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英国牛津大学Stephen Gerry团队的最新研究对成人住院患者病情恶化的早期预警评分方法进行了系统评价。2020年5月20日，该研究发表在《英国医学杂志》上。

为了对成人医院患者的预警评分提供概述和重要评估，研究组设计了一项系统评价。在Medline、CINAHL、PsycInfo和Embase等数据库中，检索从建库到2019年6月的文献，筛选出描述成人住院患者早期预警评分的开发或外部验证的研究。

最终有95篇文章被纳入分析，其中11项研究开发，23项研究开发和外部验证，61项仅外部验证。大多数预警评分是针对美国（38％）和英国（29％）开发的。死亡是开发研究（44%）和验证研究（79%）中最常见的预测结局，时间范围有所不同，最频繁的是24小时。最常见的预测指标是呼吸频率（88%）、心率（83%）、血氧饱和度-体温-收缩压（71%）。年龄（38%）和性别（9%）指标使用较少。

在开发研究（41%）或验证研究（39%）中，经常会缺失人群的关键细节分析。样本量过小和事件患者数量不足在模型开发和外部验证研究中很常见。丢失的数据经常被遗弃，仅一项研究使用了多重插补。只有9项预警评分开发得足够详细，可允许进行个性化的风险预测。19项研究进行了内部验证，但很少采用推荐的方法，例如自举法或交叉验证法（22％）。模型性能常使用辨别力进行评估（82%），但很少评估校正（15%）。研究组评定所有研究的偏倚风险较高。

总之，预警评分是广泛使用的预测模型，通常在日常临床实践中使用，以识别住院患者的早期临床恶化。但研究组发现许多临床使用的预警评分模型存在不足，其可能无法达到预期的效果，对病人治疗产生不利影响。

附：英文原文

Title: Early warning scores for detecting deterioration in adult hospital patients: systematic review and critical appraisal of methodology

Author: Stephen Gerry, Timothy Bonnici, Jacqueline Birks, Shona Kirtley, Pradeep S Virdee, Peter J Watkinson, Gary S Collins

Issue&Volume: 2020/05/20

Abstract: Objective To provide an overview and critical appraisal of early warning scores for adult hospital patients.

Design Systematic review.

Data sources Medline, CINAHL, PsycInfo, and Embase until June 2019.

Eligibility criteria for study selection Studies describing the development or external validation of an early warning score for adult hospital inpatients.

Results 13171 references were screened and 95 articles were included in the review. 11 studies were development only, 23 were development and external validation, and 61 were external validation only. Most early warning scores were developed for use in the United States (n=13/34, 38%) and the United Kingdom (n=10/34, 29%). Death was the most frequent prediction outcome for development studies (n=10/23, 44%) and validation studies (n=66/84, 79%), with different time horizons (the most frequent was 24 hours). The most common predictors were respiratory rate (n=30/34, 88%), heart rate (n=28/34, 83%), oxygen saturation, temperature, and systolic blood pressure (all n=24/34, 71%). Age (n=13/34, 38%) and sex (n=3/34, 9%) were less frequently included. Key details of the analysis populations were often not reported in development studies (n=12/29, 41%) or validation studies (n=33/84, 39%). Small sample sizes and insufficient numbers of event patients were common in model development and external validation studies. Missing data were often discarded, with just one study using multiple imputation. Only nine of the early warning scores that were developed were presented in sufficient detail to allow individualised risk prediction. Internal validation was carried out in 19 studies, but recommended approaches such as bootstrapping or cross validation were rarely used (n=4/19, 22%). Model performance was frequently assessed using discrimination (development n=18/22, 82%; validation n=69/84, 82%), while calibration was seldom assessed (validation n=13/84, 15%). All included studies were rated at high risk of bias.

Conclusions Early warning scores are widely used prediction models that are often mandated in daily clinical practice to identify early clinical deterioration in hospital patients. However, many early warning scores in clinical use were found to have methodological weaknesses. Early warning scores might not perform as well as expected and therefore they could have a detrimental effect on patient care. Future work should focus on following recommended approaches for developing and evaluating early warning scores, and investigating the impact and safety of using these scores in clinical practice.

DOI: 10.1136/bmj.m1501

Source: https://www.bmj.com/content/369/bmj.m1501

BMJ-British Medical Journal:《英国医学杂志》，创刊于1840年。隶属于BMJ出版集团，最新IF：93.333
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