Chronic Health APACHE

This article is about Chronic Health in the context of the APACHE score, see Comorbid Diagnosis for info on the comorbidities we collect, and Charlson Comorbidity Index for the Charlson comorbidities that are also used for the Alert score.

Data Element (edit)
Field Name:	Ap_Chronic
CCMDB Label:	Chronic
CCMDB tab:	Apache
Table:	L_Log
Data type:	string
Length:	30
Program:	(CC / Med / Med and CC)"(CC / Med / Med and CC)" is not in the list (CC, Med, Med and CC, not entered) of allowed values for the "DataElementProgram" property.
Created/Raw:	Raw
Start Date:	1988-07-11
End Date:	2300-01-01
Sort Index:	56

Specific chronic pre-existing conditions used for APACHE score.

• SMW

Legacy implementation right in the table

• Cargo

• Categories

• Forms

This value is used in conjunction with Admit Type for APACHE II to calculate the Chronic_Health_Score, one of the components of the.

To be considered to be a chronic disease, the chronic condition must have been documented as present before current hospitalization.

Chronic Health Table

Dropdown in CCMDB.mdb	Orignial APACHE II CH list with definitions
1. Immunocompromized (this category includes the following: Metastatic Cancer, Hematological Malignancy-Lymphoma, Leukemia and also AIDS)	(this is applicable to items 1-5. Receiving therapy that suppresses resistance to infection such as: at least one of the following: ≥15mg/kg/day hydrocortisone >3 mg/kg’day of methylprednisolone for >5 days (for entire LOS if pts LOS is less than 5 days). ≥10 mg prednisone Chemotherapy Radiation therapy Post BMT (Bone Marrow Transplant) sufficiently advanced disease to suppress resistance to infection Include patients on methotrexate or cyclophosphamide, etc. (for autoimmune disorders)
2. Met Cancer sufficiently advanced disease to suppress resistance to infection
3. HematMalign e.g. Lymphoma or Leukemia sufficiently advanced disease to suppress resistance to infection
4. AIDS
5. CRF-severe	Receiving Chronic out-patient hemo- or peritoneal dialysis prior to hospital admission.
6. Liver-severe	any of: biopsy proven cirrhosis & previously documented portal hypertension past episodes of GI bleeds related to portal hypertension or varicies hepatic failure or encephalopathy or coma
7. Lung severe	any of the following that results in severe exercise restriction (i.e. unable to climb stairs or perform household duties): COPD-severe Restrictive lung disease-severe Vascular disease-severe or any of the following documented chronic hypoxia or hypercapnia, secondary polycythemia Pulmonary HTN on home O2 (this does not include home bipap or cpap unless the pt also has one of the other listed conditions)Bipap or cpap if only for airway does not imply lung disease. Cpap for obstructive sleep apnea is just constant positive air pressure to keep the airway open during sleep. Not usually used with oxygen. Ventilator dependent Does being on bipap or cpap for obesity be considered restrictive lung disease severe?--MWaschuk 14:31, 2012 May 28 (CDT) There may be an element of restrictive lung disease with obesity as the lung cannot always fully expand related to pressure on the diaphragm of a morbidly obese pt. To be considered true restrictive lung disease however, this must result in impaired ventilatory function. Most obese pts on bipap are only on bipap at night to maximize the airway. To call this severe restrictive lung disease is incorrect. If they are on home O2 during the day as well or have any of the above issues like documented hypoxia or hypercapnea, then this would be considered severe restrictive lung disease. Bipap at night alone is not sufficient evidence of severe restrictive lung disease even if the pt is obese. --LKolesar 07:16, 2012 May 29 (CDT)
8. CVS min exert	Class 4 Angina - pain @ rest or with minimal exertion
9. No Chronic Health

Implementation

• Chronic Health is stored as a single-choice dropdown in CCMDB.mdb
• when sent for import into TMSX the chronic health score is translated into yes or no
• the fields were made into a pick list of 9 items that belong to one of the five APACHE II Chronic Health categories because Medicine wanted to use both APACHE II and SAPS II on Medicine patients. SAPS II and APACHE II scored these same chronic health items differently. SAPS is no longer collected.

Potential change

• I have a hunch that the following was done... can Julie or Trish confirm and update? Tx Ttenbergen 11:40, 2015 September 28 (CDT)
  • yes this is correct. JMojica 16:19, 2017 March 16 (CDT)

As per minutes from DB meeting 13 Dec 2013; expected implementation 2-3 quarter 2014:

There was a long discussion about the coding of the APACHE comorbidity field. This boils down to a score of 0 or 2 or 5, depending on the presence/absence of a list of specific chronic conditions. Some of the conditions result in a score of 5, and others a score of 2. A patient with none of these conditions gets a 0. If multiple conditions are present the score is 2 if all of them are 2’s and it’s 5 if any of them are 5’s.

Unfortunately, in Ed’s program this is programmed incorrectly, so legacy APACHE total scores have been incorrect.

• NOTE: Chronic Health is scored correctly in the ICU database TMSX. The only thing in the ICU database program is that the it is not transparent if patient was either emergency surgery or a medical patient (non operative) patient. At the time so long ago, medical and emerg surgery were grouped together because they both give 5 points if a chronic health condition is present. SO....if ELECTIVE surgery is chosen and PLUS one or more APACHE II specific chronic health condition is present, then 2 points. If medical patient (non operative) or emergency surgery, PLUS one or more APACHE II specific chronic health conditions are present, then 5 points. If there are NO APACHE II specific chronic Health conditions present, then 0 points, does not matter if you where elective, emergent or medical patient.Trish Ostryzniuk 20:18, 2014 January 27 (CST)
• In Ed’s program it is coded as Yes/No according to the presence/absence of ANY of the listed conditions; and thus cannot correctly distinguish a score of 2 vs. 5. With the advent of the laptops, the collectors are presented with 9 options: a list of 8 conditions and a choice of “none”. But here still they’re not provided with the scores (2 or 5) and so cannot systematically choose the highest scoring condition that’s present. Even worse, until summer 2013, we didn’t retain even that more detailed (but still problematic) information and simply converted it to Yes/No. We decided that the ultimate solution (to be implemented “later”) is to make this right by integrating identification of these specific chronic conditions with the more general comorbidity identification, in the following way:
• (a) eliminate the stand-alone listing of the APACHE comorbid conditions,
• (b) alter the general comorbidity identification such that in addition to the ability to list any number of conditions, the specific APACHE conditions are each listed with a radio button to identify it as present/absent, and change the laptop software such that if listed as present, that entity automatically gets entered into the total list of comorbid conditions, and
• (c) this more detailed information about the presence/absence of the specific APACHE conditions will enable correct scoring of the APACHE comorbidity score.

But we also want to go back and change/improve the APACHE comorbidity (and total) scoring in the legacy data. To avoid systematic bias, we will accept random error in the following way: (i) for those whose Yes/No variable in Ed’s program is “Yes”, we will randomly assign a 2 or a 5, with weighting according to the proportion expected to be present for the conditions scoring a 5 vs. those scoring a 2. We can eventually obtain these from our own data once we implement the modifications “later”, but for now we can look to published data, or try to mine our own comorbidity listings from the legacy data to obtain this proportion.