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Journal of Cardiothoracic Surgery

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Open Access 01-12-2013 | Research article

Development of a predictive model for major adverse cardiac events in a coronary artery bypass and valve population

Authors: Christine R Herman, Karen J Buth, Jean-François Légaré, Adrian R Levy, Roger Baskett

Published in: Journal of Cardiothoracic Surgery | Issue 1/2013

Abstract

Background

Quality improvement initiatives in cardiac surgery largely rely on risk prediction models. Most often, these models include isolated populations and describe isolated end-points. However, with the changing clinical profile of the cardiac surgical patients, mixed populations models are required to accurately represent the majority of the surgical population. Also, composite model end-points of morbidity and mortality, better reflect outcomes experienced by patients.

Methods

The model development cohort included 4,270 patients who underwent aortic or mitral valve replacement, or mitral valve repair with/without coronary artery bypass grafting, or isolated coronary artery bypass grafting. A composite end-point of infection, stroke, acute renal failure, or death was evaluated. Age, sex, surgical priority, and procedure were forced, a priori, into the model and then stepwise selection of candidate variables was utilized. Model performance was evaluated by concordance statistic, Hosmer-Lemeshow Goodness of Fit, and calibration plots. Bootstrap technique was employed to validate the model.

Results

The model included 16 variables. Several variables were significant such as, emergent surgical priority (OR 4.3; 95% CI 2.9-7.4), CABG + Valve procedure (OR 2.3; 95% CI 1.8-3.0), and frailty (OR 1.7; 95% CI 1.2-2.5), among others. The concordance statistic for the major adverse cardiac events model in a mixed population was 0.764 (95% CL; 0.75-0.79) and had excellent calibration.

Conclusions

Development of predictive models with composite end-points and mixed procedure population can yield robust statistical and clinical validity. As they more accurately reflect current cardiac surgical profile, models such as this, are an essential tool in quality improvement efforts.

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Shahian DM, O'Brien SM, Filardo G, Ferraris VA, Haan CK, Rich JB: The society of thoracic surgeons 2008 cardiac surgery risk models: part 1–coronary artery bypass grafting surgery. Ann Thorac Surg. 2009, 88: S2-S22. 10.1016/j.athoracsur.2009.05.053.CrossRefPubMed

Jones RH, Hannan EL, Hammermeister KE, Delong ER, O'Connor GT, Luepker RV: Identification of preoperative variables needed for risk adjustment of short-term mortality after coronary artery bypass graft surgery. The working group panel on the cooperative CABG database project. J Am Coll Cardiol. 1996, 28: 1478-1487. 10.1016/S0735-1097(96)00359-2.CrossRefPubMed

Shroyer AL, Coombs LP, Peterson ED, Eiken MC, DeLong ER, Chen A: The society of thoracic surgeons: 30-day operative mortality and morbidity risk models. Ann Thorac Surg. 2003, 75: 1856-1864. 10.1016/S0003-4975(03)00179-6. discussion 1864–5CrossRefPubMed

O’Connor G, Plume S, Olmstead E, Coffin LH, Morton JR, Maloney CT: Multivariate prediction of in-hospital mortality associated with coronary artery bypass surgery. Northern new england cardiovascular disease study group. Circ. 1992, 85: 2110-2118. 10.1161/01.CIR.85.6.2110.CrossRef

Shahian DM, O'Brien SM, Filardo G, Ferraris VA, Haan CK, Rich JB: The society of thoracic surgeons 2008 cardiac surgery risk models: part 3–valve plus coronary artery bypass grafting surgery. Ann Thorac Surg. 2009, 88: S43-S62. 10.1016/j.athoracsur.2009.05.055.CrossRefPubMed

OBrien S, Shahian D, Filardo G, Ferraris VA, Haan CK, Rich JB: The society of thoracic surgeons 2008 cardiac surgery risk models: part 2--isolated valve surgery. Ann Thorac Surg. 2009, 88: S23-S42. 10.1016/j.athoracsur.2009.05.056.CrossRef

Hannan EL, Racz MJ, Jones RH, Gold JP, Ryan TJ, Hafner JP: Predictors of mortality for patients undergoing cardiac valve replacements in new york state. Ann Thorac Surg. 2000, 70: 1212-1218. 10.1016/S0003-4975(00)01968-8.CrossRefPubMed

Hannan EL, Wu C, Bennett EV, Carlson RE, Culliford AT, Gold JP: Risk index for predicting in-hospital mortality for cardiac valve surgery. Ann Thorac Surg. 2007, 83: 921-929. 10.1016/j.athoracsur.2006.09.051.CrossRefPubMed

Jamieson WR, Edwards FH, Schwartz M, Bero JW, Clark RE, Grover FL: Risk stratification for cardiac valve replacement. national cardiac surgery database. database committee of the society of thoracic surgeons. Ann Thorac Surg. 1999, 67: 943-951. 10.1016/S0003-4975(99)00175-7.CrossRefPubMed

10.

Nowicki ER, Birkmeyer NJ, Weintraub RW, Leavitt BJ, Sanders JH, Dacey LJ: Multivariable prediction of in-hospital mortality associated with aortic and mitral valve surgery in northern new england. Ann Thorac Surg. 2004, 77: 1966-1977. 10.1016/j.athoracsur.2003.12.035.CrossRefPubMed

11.

Roques F, Nashef SA, Michel P, Gauducheau E, de Vincentiis C, Baudet E: Risk factors and outcome in european cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients. Eur J Cardiothorac Surg. 1999, 15: 816-822. 10.1016/S1010-7940(99)00106-2. discussion 822–3CrossRefPubMed

12.

Nashef SA, Roques F, Sharples LD, Nilsson J, Smith C, Goldstone AR, Lockowandt U: EuroSCORE II. Eur J Cardiothorac Surg. 2012, 41 (4): 734-744. 10.1093/ejcts/ezs043. Epub 2012 Feb 29CrossRefPubMed

13.

Howell NJ, Head SJ, Freemantle N, van der Meulen TA, Senanayake E, Menon A, Kappetein AP, Pagano D: The new EuroSCORE II does not improve prediction of mortality in high-risk patients undergoing cardiac surgery: a collaborative analysis of two European centres. Eur J Cardiothorac Surg. 2013, Epub ahead of print

14.

Di Dedda U, Pelissero G, Agnelli B, De Vincentiis C, Castelvecchio S, Ranucci M: Accuracy, calibration and clinical performance of the new EuroSCORE II risk stratification system. Eur J Cardiothorac Surg. 2013, 43 (1): 27-32. 10.1093/ejcts/ezs196. Epub 2012 Jul 20CrossRefPubMed

15.

Guru V, Anderson GM, Fremes SE, O'Connor GT, Grover FL, Tu JV: The identification and development of canadian coronary artery bypass graft surgery quality indicators. J Thorac Cardiovasc Surg. 2005, 130: 1257-CrossRefPubMed

16.

Rankin JS, Hammill BG, Ferguson TB, Glower DD, O'Brien SM, DeLong ER: Determinants of operative mortality in valvular heart surgery. J Thorac Cardiovasc Surg. 2006, 131: 547-57. 10.1016/j.jtcvs.2005.10.041.CrossRefPubMed

17.

Ambler G, Omar RZ, Royston P, Kinsman R, Keogh BE, Taylor KM: Generic, simple risk stratification model for heart valve surgery. Circulation. 2005, 112: 224-31. 10.1161/CIRCULATIONAHA.104.515049.CrossRefPubMed

18.

Nashef SA, Roques F, Hammill BG, Peterson ED, Michel P, Grover FL: Validation of european system for cardiac operative risk evaluation (EuroSCORE) in north american cardiac surgery. Eur J Cardiothorac Surg. 2002, 22: 101-5. 10.1016/S1010-7940(02)00208-7.CrossRefPubMed

19.

Cleveland WS: Robust locally weighted regression and smoothing scatter- plots. J Amer Stats Ass. 1979, 74: 829-36. 10.1080/01621459.1979.10481038.CrossRef

20.

WHO: WHO Technical Report Series 854. Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee. 1995, Geneva: World Health Organization

21.

Hanley JA, McNeil BJ: The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology. 1982, 143: 29-36.CrossRefPubMed

22.

Hosmer DW, Lemeshow S: A goodness-of-fit test for the multiple regression mdel. Commun Statistics. 1980, A10: 1043-1069.CrossRef

23.

Marcin JP, Romano PS: Size matters to a model's fit. Crit Care Med. 2007, 35: 2212-3. 10.1097/01.CCM.0000281522.70992.EF.CrossRefPubMed

24.

Harrell FE, Lee KL, Mark DB: Tutorial in biostatistics multivariable prognostic models: issues in developing mdels, evaluating assumptions and adequacy, and measuring and reducing errors. Stats Med. 1996, 15: 361-87. 10.1002/(SICI)1097-0258(19960229)15:4<361::AID-SIM168>3.0.CO;2-4.CrossRef

25.

Tu JV, Sykora K, Naylor CD: Assessing the outcomes of coronary artery bypass graft surgery: how many risk factors are enough? steering committee of the cardiac care network of ontario. J Am Coll Cardiol. 1997, 30: 1317-23. 10.1016/S0735-1097(97)00295-7.CrossRefPubMed

26.

Spiegelhalter DJ: Probabilistic prediction in patient management and clinical trials. Stat Med. 1986, 5: 421-33. 10.1002/sim.4780050506.CrossRefPubMed

27.

Concato J, Feinstein AR, Holford TR: The risk of determining risk with multivariable models. Ann Intern Med. 1993, 118: 201-10. 10.7326/0003-4819-118-3-199302010-00009.CrossRefPubMed

28.

Altman DG, Royston P: What do we mean by validating a prognostic model?. Stat Med. 2000, 19: 453-73. 10.1002/(SICI)1097-0258(20000229)19:4<453::AID-SIM350>3.0.CO;2-5.CrossRefPubMed

29.

Harrell F, Califf R, Pryor D, Lee K, Rosati R: Evaluating the yield of medical tests. JAMA. 1982, 247: 2543-6. 10.1001/jama.1982.03320430047030.CrossRefPubMed

Title: Development of a predictive model for major adverse cardiac events in a coronary artery bypass and valve population
Authors: Christine R Herman
Karen J Buth
Jean-François Légaré
Adrian R Levy
Roger Baskett
Publication date: 01-12-2013
Publisher: BioMed Central
Published in: Journal of Cardiothoracic Surgery / Issue 1/2013
Electronic ISSN: 1749-8090
DOI: https://doi.org/10.1186/1749-8090-8-177

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Development of a predictive model for major adverse cardiac events in a coronary artery bypass and valve population

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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