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Report of STS Quality Measurement Task Force

The Society of Thoracic Surgeons 2008 Cardiac Surgery Risk Models: Part 3—Valve Plus Coronary Artery Bypass Grafting Surgery

David M. Shahian, MD^a,_*, Sean M. O'Brien, PhD^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^b, Cynthia M. Shewan, PhD^h, Rachel S. Dokholyan, MPH^b, Eric D. Peterson, MD, MPH^b, Fred H. Edwards, MD^e, Richard P. Anderson, MD^i,

^a Massachusetts General Hospital, Boston, Massachusetts
^b Duke Clinical Research Institute, Durham, North Carolina
^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: Since 1999, The Society of Thoracic Surgeons (STS) has published two risk models that can be used to adjust the results of valve surgery combined with coronary artery bypass graft surgery (CABG). The most recent was developed from data for patients who had surgery between 1994 and 1997 using operative mortality as the only endpoint. Furthermore, this model did not specifically consider mitral valve repair plus CABG, an increasingly common procedure. Consistent with STS policy of periodically updating and improving its risk models, new models for valve surgery combined with CABG have been developed. These models specifically address both perioperative morbidity and mitral valve repair, and they are based on contemporary data.

Methods: The final study population consisted of 101,661 procedures, including aortic valve replacement (AVR) plus CABG, mitral valve replacement (MVR) plus CABG, or mitral valve repair (MVRepair) plus CABG between January 1, 2002, and December 31, 2006. Model outcomes included operative mortality, stroke, deep sternal wound infection, reoperation, prolonged ventilation, renal failure, composite major morbidity or mortality, prolonged postoperative length of stay, and short postoperative length of stay. Candidate variables were screened for frequency of missing data, and imputation techniques were used where appropriate. Stepwise variable selection was employed, supplemented by advice from an expert panel of cardiac surgeons and biostatisticians. Several variables were forced into models to insure face validity (eg, atrial fibrillation for the permanent stroke model, sex for all models). Based on preliminary analyses of the data, a single model was employed for valve plus CABG, with indicator variables for the specific type of procedure. Interaction terms were included to allow for differential impact of predictor variables depending on procedure type. After validating the model in the 40% validation sample, the development and validation samples were then combined, and the final model coefficients were estimated using the overall 100% combined sample. The final logistic regression model was estimated using generalized estimating equations to account for clustering of patients within institutions.

Results: The c-index for mortality prediction for the overall valve plus CABG population was 0.75. Morbidity model c-indices for specific complications (permanent stroke, renal failure, prolonged ventilation > 24 hours, deep sternal wound infection, reoperation for any reason, major morbidity or mortality composite, and prolonged postoperative length of stay) for the overall group of valve plus CABG procedures ranged from 0.622 to 0.724, and calibration was excellent.

Conclusions: New STS risk models have been developed for heart valve surgery combined with CABG. These are the first valve plus CABG models that also include risk prediction for individual major morbidities, composite major morbidity or mortality, and short and prolonged length of stay.

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