction



Clinicians… 1 2 3 4 5 NAwereness of Mortality Prognostic Scores :- Concept 0 0 16,7 55,6 2,78 18

- Use in Portuguese PICUs 0 0 10,5 21,1 47,4 19

- Use in the their specific PICU 0 10,5 21,1 47,4 21,1 19

Access to the scores 0 26,3 10,5 47,4 15,8 19

Idea of scores Calibration to Portuguese reality 5,3 10,5 42,1 36,8 5,3 19

Idea of scores usefulness in Portuguese PICUs 0 0 5,3 89,5 5,3 19


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ResultsResults

MethodsMethods




AimsAims


Introduction



Clinicians opinion … 1 2 3 4 5 NImpact of:the score use in the their specific PICU 0 0 15,8 78,9 5,3 19

recommended score (in their decision) 57,9 36,8 0 5,3 0 19

a recalibrated score (in their decision) 10,5 26,3 21,1 36,8 5,3 19

scores usefulness in clinical practice or PICU structure 5,6 38,9 44,4 11,2 0 18

Of scores abillity todiscriminate the quality of the health care 0 0 21,1 68,4 10,5 19

provide patient stratification 0 0 36,8 57,3 5,3 19


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ResultsResults

MethodsMethods




AimsAims


Introduction



Clinicians opinion … 1 2 3 4 5 NImpact of:the score use in the their specific PICU 0 0 15,8 78,9 5,3 19

recommended score (in their decision) 57,9 36,8 0 5,3 0 19

a recalibrated score (in their decision) 10,5 26,3 21,1 36,8 5,3 19

scores usefulness in clinical practice or PICU structure 5,6 38,9 44,4 11,2 0 18

Of scores abillity todiscriminate the quality of the health care 0 0 21,1 68,4 10,5 19

provide patient stratification 0 0 36,8 57,3 5,3 19


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ResultsResults

MethodsMethods




AimsAims


Introduction


Results

Clinicians … Yes (%) No(%) NKnowledge of a model 94,7 5,3 19

Opinion on the necessity of recalibration in each country 57,9 42,1 19

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ResultsResults

MethodsMethods




AimsAims


Introduction


Results

Clinicians … Yes (%) No(%) NKnowledge of a model 94,7 5,3 19

Opinion on the necessity of recalibration in each country 57,9 42,1 19

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ResultsResults

MethodsMethods




AimsAims


Introduction

Results


PIM-2 AUC

2002 0,639

2006 0,644

2008 0,647

2005/2006

AUC – Area Under the Curve; PIM – Pediatric Index of Mortality

1-Specificity

Sen

sitiv

ity

41

ResultsResults

MethodsMethods




AimsAims


Introduction


Results

PIM-2 AUC

2002 0,633

2006 0,632

2008 0,645

2007/2008


1-Specificity

Sen

siti

vity

42

ResultsResults

MethodsMethods




AimsAims


Introduction


Results

43

ResultsResults

MethodsMethods




AimsAims


Introduction


Results

44

ResultsResults

MethodsMethods




AimsAims


Introduction


Results

45

ResultsResults

MethodsMethods




AimsAims


Introduction


Results

AUC

PIM2

2002 2006 2008

2005/2006

2007/2008

2005/2006

2007/2008

2005/2006

2007/2008

Accidents/External Causes

0,422 0,498 0,432 0,525 0,405 0,506

Cardiovascular 0,917 0,667 0,833 0,667 0,833 0,667

Neurologic 0,603 0,399 0,609 0,413 0,596 0,406

Respiratory 0,661 0,688 0,657 0,695 0,665 0,693

Postoperative 0,770 0,747 0,755 0,747 0,758 0,699

Others 0,657 0,745 0,674 0,725 0,661 0,716


46

ResultsResults

MethodsMethods




AimsAims


Introduction


Results

AUC

PIM2

2002 2006 2008

2005/2006

2007/2008

2005/2006

2007/2008

2005/2006

2007/2008


0,422 0,498 0,432 0,525 0,405 0,506

Cardiovascular 0,917 0,667 0,833 0,667 0,833 0,667

Neurologic 0,603 0,399 0,609 0,413 0,596 0,406

Respiratory 0,661 0,688 0,657 0,695 0,665 0,693

Postoperative 0,770 0,747 0,755 0,747 0,758 0,699

Others 0,657 0,745 0,674 0,725 0,661 0,716


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ResultsResults

MethodsMethods




AimsAims


Introduction


Results

AUC

PIM2

2002 2006 2008

2005/2006

2007/2008

2005/2006

2007/2008

2005/2006

2007/2008


0,422 0,498 0,432 0,525 0,405 0,506

Cardiovascular 0,917 0,667 0,833 0,667 0,833 0,667

Neurologic 0,603 0,399 0,609 0,413 0,596 0,406

Respiratory 0,661 0,688 0,657 0,695 0,665 0,693

Postoperative 0,770 0,747 0,755 0,747 0,758 0,699

Others 0,657 0,745 0,674 0,725 0,661 0,716


48

ResultsResults

MethodsMethods




AimsAims


Introduction


Results

• New Algorithm:

o PIM-2 IM=(-0.015 x SBP)+(4.270 x PUPIL REACTION)+ - 0.011 x mm)+(0.040 x BASE EXCESS)+(- 0.695 x VENTILATION)+(- 3.019 x PLANED ADMISSION)+(-1.099 x POST OPERATORY)+(19.805 x CARDIAC SURGERY)+(0.702 x RECOVERY)+(0.426 x DIGESTIVE) + 2.779

49

ResultsResults

MethodsMethods




AimsAims


Introduction


Results

PIM-2 AUC

2002 0,633

2006 0,632

2008 0,645

2007/2008


1-Specificity

Sen

siti

vity

PIM-2 AUC

IM 0,875

50

ResultsResults

MethodsMethods




AimsAims


Introduction


Results

51

ResultsResults

MethodsMethods




AimsAims


Introduction


ResultsGroup AUC Chi-square p-value


0,848 19,336 0,013

Cardiovascular 0,500 5,000 0,172

Neurologic 0,865 7,326 0,502

Respiratory 0,674 10,329 0,243

Postoperative 0,731 7,816 0,452

Others 0,745 8,787 0,361

Group AUC Chi-square p-value


0,525 11,043 0,199


Neurologic 0,413 7,469 0,487

Respiratory 0,695 9,219 0,324


Others 0,725 12,430 0,133

PIM-2 IM

PIM-2 2006

52

ResultsResults

MethodsMethods




AimsAims


Introduction


ResultsGroup AUC Chi-square p-value


0,848 19,336 0,013


Neurologic 0,865 7,326 0,502

Respiratory 0,674 10,329 0,243


Others 0,745 8,787 0,361

Group AUC Chi-square p-value


0,525 11,043 0,199


Neurologic 0,413 7,469 0,487

Respiratory 0,695 9,219 0,324


Others 0,725 12,430 0,133

PIM-2 IM

PIM-2 2006

53

ResultsResults

MethodsMethods




AimsAims


Introduction


Conclusions and Discussion

PIM-2 showed acceptable discrimination but poor calibration in specific diagnosis groups and in general Portuguese PICUs.

Recalibrated version of PIM-2 showed better discrimination and calibration either in specific diagnosis groups either general Portuguese PICUs than the ones used nowadays.

Mortality Prognostic Scores’ importance is recognized in Portuguese PICUs, however:

Clinicians don’t feel the need of a recalibration Scores don’t frequently lead to a change in clinical practice.

54

ResultsResults

MethodsMethods




AimsAims


Introduction



PIM-2 showed acceptable discrimination but poor calibration in specific diagnosis groups and in general Portuguese PICUs.

Recalibrated version of PIM-2 showed better discrimination and calibration either in specific diagnosis groups either general Portuguese PICUs than the ones used nowadays.


Clinicians don’t feel the need of a recalibration Scores don’t frequently lead to a change in clinical

practice.

55

ResultsResults

MethodsMethods




AimsAims


Introduction



PIM-2 showed acceptable discrimination but poor calibration in specific diagnosis groups, and in general Portuguese PICUs.

Recalibrated version of PIM-2 showed better discrimination and calibration either in specific diagnosis groups and general Portuguese PICUs than the ones used nowadays.


Clinicians don’t feel the need of a recalibration Scores don’t frequently lead to a change in clinical

practice.

• Anthony R. Brady, D.H., Stephanie Black, Sam Jones, Kathy Rowan, Gale Pearson, Jane Ratcliffe and Gareth J. Parry, Assessment and Optimization of Mortality Prediction Tools for Admissions to Pediatric Intensive Care in the United Kingdom. Pediatrics, 2006. 117;

• Carmen Ferández, J.L.-H., Jose C. Flores, Dolores Galaviz, Marta Rupérez, Kay B. Brandstrup, Amaya Bustinza, Prognosis in critically ill children requiring continuous renal replacement therapy. IPNA, 2005;

• César Sánchez, J.L.-H., Santiago Mencía, Javier Urbano, Angel Carrillo and José María Bellón, Clinical severity scores do not predict tolerance to enteral nutrition in critically ill children. British Journal of Nutrition, 2009. 102: p. 191–194;

• Esra Arun Ozer, A.K., Berrak Sarioglu, Oya Halicioglu, Sumer Sutcuoglu, and Isin Yaprak, The Comparison of PRISM and PIM Scoring Systems for Mortality Risk in Infantile Intensive Care. Journal of Tropical Pediatrics, 2004. 50;

References



MethodsMethods




AimsAims


ResultsResults

Introduction

• Ganapathy Balakrishnan, T.A., David Hallworth, Neil S Morton, Prospective evaluation of the Paediatric Risk of Mortality (PRISM) score. Archives ofDisease in Childhood, 1992. 67: p. 196-200.

• Okay, G.A.C.A.F.D.A.F.T.S., Application of the pediatric risk of mortality (PRISM) score and determination of mortality risk factors in a tertiary pediatric intensive care unit. Clinics, 2010. 65.

• Pollack MM, R.U., Getson PR, Pediatric risk of mortality (PRISM) score. Crit Care Med, 1998. 16(11): p. 1110-6.

• Slater, A.M.B., FRACP, FJFICM; Shann, Frank MB, BS, MD, FRACP, FJFICM; the ANZICS Paediatric Study Group, The suitability of the Pediatric Index of Mortality (PIM), PIM2, the Pediatric Risk of Mortality (PRISM), and PRISM III for monitoring the quality of pediatric intensive care in Australia and New Zealand. Pediatric Critical Care Medicine, 2004. 5(5): p. 447-453.

• S. Prieto Espuñes, J.L.-H.C., C. Rey Galán, A. Medina Villanueva, A. Concha Torre y P. Martínez Camblor, Índices pronósticos de mortalidad en cuidados intensivos pediátricos. An Pediatr (Barc), 2007. 66: p. 345-50.

References



MethodsMethods




AimsAims



Introduction

• S M Tibby, D.T., M Festa, S Hanna, M Hatherill, G Jones, P Habibi, A Durward, I A Murdoch, A comparison of three scoring systems for mortality risk among retrieved intensive care patients. Arch Dis Child, 2002. 87: p. 421-425;

• Vanessa Feller Martha, P.C.R.G., Jefferson Pedro Piva, Paulo Roberto Einloft, Francisco Bruno, Viviane Rampon, Comparação entre dois escores de prognóstico (PRISM e PIM) em unidade de terapia intensiva pediátrica. Jornal de Pediatria, 2005. 81(3): p. 259-64.

References



MethodsMethods




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Introduction

We gratefully acknowledge :

• Professor Altamiro Costa Pereira;

• Phd Armando Teixeira-Pinto;

• Msc Rosa Oliveira;

• Daniel Martins;

for their guidance and time

• And you;

For your attention.


Acknowledgments


MethodsMethods




AimsAims



Introduction


The End

60

Introdução à Medicina II

2011/2012Class 121

Advisors: Rosa Oliveira2 and Daniel Martins3

1. [email protected];

2. [email protected]; 3. [email protected];

Questions?

1 case-mix and optimization of mortality prognostic scores in portuguese pediatric intensive care...

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