基于竞争风险模型构建COPD急性加重期出院后死亡的预测模型
Development of a prediction model for post-discharge death in acute exacerbation of COPD based on the competing risk model

吴明先.基于竞争风险模型构建COPD急性加重期出院后死亡的预测模型[J].内科急危重症杂志,2026,32(3):265-268

DOI：10.11768/nkjwzzzz20260312

英文关键词:Chronic obstructive pulmonary disease Acute exacerbation Death Influencing factors

基金项目:

作者	单位	E-mail
吴明先	达州市中心医院全科医学科	mipx91@163.com

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中文摘要:

摘要目的：基于竞争风险模型探讨慢性阻塞性肺疾病（COPD）急性加重期出院后死亡的影响因素并构建预警模型。方法：回顾性分析285例COPD急性加重期患者的临床资料并随访。将随访期间因COPD死亡的患者纳入结局事件组，因其他原因死亡患者纳入竞争事件组，随访结束时生存患者纳入生存组。比较3组临床资料，对出院后死亡影响因素进行竞争风险回归分析。采用Kaplan-Meier生存曲线与竞争风险模型计算COPD急性加重期患者出院后累积死亡率。构建COPD急性加重期患者出院后死亡的风险预警列线图模型，采用受试者工作特征（ROC）曲线、Hosmer-Lemeshow拟合优度检验验证模型的预测效能及校准度。结果：随访2~53个月，中位数36（11，45）个月；发生结局事件61例（占21.40%），竞争事件8例（占2.81%），生存患者216例（占75.79%）；近1年急性加重次数（HR=2.517，95%CI：1.694~3.739）、出院时改良版英国医学研究委员会呼吸问卷（mMRC）分级2级（HR=2.328，95%CI：1.539~3.520）、慢性呼吸系统早期预警评分量表（CREWS）评分（HR=2.489，95%CI：1.519~4.079）及C-反应蛋白（CRP）（HR=2.469，95%CI：1.540~3.960）是出院后死亡的危险因素（P均＜0.05），出院时预后营养指数（PNI）（HR=0.438，95%CI：0.271~0.708）、维持治疗依从性（HR=0.356，95%CI：0.205~0.618）是出院后死亡的保护因素（P均＜0.05）；Kaplan-Meier生存曲线所得累积死亡率为22.02%，高于竞争风险模型的21.40%；构建COPD急性加重期患者出院后死亡的风险预警列线图模型，该模型预测出院后死亡的ROC曲线下面积、灵敏度及特异性分别为0.931（95%CI：0.895~0.957）、86.89%、95.54%，其预测概率与实际概率比较差异无统计学意义（P＞0.05）。结论：COPD急性加重期患者近1年急性加重次数、出院时mMRC分级2级、CREWS评分及血CRP水平是其出院后死亡的危险因素，出院时PNI、维持治疗依从性是保护因素，构建风险预警列线图模型对出院后死亡的预测价值高。

英文摘要:

Abstract Objective: To explore the influencing factors of death after discharge from the acute exacerbation period of COPD based on the competing risk model and to construct a warning model. Methods: The clinical data of 285 patients with COPD acute exacerbation were retrospectively analyzed and followed up. Patients who died from COPD during the follow-up period were included in the outcomes event group, those who died for other reasons were included in the competing event group, and those who survived at the end of the follow-up were included in the survival group. The clinical data of the three groups were compared, and the competing risk regression analysis was conducted to explore the influencing factors of death after discharge. The cumulative mortality rate after discharge from the acute exacerbation period of COPD was calculated using the Kaplan-Meier survival curve and the competing risk model. A risk warning nomogram model for death after discharge from the acute exacerbation period of COPD was constructed, and the predictive efficacy and calibration of the model were verified using the receiver operating characteristic (ROC) curve and Hosmer-Lemeshow goodness-of-fit test. Results: The follow-up period was 2 to 53 months, with a median of 36 (11, 45) months. A total of 61 cases (21.40%) had outcomes events, 8 cases (2.81%) had competing events, and 216 patients (75.79%) survived. The number of acute exacerbations in the past year (HR = 2.517, 95%CI:1.694-3.739), mMRC grade 2 at discharge (HR = 2.328, 95%CI: 1.539-3.520), CREWS score (HR = 2.489, 95%CI: 1.519-4.079) and C-reactive protein (CRP) (HR = 2.469, 95%CI: 1.540-3.960) were risk factors for death after discharge (P< 0.05), and the prognostic nutritional index (PNI) at discharge (HR= 0.438, 95%CI: 0.271-0.708), adherence to maintenance treatment (HR = 0.356, 95%CI: 0.205-0.618) were protective factors for death after discharge (P < 0.05). The cumulative mortality rate obtained from the Kaplan-Meier survival curve was 22.02%, which was higher than 21.40% of the competing risk model. The risk warning nomogram model for death after discharge from the acute exacerbation period of COPD was constructed, and the area under the ROC curve, sensitivity, and specificity of the model for predicting death after discharge were 0.931 (95%CI: 0.895-0.957), 86.89%, and 95.54%, and there was no statistically significant difference between the predicted probability and the actual probability (P> 0.05). Conclusion: The number of acute exacerbations in the past year, mMRC grade 2 at discharge, CREWS score, and blood CRP level are risk factors for death after discharge from the acute exacerbation period of COPD, and PNI at discharge and adherence to maintenance treatment are protective factors for death after discharge; the risk warning nomogram model for death after discharge from the acute exacerbation period of COPD has high predictive value for death.