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Eur J Cardiothorac Surg 2001;20:961-966
© 2001 Elsevier Science NL

Risk stratification analysis of operative mortality in heart and thoracic aorta surgery: comparison between Parsonnet and EuroSCORE additive model

Yoshito Kawachi, Atsuhiro Nakashima, Yoshihiro Toshima, Kouich Arinaga, Hiroshi Kawano

a Cardiovascular Surgery, Clinical Research Institute, National Kyushu Medical Center Hospital, 1-8-1 Jigyo-hama, Chuo-ku, Fukuoka 810-8563, Japan

Received 20 June 2001; received in revised form 6 August 2001; accepted 7 August 2001.

Corresponding author. Tel.: +81-92-852-0700; fax: +81-92-846-8485
e-mail: kawachiy{at}qmed.hosp.go.jp


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 
Objective: Our purpose was to compare the performance of risk stratification model between Parsonnet and European System for Cardiac Operative Risk Evaluation (EuroSCORE) in our patient database. Methods: From August 1994 to December 2000, 803 consecutive patients have undergone heart and thoracic aorta surgery using cardiopulmonary bypass and scored according to Parsonnet and EuroSCORE algorithm. The population was divided into five clinically relevant risk categories. We compared correlation of predicted mortality and observed mortality between these two models. Score validity was assessed by calculating the area under the receiver operating characteristic (ROC) curve. Results: Overall hospital mortality was 4.5%. In Parsonnet model, predicted mortality was 2.4% for 0–4% risk, 6.7% for 5–9% risk, 12% for 10–14% risk, 17% for 15–19% risk, 25% for 20% plus risk, and 10.4% for overall patients. Observed mortality was 2.4, 0.4, 5.9, 8.7, 11, and 4.5%, respectively. The thoracic aorta and valve cohort indicated poor correlation between predicted and observed mortality compared to coronary cohort. In the EuroSCORE model, predicted mortality was 1.4% for 0–2% risk, 4.0% for 3–5% risk, 6.7% for 6–8% risk, 9.7% for 9–11% risk, 13% for 12% plus risk, and 5.3% for overall patients. Actual mortality was 0, 1.5, 6.8, 11, 21, and 4.5%, respectively. Each of the thoracic aorta, valve, and coronary cohort indicated good correlation between predicted and observed mortality. Areas under the ROC curves were 0.72 in Parsonnet and 0.82 in EuroSCORE. Conclusions: The EuroSCORE additive model yielded good predictive value for hospital mortality of Japanese patients undergoing not only cardiac but also thoracic aortic surgery.

Key Words: Risk stratification • Parsonnet score • EuroSCORE • Coronary artery bypass grafting • Valve surgery • Thoracic aortic surgery


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 References
 
Comparing our operative results using risk stratification with those of different institutions or surgeons enables us to implement quality control of our own results. We have used Parsonnet model since the opening of our institution in August 1994 because of classic and easy application [1]. However, we have found difficulty in predicting operative mortality of thoracic aortic surgery according to the Parsonnet algorithm. Generally, many Japanese cardiac surgeons have done not only heart surgery but surgery on thoracic aorta. Recently, the European System for Cardiac Operative Risk Evaluation (EuroSCORE) additive model was introduced, which had not only simple and objective definitions provided at the data collection stage but also risk factor for surgery of the thoracic aortic disease [2]. We assessed the accuracy of these two models for predicting operative mortality in cardiac and thoracic aortic surgery.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 References
 
From August 1994 to December 2000, 803 consecutive patients — 486 men and 317 women aged 13–90 years (mean: 63.1±12.2 years) — were operated on for cardiac and thoracic aortic diseases. Of these, 566 (70.5%) were older than 60 years and 255 (31.8%) were older than 70 years. Table 1 shows the distribution of surgeries performed. All the patients who underwent cardiac and thoracic aortic surgery using cardiopulmonary bypass were selected, so off-pump coronary artery bypass patients were excluded from this study. Detailed data for the Parsonnet and EuroSCORE risk factor were collected and all patients were scored according to the Parsonnet and EuroSCORE additive model, retrospectively or prospectively [1–3]. Expected or predicted mortality was calculated for individual patients using the Parsonnet and EuroSCORE algorithms, arranged sequentially in order of predicted score. The population was divided into five clinically relevant risk categories according to the range of predicted mortality rate [2,3]. Expected mortality was compared to observed or actual mortality for each risk category. Mortality was defined as death from any cause within 30 days of operation or within the same hospital admission.


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  		Table 1. Distribution of cardiac and thoracic aortic surgical proceduresa

 
The continuous data were expressed as the mean±1 standard deviation, and categorical variables were expressed as percentages. Statistical analysis was conducted using StatView5.0 (SAS Institute Inc., Cary, NC). Comparison of two groups was performed for categorical variables with the chi-square test with 2x2 contingency tables or Fisher's exact test as appropriate. The receiver operating characteristic (ROC) curves were plotted for each score system and the area under the ROC curve was calculated as an index for the predictive value of the model [4]. Variables were judged significant at P<0.05.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 References
 
Overall hospital mortality was 4.5% (36 of 803 patients) and mortality of each surgical distribution was shown (Table 1). Table 2 shows the impact of Parsonnet risk factors on hospital mortality based on univariate analysis. Only four of these 18 variables influenced mortality significantly, namely ejection fraction, preoperative intraaortic balloon pumping, catastrophic states, and pulmonary artery pressure over 60 mmHg. Table 3 shows the impact of EuroSCORE risk factors on hospital mortality based on univariate analysis. Eight of these 17 variables influenced mortality significantly, namely serum creatinine over 2 mg/dl, critical preoperative state, unstable angina, left ventricular dysfunction, recent myocardial infarct, pulmonary hypertension, emergency, and surgery on thoracic aorta. In the Parsonnet model, the overall patient distribution by preoperative risk classification was 21% at 0–4% risk, 28% at 5–9% risk, 27% at 10–14% risk, 13% at 15–19% risk, and 10% at 20% plus risk. Predicted mortality was 2.4% in 0–4% risk, 6.7% in 5–9% risk, 12% in 10–14% risk, 17% in 15–19% risk, and 25% in 20% plus risk patients. Observed mortality was 2.4, 0.4, 5.9, 8.7, and 11%, respectively. Predicted average mortality was 10.4% and observed average mortality was 4.5%. Patient group that received coronary artery bypass grafting (CABG) surgery alone showed good correlation between predicted and observed mortality (Fig. 1). However, patient groups that received thoracic aortic aneurysm (TAA) surgery alone and valve surgery alone indicated poor correlation.


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  		Table 2. Evaluation of Parsonnet risk factors by univariate analysisa

 

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  		Table 3. Evaluation of EuroSCORE risk factors by univariate analysisa

 


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  		Fig. 1. Observed mortality calculated by the Parsonnet additive model in each surgical distribution.

 
In the EuroSCORE model, overall patient distribution by preoperative risk classification was 18% at 0–2% risk, 43% at 3–5% risk, 24% at 6–8% risk, 9% at 9–11% risk, and 6% at 12% plus risk. Predicted mortality was 1.4% in 0–2% risk, 4.0% in 3–5% risk, 6.7% in 6–8% risk, 9.7% in 9–11% risk, and 13% in 12% plus risk patients. Observed mortality was 0, 1.5, 6.8, 11, and 21%, respectively. Predicted average mortality was 5.3% and observed average mortality was 4.5%. Each patient group that received CABG, valve, and TAA surgery alone showed good correlation between predicted and observed mortality (Fig. 2).



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  		Fig. 2. Observed mortality calculated by the EuroSCORE additive model in each surgical distribution.

 
The predictive ability of the EuroSCORE model for mortality prediction was better than that of the Parsonnet's score (Fig. 3). The area under the ROC curve was 0.82 in EuroSCORE and 0.72 in Parsonnet's score. Both discriminative values of the EuroSCORE and Parsonnet's score were excellent in the subgroups of CABG only and valve only (area under the ROC curve >0.8) but poor in the subgroup of TAA only (area under the ROC curve <0.7) (Table 4).



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  		Fig. 3. ROC curves of the Parsonnet's score and EuroSCORE for the prediction of mortality.

 

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  		Table 4. Validity of scores (areas under the ROC curve)

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
References
 
Risk stratification enables preoperative estimation of surgical risk faced by individual patient and retrospective analysis of operative results. The ability to compare outcome at different times and at different institutions is a major advantage of risk stratification. Risk stratification has become an important tool in assessing the quality of surgical care with increasing age, disease severity, and comorbidity in patients undergoing heart and thoracic aorta surgery.

Quality monitoring is a mainstay of good surgical practice and the Parsonnet additive model is a useful tool for accomplishing the same [3]. In CABG patients, we have reported good correlation between observed mortality and expected mortality calculated by the Parsonnet additive model and an observed-to-expected mortality ratio of 0.48 [1]. However, in this study, valve and TAA patient population indicated poor correlation between observed mortality and predicted mortality according to Parsonnet's score. Parsonnet et al. [3] developed the score from 3500 consecutive open heart surgery procedures and validated the score from 1332 cases — CABG only in 1056, valve only in 127, CABG+valve in 71, and others in 78 cases. The vast majority of the procedures entered were CABG operations. The Japanese Association for Thoracic Surgery (JATS) has published an annual report of the operative results of thoracic and cardiovascular surgery in Japan since 1996. The latest report of 1998 presented data on valvular heart disease conducted in 8788, isolated CABG in 15 974, and TAA in 4605 patients [5]. The ratio of TAA, valve, and CABG was 1:2:4 in this JATS annual report, which was parallel to our ratio of 1:2:2.5. In this way, the makeup of the population undergoing cardiovascular surgery in Japan is very different in terms of its preoperative characteristics to the North American population. Therefore, it is natural that Parsonnet model shows good correlation between predicted and observed mortality in our CABG patients but poor correlation in our valve or TAA patients (Fig. 1). Gabrielle et al. [6] reported that many risk factors in the Parsonnet model were not significant and that the initial Parsonnet score had a moderate predictive value from assessment by a French multicenter study.

Nashef et al. [2] introduced EuroSCORE in 1999, in which the risk factor of surgery on thoracic aorta was associated with increased mortality at a score of 3. Moreover, it had simple and objective definitions provided at the data collection stage. Therefore, we had started to collect detailed data for EuroSCORE since January 2000 in our database, prospectively and retrospectively. For development of EuroSCORE additive model, data collection was carried out in 132 centers from eight European countries between September and December 1995 and all adult patients who underwent cardiac surgery under cardiopulmonary bypass were included [7]. The patient characteristics were reported in detail, so we compared our 803 patients to 19,030 patients of EuroSCORE database (Table 5). Background of score development in EuroSCORE was similar to distribution of our patients with little exception. Our patient population had higher incidence of surgery on thoracic aorta and emergency operation but lower incidence of isolated CABG, left ventricular dysfunction, and morbid obesity. Despite epidemiological differences between European countries, the discriminative power of EuroSCORE was good and excellent in European countries [8,9]. Moreover, the EuroSCORE worked very well in an institution of Japan. The predictive value of the EuroSCORE model assessed by ROC curve was excellent (area under the ROC curve was 0.82).


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  		Table 5. Comparison of incidence of preoperative and operative risk factors between EuroSCORE and our patient population

 
The original EuroSCORE applied the scoring system in three risk groups – expected mortality 0–2, 3–5, and 6% plus [2]. Nashef et al. [2] reported observed mortality to be 0.8% in 0–2% risk, 3.0% in 3–5% risk, 11.2% in 6% plus risk, and 4.7% in overall patients. Our observed mortality was parallel to this EuroSCORE application data – 0% in 0–2% risk, 1.5% in 3–5% risk, 9.8% in 6% plus risk patients, and 4.5% in overall patients. However, we divided the scoring system into five risk categories like the Parsonnet model because higher risk is more meaningful for estimating the risk of surgical mortality faced by an individual patient, as an aid to patient and physician contemplating cardiovascular surgery (Fig. 2). The association between actual mortality and predicted mortality according to EuroSCORE indicated good fitness in patients with EuroSCORE value 9–11% or less. The predicted mortality in 12% plus risk patients was 13% but 21% of patients with EuroSCORE value of 12 or higher died. Pitkanen et al. [10] also reported high mortality rate of 25% in patients with a EuroSCORE value of 13 or higher. Therefore, patients with EuroSCORE value of 12 or higher may be thought literally as an extremely high-risk group.

Large multiinstitutional databases such as the Society of Thoracic Surgeons National Database (STS database) enable us to determine modern operative risk and provide a benchmark for quality assurance [11,12]. Individual institutions can enter their patient population data to computer software and obtain direct risk-adjusted comparisons of their results compared to the national standard derived from the North American patient population. However, we must buy an expensive computer software to use STS database for risk stratification of our patients.

This study is limited by the relatively small sample size of patients, particularly in the subgroups such as CABG only, valve only, TAA only, and 12% plus risk patients. Ongoing trials and reexamination with a large number of patients may confirm the several observations in this study.

In conclusion, according to the EuroSCORE additive model, we can calculate the predicted risk of surgical mortality faced by an individual patient and evaluate the operative mortality rates of hospitals and surgeons fairly in not only the heart but also in the thoracic aorta surgery. The EuroSCORE is useful for constructing a risk stratification scoring system for Japanese cardiovascular patients despite epidemiological difference.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 

  1. Kawachi Y., Nakashima A., Toshima Y., Komesu I., Kimura S., Arinaga K. Risk stratification analysis of operative mortality in coronary artery bypass surgery. Jpn J Thorac Cardiovasc Surg 2001;49:557-563.[Medline]
  2. Nashef S.A.M., Roques F., Michel P., Gauducheau E., Lemeshow S., Salamon R. European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardio-thorac Surg 1999;16:9-13.[Abstract/Free Full Text]
  3. Parsonnet V., Dean D., Bernstein A.D. A method of uniform stratification of risk for evaluating the results of surgery in acquired adult heart disease. Circulation 1989;79(Suppl I):I-3-I-12.
  4. Swets J.A. Measuring the accuracy of diagnostic systems. Science 1988;240:1285-1293.[Abstract/Free Full Text]
  5. Yasuda K., Ayabe H., Ide H., Uchida Y., Committee of Science. Thoracic and cardiovascular surgery in Japan during 1998. Annual report by the Japanese Association for Thoracic Surgery. Jpn J Thorac Cardiovasc Surg 2000;48:401-415.[Medline]
  6. Gabrielle F., Roques F., Michel P., Bernard A., de Vicentis C., Roques X., Brenot R., Baudet E., David M. Is the Parsonnet's score a good predictive score of mortality in adult cardiac surgery: assessment by French multicentre study. Eur J Cardio-thorac Surg 1997;11:406-414.[Abstract]
  7. Roques F., Nashef S.A.M., Michel P., Gauducheau E., de Vincentiis C., Baudet E., Cortina J., David M., Faichney A., Gabrielle F., Gams E., Harjula A., Jones M.T., Pintor P.P., Salamon R., Thulin L. Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19 030 patients. Eur J Cardio-thorac Surg 1999;15:816-823.[Abstract/Free Full Text]
  8. Roques F., Nashef S.A.M., Michel P., Pintor P.P., David M., Baudet E. The EuroSCORE Study Group. Does EuroSCORE work in individual European countries?. Eur J Cardio-thorac Surg 2000;18:27-30.[Abstract/Free Full Text]
  9. Nashef S.A.M., Roques F., Michel P., Cortina J., Faichney A., Gams E., Harjula A., Jones M.T. Coronary surgery in Europe: comparison of the national subsets of the EuroSCORE database. Eur J Cardio-thorac Surg 2000;17:396-399.[Abstract/Free Full Text]
  10. Pitkanen O., Niskanen M., Rehnberg S., Hippelainen M., Hynynen M. Intra-institutional prediction of outcome after cardiac surgery: comparison between a locally derived model and the EuroSCORE. Eur J Cardio-thorac Surg 2000;18:703-710.[Abstract/Free Full Text]
  11. Grover F.L. The Society of Thoracic Surgeons National Database: current status and future directions. Ann Thorac Surg 1999;68:367-373.[Abstract/Free Full Text]
  12. Ferguson T.B., Jr, Dziuban S.W., Jr, Edwards F.H., Eiken M.C., Shroyer A.L.W., Pairolero P.C., Anderson R.P., Grover F.L. The STS National Database: current changes and challenges for the new millennium. Ann Thorac Surg 2000;69:680-691.[Abstract/Free Full Text]



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