HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Full Text Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Sean M. O'Brien David M. Shahian Giovanni Filardo Victor A. Ferraris Constance K. Haan Jeffrey B. Rich Sharon-Lise T. Normand Cynthia M. Shewan Rachel S. Dokholyan Eric D. Peterson Fred H. Edwards Richard P. Anderson Permission Requests Google Scholar Articles by O'Brien, S. M. Articles by Anderson, R. P. PubMed Articles by O'Brien, S. M. Articles by Anderson, R. P. Related Collections Cardiac - other Education Related Article

---

Report of STS Quality Measurement Task Force

The Society of Thoracic Surgeons 2008 Cardiac Surgery Risk Models: Part 2—Isolated Valve Surgery

Sean M. O'Brien, PhD^a, David M. Shahian, MD^b,_*, Giovanni Filardo, PhD, MPH^c, Victor A. Ferraris, MD^d, Constance K. Haan, MD^e, Jeffrey B. Rich, MD^f, Sharon-Lise T. Normand, PhD^g, Elizabeth R. DeLong, PhD^a, Cynthia M. Shewan, PhD^h, Rachel S. Dokholyan, MPH^a, Eric D. Peterson, MD, MPH^a, Fred H. Edwards, MD^e, Richard P. Anderson, MD^i,

^a Duke Clinical Research Institute, Durham, North Carolina
^b Massachusetts General Hospital, Boston, Massachusetts
^c Institute for Health Care Research and Improvement, Baylor Health Care System, Dallas, Texas
^d University of Kentucky Chandler Medical Center, Division of Cardiovascular and Thoracic Surgery, Lexington, Kentucky
^e University of Florida, Division of Cardiothoracic Surgery, Jacksonville, Florida
^f Sentara Cardiovascular Research Institute, Norfolk, Virginia
^g Department of Health Care Policy, Harvard Medical School, and Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
^h The Society of Thoracic Surgeons, Chicago, Illinois
ⁱ Seattle, Washington

^_* Address correspondence to Dr Shahian, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114 (Email: dshahian{at}partners.org).

Background: Adjustment for case-mix is essential when using observational data to compare surgical techniques or providers. That is most often accomplished through the use of risk models that account for preoperative patient factors that may impact outcomes. The Society of Thoracic Surgeons (STS) uses such risk models to create risk-adjusted performance reports for participants in the STS National Adult Cardiac Surgery Database (NCD). Although risk models were initially developed for coronary artery bypass surgery, similar models have now been developed for use with heart valve surgery, particularly as the proportion of such procedures has increased. The last published STS model for isolated valve surgery was based on data from 1994 to 1997 and did not include patients undergoing mitral valve repair. STS has developed new valve surgery models using contemporary data that include both valve repair as well as replacement. Expanding upon existing valve models, the new STS models include several nonfatal complications in addition to mortality.

Methods: Using STS data from 2002 to 2006, isolated valve surgery risk models were developed for operative mortality, permanent stroke, renal failure, prolonged ventilation (> 24 hours), deep sternal wound infection, reoperation for any reason, a major morbidity or mortality composite endpoint, prolonged postoperative length of stay, and short postoperative length of stay. The study population consisted of adult patients who underwent one of three types of valve surgery: isolated aortic valve replacement (n = 67,292), isolated mitral valve replacement (n = 21,229), or isolated mitral valve repair (n = 21,238). The population was divided into a 60% development sample and a 40% validation sample. After an initial empirical investigation, the three surgery groups were combined into a single logistic regression model with numerous interactions to allow the covariate effects to differ across these groups. Variables were selected based on a combination of automated stepwise selection and expert panel review.

Results: Unadjusted operative mortality (in-hospital regardless of timing, and 30-day regardless of venue) for all isolated valve procedures was 3.4%, and unadjusted in-hospital morbidity rates ranged from 0.3% for deep sternal wound infection to 11.8% for prolonged ventilation. The number of predictors in each model ranged from 10 covariates in the sternal infection model to 24 covariates in the composite mortality plus morbidity model. Discrimination as measured by the c-index ranged from 0.639 for reoperation to 0.799 for mortality. When patients in the validation sample were grouped into 10 categories based on deciles of predicted risk, the average absolute difference between observed versus predicted events within these groups ranged from 0.06% for deep sternal wound infection to 1.06% for prolonged postoperative stay.

Conclusions: The new STS risk models for valve surgery include mitral valve repair as well as multiple endpoints other than mortality. Model coefficients are provided and an online risk calculator is publicly available from The Society of Thoracic Surgeons website.

Related Article

The Society of Thoracic Surgeons 2008 Cardiac Surgery Risk Models: Introduction

David M. Shahian and Fred H. Edwards
Ann. Thorac. Surg. 2009 88: S1. [Extract] [Full Text] [PDF]