2003 Indian Journal of Surgery www.indianjsurg.

com
© 2004

Original Article

Penetrating abdominal trauma index: Sensitivity and

specificity for morbidity and mortality by ROC analysis
Jose Francisco Gomez-Leon
Department of Surgery, Division of General Surgery, Hospital Universitario Dr. Luis Razetti, Barcelona, Anzoategui, Venezuela, South
America.

ABSTRACT
Background: When developed in 1981 by Moore and colleagues the Penetrating Abdominal Trauma Index (PATI)
was used to identify trauma patients at risk of postoperative complications. Methods of trauma quantification have
been extensively developed but their outcome evaluations have been naïve, subject only to basic statistical analyses.
The accuracy of PATI was assessed by means of Receiver Operating Characteristics (ROC) curve analysis.
Aims: To evaluate PATI by means of ROC curve analysis and establish its sensitivity and specificity for predicting
the morbidity and mortality in penetrating abdominal trauma.
Settings and design: Patients who attended the University hospital trauma unit; prospective cohort study.
Methods: This was a prospective study over an 11-month period, patients with penetrating abdominal trauma who
underwent laparotomy were enrolled. Initial assessment of the patients was done following the ATLS guidelines.
Patients were stratified on the basis of those who developed complications, no complications and postoperative
mortality. PATI was calculated based on operative findings and the outcomes were measured on the basis of
complications or mortality in the postoperative period.
Statistical analysis: Receiver Operating Characteristics curve analysis and Logistic regression analysis using
PATI as independent variable.
Results: Eighty-nine consecutive patients underwent laparotomy for abdominal trauma, 49 for stab wounds and 40
for gunshot wounds. Patients with complications scored a mean PATI of 21.47; those who died scored a mean PATI
of 25.29. ROC curve analysis of PATI scores in patients who developed complications showed results of 42.1%
sensitivity and 91.4% specificity. Sensitivity and specificity for mortality prediction was 42.9% and 91.5% respectively.
Conclusion: The statistical evaluation of trauma scores should be performed using an adequate methodology to
avoid naive evaluations. ROC curve evaluation of this trauma score index allows a comprehensive study of the
instrument’s performance, avoids data simplification and permits cross-analysis of different trauma score indexes.

KEY WORDS
Penetrating Abdominal Trauma Index, ROC curve, instrument performance, Venezuela.

How to cite this article: Gomez-Leon JF. Penetrating abdominal trauma index: Sensitivity and specificity for morbidity and mortality by roc
analysis. Indian J Surg 2004;66:347-51.

The Penetrating Abdominal Trauma Index (PATI) is
described as a method for quantifying the risk of
complications following penetrating abdominal trauma,
introduced in 1981 by Moore et al. PATI provided a
useful means to investigate and served as a tool in the
decision-making process when managing penetrating
abdominal trauma.1 In order to quantify trauma, injury
severity instruments (ISI) are used in the different
phases of trauma management for injury evaluation.
Thus, pre-hospital triage instruments, in-hospital and
outcome instruments are used to assess the level or
type of care needed, for decision-making, and for
evaluation of trauma outcome for policy decisions,
respectively; that is why performance evaluation of
these instruments have important clinical
consequences. 2 ISI are evaluated via either naïve

Address for correspondence: Jose Francisco, Department of Surgery, Division of General Surgery, Hospital Universitario Dr. Luis Razetti,
Barcelona, Anzoategui, Venezuela. E-mail: jfgldoc@Hotmail.com
Paper Received: June 2004. Paper Accepted: October 2004. Source of Support: Nil.

Indian Journal of Surgery 2004 Volume 66 Issue 6 (December) 347

Gomez-León JF
evaluations which depend upon the prevalence of the
disease or outcome of interest in the study population,
or calculations of sensitivity and specificity. Naïve
assessments suppose the instrument’s performance in
a single figure: accuracy prediction of events that are
affected by prevalence-dependent populations that
cannot be generalized, but can be valid within a specific
study. Logistic regression analysis and sensitivity-
specificity assessments avoid the aforementioned
problems because they evaluate the instrument’s
performance in two separate populations, where
sensitivity equals the number of patients correctly
predicted to live and specificity the number of patients
correctly predicted to die, who actually die.3 Several
ISI have been correctly evaluated by means of these
figures, these include the Injury Severity Score, New
Injury Severity Score, ICD-9 codes and Revised Trauma
Score. PATI lacks sensitivity, specificity or logistic
regression analysis evaluations as evidenced in the
available literature. It is being used as a powerful tool
in our setting to asses penetrating abdominal trauma
management. The goal of this paper is to evaluate this
instrument’s behaviour, and study its ability to correctly
prognosticate patients using the advantages of logistic
regression analysis and ROC curve analysis over the
traditional statistical techniques.
MATERIALS AND METHODS
The study was carried out in a university teaching
hospital of Universidad de Oriente, Venezuela, in a
prospective manner during a period of 11 months.
Consecutive patients who arrived in the emergency
room with penetrating abdominal trauma by stab
wound or gunshot wound, and underwent exploratory
laparotomy after evaluation by the general surgeon.
Patients who had no lesion at laparotomy or died during
the first 24 hours of the postoperative period were
excluded. Each patient with penetrating abdominal
trauma considered for laparotomy is assigned a PATI
score after laparotomy abdominal evaluation in our
centre. Patients received standard post-surgical care
at the intensive care unit when needed and/or general
surgical hospitalisation care if not amenable to the ICU.
Complications and/or the cause of death were recorded
and tabulated against the PATI scores. After laparotomy,
PATI was assigned to each patient calculating the risk
factor per organ injured and multiplying by the severity
of injury estimate. Complications were recorded during
the hospitalisation stay and this outcome was managed
as a dichotomous variable, that is, patients who had
postoperative complications and patients who did not
have a complication until the time of discharge. The
348
severity of trauma outcome was also analyzed as a
dichotomous variable, thus, patients were stratified as
survivors or deaths.
Statistics: Mean score results for the two subsets of
populations were obtained by analysis of variance
(ANOVA) of the difference of points obtained by each
subset of patients i.e. complicated vs. non-complicated
and survival vs. non-survival. For logistic regression
and ROC analysis PATI was used as the independent
variable; complications and trauma severity outcome
(death) were used as binary dependent variables, that
is, binary response was set as complications present
and no complications present until discharge and
survival or no survival of patients. Logistic regression
analysis was performed to determine the association
of the relative predictive power of the independent
variable with respect to the categorical dichotomous
complication/no complication and survival/death
dependent variables. ROC curve analysis was
performed to summarize the instrument’s performance
with respect to discriminating patients who will or not
complicate and those who will or will not survive. Thus,
mean PATI scores for each subset of the population
were plotted and sensitivity/specificity calculated by
means of non-parametric estimates of the Area under
the curve. Statistical analysis was done using SPSS®
9.0. Significance was attributed to P values < 0.05.
RESULTS
Eighty-nine consecutive patients admitted for
penetrating abdominal trauma who underwent
laparotomy were included in the analysis. The mean
age was 27.10 ± 9.98 yrs. with a range of 14 to 69.
Eighty-six patients were male, 3 patients female. 55.1%
lesions were caused by gunshot wounds whereas
44.6% by stab wounds to the abdomen.
PATI results in the Complications/No Complication
subset of patients
When stratified as subsets of populations, mean PATI
score in patients who developed complications was
21.47 ± 12.97 (95% CI for mean PATI from 18.77 to
24.16), in contrast with those who did not complicate
for whom the score was 11.24 ± 8.33 (95% CI for mean
PATI from 9.50 to 12.97) (Table 1). Figure 1 depicts
this, PATI separated complicated from non-complicated
patients but overlapping is present. As obtained from
the logistic regression model (Table 2), we can assume
that patients with PATI scores of 22 are 1.09 (95% CI
1.04 to 1.16) times more likely to present with
complications than those with lesser score points,
Indian Journal of Surgery 2004 Volume 66 Issue 6 (December)
 © 2003 Indian Journal of Surgery
Penetrating www.indianjsurg.com
abdominal trauma index

Table 1: Mean PATI scores in patients who Table 2: Logistic Regression results dependent
complicated and not complicated variable: Complication
PATI Variable B *Wald †
Model Chi-Square Exp(B)
Complications Mean N Std. Deviation PATI 0.9003 10.7654 13.366 1.0945
*No 11.24 70 8.33 *P=0.001; †P =0.0003
**Yes 21.47 19 12.97
Total 13.43 89 10.33 1.00
*95 % CI for mean PATI from 9.50 to 12.97
**95 % CI for mean PATI from 18.77 to 24.16
.75

20%

.50
15%
P e r c e n t c o m p l ic a t i o n

Sensitivity
.25
10%

0.00
5% 0.00 .25 .50 .75 1.00
Non Complic ation 1-Specificity
0% Complication
1Diagonal
- Specificity
segments are produced by ties.
2 6 11 15 19 24 32 45
4 9 13 17 21 26 41 Figure 2: ROC Curve PATI scores in the complication subset
Penetrating Abdominal Trauma Index

Figure 1: Frequency distribution of complication rate stratified

by the Penetrating Abdominal Trauma Index significant with a 99.4% confidence level (P = 0.006).
Model Chi-square statistic assumes that the overall
coefficient of PATI has a Wald statistic of 10.77 which model is significant (P = 0.006) and the percentage of
is significant at the 0.001 level (99.9% confidence level). correct predictions rises to 93.26% (Table 5).
The overall model is significant according to the Model
Chi-Square statistic (P = 0.0003). The model predicts Area Under the Curve for this model test is 0.787 (95%
79.78 % of the responses correctly. IC 0.626 to 0.948) (Figur e 4); the ROC curve
coordinates for cut-off values of 25 (Table 6) give 42.9%
The ROC curve analysis for this model gives an Area and 91.5% sensitivity and specificity respectively,
under the curve of 0.776 (95% CI 0.667 to 0.885) making this a fair model for prediction of mortality.
(Figure 2), which makes this a fair test to discriminate
complicated from non-complicated patients. At the Table 7 shows causes of complications and death in
score level of 22, the coordinates of the ROC curve the patients who complicated and did not survive.
(Table 3) show a sensitivity of 42.1%, and specificity of
91.4%. DISCUSSION

PATI results in the Death/Survivors subset of In our study, we could observe how increasing PATI
patients score values correlate with complications in the
Mean PATI score in patients who died was 25.29 ± postoperative period and even mortality secondary to
15.98 (CI 95% for mean PATI from 21.97 to 28.60), complications; this is congruent with the published
compared to the patients who survived (which account literature. Our aim was then to evaluate how this
for all those who complicated and did not complicate) instrument’s perfor mance fits with the standard
that was 12.41 ± 9.15 (95% CI for mean PATI from statistical techniques currently used to asses the
10.50 to 14.31) (Table 4). Figure 3 shows how survivors models.
are separated from non-survivors according to
increasing PATI scores, although, overlapping exists PATI has been used to measure injury severity in
as in almost all injury scores. The logistic regression abdominal trauma in order to assist the surgeon in
model depicts that patients with this score of 25 or categorizing the patients at risk of developing
more are 1.08 (95% CI 1.02 to 1.16) times more likely complications, and even in decision-making techniques
to die when compared to patients scoring less points. for repairing intra-abdominal organs according to its
Coefficient’s Wald statistic for PATI is 7.46, which is severity score.4-8

Indian Journal of Surgery 2004 Volume 66 Issue 6 (December) 349

Gomez-León JF

20%
Table 3: Coordinates of the Curve, PATI scores in
the complications subset 16%
Test Result Variable(s): PATI
Positive if Greater

P er c e n t S u r vi v o r s /D e a th
12%
Than or Equal To* Sensitivity 1-Specificity
1.00 1.000 1.000
8%
2.50 1.000 0.871
3.50 1.000 0.857
4.50 1.000 0.786 4%

5.50 1.000 0.757 Surv iv ors

7.00 0.947 0.671 0% Death

8.50 0.947 0.500 2 4 6 9 11 13 15 17 19 21 24 26 32 41 45

9.50 0.842 0.471 Penetrating Abdominal Trauma Index

10.50 0.789 0.386
11.50 0.789 0.371 Figure 3: Frequency distribution of patients who lived or died
12.50 0.684 0.329 stratified by the Penetrating Abdominal Trauma Index
13.50 0.632 0.329
14.50 0.579 0.300
15.50 0.579 0.257 Table 6. Coordinates of the Curve, PATI scores in
16.50 0.579 0.214 the outcome subset
17.50 0.526 0.200 Test Result Variable(s): PATI
18.50 0.474 0.186 Positive if Greater
19.50 0.474 0.157 Than or Equal To* Sensitivity 1-Specificity
20.50 0.474 0.100 1.00 1.000 1.000
21.50 0.421 0.086 2.50 1.000 0.890
23.00 0.368 0.071 3.50 1.000 0.878
24.50 0.316 0.071 4.50 1.000 0.817
25.50 0.316 0.057 5.50 1.000 0.793
28.50 0.211 0.043 7.00 1.000 0.707
31.50 0.158 0.043 8.50 1.000 0.561
34.00 0.158 0.029 9.50 0.857 0.524
38.50 0.158 0.014 10.50 0.714 0.451
42.00 0.105 0.014 11.50 0.714 0.439
44.00 0.105 0.000 12.50 0.714 0.378
48.50 0.053 0.000 13.50 0.714 0.366
53.00 0.000 0.000 14.50 0.714 0.329
The test result variable(s): PATI has at least one tie between the 15.50 0.714 0.293
positive actual state group and the negative actual state group. 16.50 0.714 0.256
*The smallest cutoff value is the minimum observed test value
17.50 0.714 0.232
minus 1, and the largest cutoff value is the maximum observed
test value plus 1. All the other cutoff values are the averages of
18.50 0.571 0.220
two consecutive ordered observed test values. 19.50 0.571 0.195
20.50 0.571 0.146
21.50 0.429 0.134
Table 4: Mean PATI scores in patients who 23.00 0.429 0.110
survived and did not survive 24.50 0.429 0.098
PATI 25.50 0.429 0.085
Outcome Mean N Std. Deviation 28.50 0.286 0.061
*Survived 12.41 82 9.15 31.50 0.286 0.049
**Death 25.29 7 15.98 34.00 0.286 0.037
Total 13.43 89 10.33 38.50 0.286 0.024
42.00 0.143 0.024
*95 % CI for mean PATI from 10.50 to 14.31
44.00 0.143 0.012
**95 % CI for mean PATI from 21.97 to 28.60
48.50 0.143 0.000
53.00 0.000 0.000
Table 5: Logistic Regression results dependent The test result variable(s): PATI has at least one tie between the
variable: Outcome (Death) positive actual state group and the negative actual state group.
† *The smallest cutoff value is the minimum observed test value
Variable B *Wald Model Chi-Square Exp(B) minus 1, and the largest cutoff value is the maximum observed
PATI 0.0853 7.4674 7.560 1.0891 test value plus 1. All the other cutoff values are the averages of
*P=0.0063; †P=0.006 two consecutive ordered observed test values.

350 Indian Journal of Surgery 2004 Volume 66 Issue 6 (December)

 © 2003 Indian Journal of Surgery
Penetrating www.indianjsurg.com
abdominal trauma index

Table 7: Complications and cause of death in the survival / not survival subset of patients
Count
Outcome
Survival Not survival Total
Complications Intra-abdominal abcess 1 1
Evisceration 2 2
Wound infection 3 3
Urinary tract infection 1 1
Urinary retention 1 1
ARDS 2 2
SEPSIS 2 2
MODS 1 1
Pulmonary embolism 1 1
Total 82 7 89

1.00 This study supports the use of PATI as a useful method

of quantifying penetrating abdominal trauma and as a
predictor of complications and mortality, with an ample
.75
specificity level as confirmed by the ROC analysis.
Limitations are those of the observational study type,
.50 as no experimental groups can be established,
confidence evidence level is not the highest, but further
robust statistical evaluations of the different trauma
Sensitivity

.25
0.00
0.00 .25 .50
1-Specificity
Diagonal segments are produced by ties.
1 - Specificity
Figure 4: ROC Curve PATI scores in the outcome subset
Several methods to asses abdominal trauma have been
evaluated with adequate statistical techniques that
quantify sensitivity and specificity, but they include
invasive approaches as laparoscopy or image studies.9-
10
Among the trauma indices that have used this
methodology of evaluation are the injury severity score
and the new injury severity score.2
A Trauma index instrument’s behaviour in categorizing
a specific characteristic in trauma patients should be
evaluated by a methodology that avoids data
simplification and therefore bias in the conclusions
obtained by its application.
Logistic regression analyses allow evaluations on how
an instrument’s performance can be graded with
respect to the relative predictive power of a study
variable on the ef fect of a specific characteristic
outcome. ROC curve analysis evaluates an instrument’s
performance in a comprehensive manner; as results
are summarized in a simple way, this methodology
avoids data loss and simplification.2
indices could produce enough evidence to set
statements to encourage their use in the management
.75 1.00
of the trauma patients in our countries.
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