Performance of new adjustments to the TRISS equation model in developed and developing countries

Abstract

BackgroundThe Trauma and Injury Severity Score (TRISS) has been criticized for being based on data from the USA and Canada—high-income countries—and therefore, it may not be applicable to low-income and middle-income countries. The present study evaluated the accuracy of three adjustments to the TRISS equation model (NTRISS-like; TRISS SpO2; NTRISS-like SpO2) in a high-income and a middle-income country to compare their performance when derived and applied to different groups.MethodsThis was a retrospective study of trauma patients admitted to two institutions: a university medical center in São Paulo, Brazil (a middle-income country), and a level 1 university trauma center in San Diego, USA (a high-income country). Patients were admitted between January 1, 2006, and December 31, 2010. The subjects were 2416 patients from Brazil and 8172 patients from the USA. All equations had adjusted coefficients for São Paulo and San Diego and for blunt and penetrating trauma. Receiver operating characteristic (ROC) curves were used to evaluate performance of the models.ResultsRegardless of the population where the equation was generated, it performed better when applied to patients in the USA (AUC from 0.911 to 0.982) compared to patients in Brazil (AUC from 0.840 to 0.852). When the severity was considered and homogenized, the performance of equations were similar to both application in the USA and Brazil.ConclusionsSurvival probability models showed better performance when applied in data collected in the high-income countries (HIC) regardless the country they were derived. The severity is an important factor to consider when using non-adjusted survival probability models for the local population. Adjusted models for severely traumatized patients better predict survival probability in less severely traumatized populations. Other factors besides physiological and anatomical data may impact final outcomes and should be identified in each environment if they are to be used in the development of the trauma care performance improvement process in middle-income countries.

Predicting Outcomes in Patients with Diffuse Axonal Injury: External Validation of the Widely Used Prognostic Instruments

“…We externally validated GCS, AIS/Head, TRISS, NTRISS, CRASH CT and two IMPACT prognostic models for the prediction of 14-day mortality, 6-month mortality, and 6-month unfavorable outcome in a cohort of patients in Brazil. We found good discrimination in almost all models, consistent with other validation studies [26,35]. Using Cox calibration, we identified the overestimation of 14day mortality when using TRISS, NTRISS, and CRASH CT and also the overestimation of 6-month unfavorable outcomes when using NTRISS and CRASH CT. IMPACT Lab and extended models led to statistically perfect calibration for both 6-month mortality and 6-month unfavorable outcomes.…”

Thefeasibility, appropriateness, and applicability of trauma scoring systems in low and middle-income countries: a systematic review

“…TRISS methodology consistently performed better when applied to high-income settings as opposed to LMICs. 93 Three studies in Uganda, Thailand, and Indonesia indicated low M-statistics (0.791-0.843), suggesting that TRISS may not be appropriate for their settings. 7 27 95 On the other hand, studies in Pakistan, Iran, India, Nigeria, and Kenya reported reasonably comparable M-statistics (ranging from 0.889 to 0.97) and, in the Kenya case, consistent and high performance across facilities.…”

Performance of the Modified Rapid Emergency Medicine Score in Patients With and Without Traumatic Brain Injury

“…These systems have been used to assist in evaluating the care provided and planning emergency care, in addition to enabling documentation of the severity in the description of the epidemiological characteristics of the trauma victims. 4,5 In daily practice, trauma nurses continuously plan and make decisions about nursing interventions 6 that are influenced by severity of trauma patients. Therefore, the reliability of severity indices is within the scope of interest of the trauma nurses.…”

“…In this context, trauma indices have been developed over the years to determine the severity of patients, which assess the severity level of anatomical injuries and/or the physiological conditions of them by using uniform language, making it possible to estimate the survival probability of the trauma patients. These systems have been used to assist in evaluating the care provided and planning emergency care, in addition to enabling documentation of the severity in the description of the epidemiological characteristics of the trauma victims 4,5. In daily practice, trauma nurses continuously plan and make decisions about nursing interventions6 that are influenced by severity of trauma patients.…”