Limitations of the accuracy of scoring systems

The accuracy of scoring systems must be investigated. Inaccuracy may arise from insufficient adjustment for case mix. Insufficient adjustment for case mix

The use of case-mix-adjusted mortality as a measure of effectiveness of intensive care assumes that the scoring system can define a baseline rate and that mortality in excess of this baseline rate reflects poor-quality care. If the baseline is set incorrectly, too many or too few cases will be labeled as receiving poor-quality care. Therefore the accuracy of the scoring system used to adjust mortality must be thoroughly tested to avoid under- or overestimation of effectiveness.

If the proportion of variance in outcome explained by the scoring system is high, such statistical adjustment may be extremely potent and yield meaningful comparisons of treatment. However, it must be remembered that, however exhaustive the method employed, some of the residual outcome differences may be due to unmeasured differences in case mix.

The fact that different scoring systems yield different probabilities for the same patients may indicate that other factors, not currently incorporated into the current scoring systems, may be important for estimating outcome (Lemeshow. ..efial 1995).

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