Impact of type of procedure and surgeon on EuroSCORE
               operative risk validation

Atik, Fernando A.; Cunha, Claudio Ribeiro da

doi:10.5935/1678-9741.20140023

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Brazilian Journal of Cardiovascular Surgery

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Sumário

ORIGINAL ARTICLES • Rev Bras Cir Cardiovasc 29 (2) • Apr-Jun 2014 • https://doi.org/10.5935/1678-9741.20140023 copy

Impact of type of procedure and surgeon on EuroSCORE operative risk validation

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective:

EuroSCORE has been used in cardiac surgery operative risk assessment, despite important variables were not included. The objective of this study was to validate EuroSCORE on mortality prediction in a Brazilian cardiovascular surgery center, defining the influence of type of procedure and surgical team.

Methods:

Between January 2006 and June 2011, 2320 consecutive adult patients were studied. According to additive EuroSCORE, patients were divided into low risk (score<2), medium risk (3 - 5), high risk (6 - 11) and very high risk (>12). The relation between observed mortality (O) and expected mortality (E) according to logistic EuroSCORE was calculated for each of the groups, types of procedures and surgeons with > 150 operations, and analyzed by logistic regression.

Results:

EuroSCORE correlated to the observed mortality (O/E=0.94; P<0.0001; area under the curve 0.78). However, it overestimated the mortality in very high risk patients (O/E=0.74; P=0.001). EuroSCORE tended to overestimate isolated myocardial revascularization mortality (O/E=0.81; P=0.0001) and valve surgery mortality (O/E=0.89; P=0.007) and it tended to underestimate combined procedures mortality (O/E=1.09; P<0.0001). EuroSCORE overestimated surgeon A mortality (O/E=0.46; P<0.0001) and underestimated surgeon B mortality (O/E=1.3; P<0.0001), in every risk category.

Conclusion:

In the present population, EuroSCORE overestimates mortality in very high risk patients, being influenced by type of procedure and surgical team. The most appropriate surgical team may minimize risks imposed by preoperative profiles.

Cardiovascular Surgical Procedures; Risk Assessment/methods; Logistic Models; Quality of Health Care

Variables	Study % (N=2320)	EuroSCORE % (N=19030)
Mean age (years)	55	62.5
< 60 years	45.4	33.2
60 - 64 years	15.7	17.8
65 - 69 years	17	20.7
70 - 74 years	12.7	17.9
> 75 years	9.2	9.6
Female	42.7	27.8
COPD	9.7	3.9
Extracardiac arteriopathy	3.3	11.3
Neurological dysfunction	5.5	1.4
Previous cardiac Surgery	11.2	7.3
Elevated creatinine	14.6	1.8
Critical preoperative status	3.5	4.1
Unstagle angina	19.6	8
Moderate ventricular dysfunction	16.3	25.6
Severe ventricular dysfunction	1.5	5.8
Recent myocardial infarction	13	9.7
Pulmonary hypertension	7.7	2
Emergency Surgery	3.1	4.9
Active endocarditis	2.7	1.1
Procedures other than CABG	54.4	36.4
Surgery on thoracic aorta	7.8	2.4

Variable	Estimation ± SE	P	OR	CI 95%
Mortality^† † Hosmer-Lemeshow test, P=0.15; C-statistic 0.79. Legend: CPB - cardiopulmonary bypass
	2.86 ± 0.13	<0.0001
Intercept			7.41	5.19 - 10.75
	0.89 ± 0.1	<0.0001
EuroSCORE > 7			4.29	2.99 - 6.23
	0.5 ± 0.1	<0.0001
CPB > 120 minutes			1.9	1.22 - 3.09
	0.35 ± 0.12	0.003
Surgeon A (no)

	N (%)	Mortality	Mortality	O/E	P	AUC
		O % (IC95%)	E % (IC95%)
Group 1	552 (23.8)	0.9 (0.4 - 2.1)	1.4 (1.3 - 1.5)	0.65	0.006	0.6
Group 2	974 (42)	3.5 (2.5 - 4.8)	3 (2.9 - 3.1)	1.16	0.85	0.51
Group 3	698 (30.1)	10.6 (8.5 - 13.1)	10.6 (10.1 - 11)	1	<0.0001	0.61
Group 4	96 (4.1)	35.5 (26.5 - 45.6)	47.4 (43.9 - 51)	0.74	0.001	0.69
Total		6.3 (5.4 - 7.4)	6.7 (6.3 - 7.1)	0.94	<0.0001	0.78

	N (%)	Mortality	Mortality	O/E	P	AUC
		O % (IC95%)	E % (IC95%)
CABG	1055(49.4)	3.1 (2.2 - 4.4)	3.9 (3.5 - 4.2)	0.81	0.0001	0.71
Valve	627(29.4)	5.7 (4.2 - 7.8)	6.4 (5.7 - 7.1)	0.89	0.007	0.69
Combined	454(21.2)	14.1 (11.3 - 17.7)	12.9 (12 - 13.8)	1.09	<0.0001	0.79

	N (%)	Mortality	Mortality	O/E	P	AUC
		O % (IC95%)	E % (IC95%)
Surgeon A	565 (30.5)	3.9 (2.6 - 5.8)	8.4 (7.6 - 9.3)	0.46	<0.0001	0.89
Surgeon B	491 (26.5)	8.4 (6.2 - 11.1)	6.4 (5.5 - 7.3)	1.3	<0.0001	0.76
Surgeon C	173 (9.3)	6.4 (3.6 - 11.1)	9.1 (7.5 - 10.6)	0.71	<0.0001	0.86
Surgeon D	448 (24.2)	7.4 (5.3 - 10.2)	6.3 (5.4 - 7.3)	1.16	<0.0001	0.73
Surgeon E	176 (9.5)	7.9 (4.8 - 12.9)	6.5 (4.9 - 8)	1.23	0.001	0.87

	N (%^* * Percentage of patients operated in each risk group; O: observed in 30 days; E: expected for EuroSCORE; CI = confidence interval; O/E: ratio of observed mortality over expected; AUC: area under the ROC curve )	Mortality	Mortality	O/E	P
		O % (IC95%)	E % (IC95%)
Group 1
Surgeon A	128 (31.3)	0	1.5 (1.3 - 1.6)	0
Surgeon B	102 (24.9)	2 (0.5 - 6.9)	1.5 (1.3 - 1.7)	1.3
Surgeon C	24 (5.9)	0	1.3 (0.9 - 1.7)	0	<0.0001
Surgeon D	119 (29.1)	3.4 (1.3 - 8.3)	1.6 (1.4 - 1.7)	2.1
Surgeon E	36 (8.8)	0	1.3 (1 - 1.6)	0
Group 2
Surgeon A	229 (30.6)	1.3 (0.4 - 3.8)	2.9 (2.8 - 3)	0.45
Surgeon B	198 (26.5)	4 (2.1 - 7.8)	3.1 (2.9 - 3.2)	1.29
Surgeon C	61 (8.2)	1.7 (0.3 - 8.9)	2.8 (2.6 - 3)	0.61	<0.0001
Surgeon D	179 (23.9)	3.9 (1.9 - 7.9)	3.4 (2.8 - 3.9)	1.15
Surgeon E	81 (10.8)	2.5 (0.7 - 8.6)	2.9 (2.7 - 3.1)	0.86
Group 3
Surgeon A	169 (27.4)	4.1 (2 - 8.3)	10.9 (10 - 11.9)	0.38
Surgeon B	180 (29.2)	15 (10.5 - 20.9)	10.6 (9.8 - 11.4)	1.42
Surgeon C	77 (12.5)	7.8 (3.6 - 16)	11.3 (10 - 12.7)	0.69	<0.0001
Surgeon D	134 (21.8)	12.7 (8.1 - 19.4)	10.3 (9,4 - 11.1)	1.23
Surgeon E	56 (9.1)	16.1 (8.7 - 27.8)	11.5 (9.7 - 13.2)	1.4
Group 4
Surgeon A	39 (49.4)	30.7 (18.6 - 46.4)	52.6 (46.5 - 58.7)	0.58
Surgeon B	11 (13.9)	36.4 (15.2 - 64.6)	44.8 (34.2 - 55.4)	0.81
Surgeon C	10 (12.7)	40 (16.8 - 68.7)	48 (38.4 - 57.7)	0.83	<0.0001
Surgeon D	16 (20.2)	31.3 (14.2 - 55.6)	41.5 (34.8 - 48.1)	0.76
Surgeon E	3 (3.8)	100	71.2 (51.1 - 91.3)	1.4

	N (%^* * Percentage ofpatients operated within each type ofprocedure; O: observed in 30 days; E: expected for EuroSCORE; CI = confidence interval; O/E: ratio of observed mortality over expected; AUC: area under the ROC curve )	Mortality	Mortality	O/E	P
		O % (IC95%)	E % (IC95%)
CABG
Surgeon A	263 (32.2)	0.7 (0.2 - 2.7)	4.7 (3.9 - 5.4)	0.15
Surgeon B	200 (24.4)	4 (2 - 7.7)	3.5 (3 - 4)	1.14
Surgeon C	51 (6.2)	1.9 (0.3 - 10.3)	4.7 (2.5 - 6.8)	0.4	<0.0001
Surgeon D	221 (27)	4.5 (2.5 - 8.1)	3.6 (3 - 4.2)	1.25
Surgeon E	83 (10.2)	3.6 (1.2 - 10.1)	3.2 (2.5 - 3.9)	1.12
Valve
Surgeon A	152 (30.6)	3.9 (1.8 - 8.3)	8.7 (6.5 - 10.8)	0.45
Surgeon B	127 (25.6)	7.9 (4.3 - 13.9)	5.6 (4.7 - 6.4)	1.41
Surgeon C	43 (8.7)	2.3 (0.4 - 12)	5.2 (3.9 - 6.4)	0.44	<0.0001
Surgeon D	126 (25.4)	5.5 (2.7 - 11)	7.3 (5.7 - 9)	0.75
Surgeon E	48 (9.7)	6.3 (2.1 - 16.8)	5.2 (3.7 - 6.7)	1.21
Combined
Surgeon A	98 (24.2)	12.2 (7.1 - 20.2)	16.9 (12.5 - 21.3)	0.72
Surgeon B	122 (30.1)	14.8 (9.5 - 22.1)	11.9 (9.7 - 14.2)	1.24
Surgeon C	65 (16.1)	12.3 (6.4 - 22.5)	15.3 (11.5 - 19.2)	0.8	<0.0001
Surgeon D	79 (19.5)	19 (11.9 - 29)	10.9 (8.2 - 13.5)	1.74
Surgeon E	41 (10.1)	17.1 (8.5 - 31.3)	12 (7.4 - 16.6)	1.42

Sociedade Brasileira de Cirurgia Cardiovascular Rua Afonso Celso, 1178 Vila Mariana, CEP: 04119-061 - São Paulo/SP Brazil, Tel +55 (11) 3849-0341, Tel +55 (11) 5096-0079 - São Paulo - SP - Brazil
E-mail: bjcvs@sbccv.org.br

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[1] Correspondence address: Fernando A. Atik, Instituto de Cardiologia do Distrito Federal (ICDF) Estrada Parque Contorno do Bosque, s/n - Brasília, DF, Brasil, Zip code: 70670-204. E-mail: atikf@mac.com