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Eur J Cardiothorac Surg 2002;22:101-105
© 2002 Elsevier Science NL

Validation of European System for Cardiac Operative Risk Evaluation (EuroSCORE) in North American cardiac surgery

Samer A.M. Nashefa,1*, Francois Roquesb,,1, Bradley G. Hammillc, Eric D. Petersonc, Philippe Micheld,,1, Frederick L. Grovere, Richard K.H. Wysee,f, T. Bruce Fergusone

a Cardiothoracic Surgical Unit, Papworth Hospital, Papworth Everard, Cambridge CB3 8RE, UK
b CHU Fort-de-France, Martinique, France
c Dukes Clinical Research Institute, Durham, NC, USA
d CCECQA 12 rue Dubernat, 33404 Talence cedex, France
e The Society of Thoracic Surgeons National Database, London, UK
f Department of Cardiac Surgery, Hammersmith Hospital, London, UK

Received 17 September 2001; received in revised form 8 March 2002; accepted 25 March 2002.

* Corresponding author. Tel.: +44-1480-364-299; fax: +44-1480-364-744
e-mail: sam.nashef{at}euroscore.org


   Abstract
Top
 Abstract
1. Introductions
 2. Methods
 3. Results
 4. Discussion
 Appendix A. Conference...
 References
 
Objective: To assess the performance of the European System for Cardiac Operative Risk Evaluation (EuroSCORE) when applied in a North American cardiac surgical population. Methods: The simple additive EuroSCORE model was applied to predict operative mortality (in-hospital or 30-day) in 401 684 patients undergoing coronary or valve surgery in 1998 and 1999 as well as in 188 913 patients undergoing surgery in 1995 in the Society of Thoracic Surgeons (STS) database. Results: The proportion of isolated coronary artery bypass grafting (CABG) was greater in STS patients (84%) than in Europe (65%). STS patients were also older (mean age 65.3 versus 62.5), and had more diabetes (30 versus 17%) and prior cardiac surgery (11 versus 7%). Other comorbidity was also significantly more prevalent in STS patients. EuroSCORE predicted overall mortality was virtually identical to the observed mortality (1998/1999: predicted 3.994%, observed 3.992%; 1995: observed and predicted 4.156%). Predicted mortality also closely matched observed mortality across the risk groups. Discrimination was good to very good for the population overall and for isolated CABG in both time periods, with the area under the receiver operating characteristic curve between 0.75 and 0.78. Conclusion: Despite substantial demographic differences between Europe and North America, EuroSCORE performs very well in the STS database, and can be recommended as a simple, additive risk stratification system on both sides of the Atlantic.

Key Words: European System for Cardiac Operative Risk Evaluation • Society of Thoracic Surgeons • Database • Risk stratification


   1. Introductions
Top
 Abstract
 1. Introductions
2. Methods
 3. Results
 4. Discussion
 Appendix A. Conference...
 References
 
The European System for Cardiac Operative Risk Evaluation (EuroSCORE) was developed between 1995 and 1999 to provide a simple, additive risk model in European adult cardiac surgery [1,2] and has gained wide acceptance in Europe and elsewhere. In North America, the Society of Thoracic Surgeons (STS) has developed a national database which was first established in 1989 for the primary purpose of outcome assessment following cardiac surgery in adults [3] as well as to provide a potential clinical research tool for the future [4]. The STS database is now without doubt the largest of its kind in the medical world. The purpose of this study was to evaluate the performance of EuroSCORE in North American cardiac surgery by testing it on the STS database.


   2. Methods
Top
 Abstract
 1. Introductions
 2. Methods
3. Results
 4. Discussion
 Appendix A. Conference...
 References
 
The development of the EuroSCORE risk model has been described in full previously [1,2]. Briefly, comprehensive data were obtained for over 19 000 consecutive patients undergoing open heart surgery in 128 centres in eight European countries. The database thus generated was subjected to multiple regression analysis to determine which risk factors were associated with operative mortality. Weights were allocated to each risk factor on the basis of the odds ratios and a risk model was constructed in which the percentage predicted mortality for a patient could be calculated by adding the weighted values of risk factors which are present. The genesis, growth and development of the STS database has also been described previously [5,6] and the database has already served to produce risk models for coronary surgery [7].

The American and European patient populations were compared for demographic characteristics, incidence of surgical procedures performed and prevalence of risk factors. The simple, additive EuroSCORE model was then tested on two groups of patients in the STS database: all patients who underwent adult cardiac surgery in 1995 and in the period spanning 1998 and 1999. The first was chosen because EuroSCORE was developed from a 1995 European patient cohort and the second because of greater similarity between the American and European datasets and greater recency and relevance. Nevertheless, the definitions of some of the risk variables were not identical in both Europe and America and some adjustments or approximate assumptions were made to enable complete analysis. The risk factors, together with their corresponding definitions are listed in Table 1.


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  		Table 1. Exact definitions of risk factors in Europe (EuroSCORE) and America (STS)

 
Statistical analysis was by t-test for continuous variables and Chi square for categorical variables. P values under 0.05 were considered significant.

After applying the EuroSCORE algorithm to the STS data, a logistic regression of operative mortality on the resulting score was performed. This enabled the measurement of both the calibration and the discrimination of EuroSCORE on the STS population. Calibration was measured by comparing the observed mortality to the expected mortality for equal-sized quintiles of risk. Discrimination was measured by reporting the c-index of the above logistic regression model.

The c-index can be considered as a generalisation of the area under the receiver operating characteristic (ROC) curve and is calculated by analysing all possible pairs of patients that can be formed such that one patient died and the other did not. For a given pair, the predictions are said to be concordant with the outcome if the patient that died has a higher predicted probability of mortality than the patient that survived. The c-index is the proportion of these predictions that are concordant. Values of the c-index range from 0.5 (no ability to discriminate) to 1.0 (full ability to discriminate).


   3. Results
Top
 Abstract
 1. Introductions
 2. Methods
 3. Results
4. Discussion
 Appendix A. Conference...
 References
 
3.1. Demographics
There were very important differences between the American and European surgical populations. American patients were older with proportionately more females. Europeans were twice as likely to have surgery other than isolated coronary artery bypass grafting (CABG), whereas American patients were more than twice as likely to have or be labelled as having unstable angina. American patients also had more comorbidity (respiratory, vascular, neurological and renal). Endocarditis had a higher incidence in Europe and proportionately more European patients had surgery on the thoracic aorta. All differences were highly significant (P<0.0001) and the only similarity between the two populations was the percentage of patients operated for postinfarction septal rupture (0.2%). The prevalence of risk factors and the surgical profile in the two populations are detailed in Table 2.


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  		Table 2. Prevalence of risk factors in Europe (EuroSCORE) and America (STS)

 
3.2. Calibration
The EuroSCORE risk model was applied to the two STS datasets (1998–1999 and 1995). EuroSCORE predicted mortality was virtually identical to the observed mortality in 1998–1999 (3.994 versus 3.998%) and in 1995 (4.156 versus 4.156%). This predictive power was maintained when patients were divided into five approximately equal risk quintiles both in 1998/1999 and in 1995 (Tables 3 and 4) where EuroSCORE predicted mortality very accurately in all five risk groups.


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  		Table 3. EuroSCORE predicted versus actual mortality in patients operated in 1998 and 1999 in the STS database

 

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  		Table 4. EuroSCORE predicted versus actual mortality in patients operated in 1995 in the STS database

 
3.3. Discriminatory power
The discriminatory ability of EuroSCORE on the prediction of mortality was assessed using the area under the ROC curve. The performance was good to very good throughout in all cardiac surgery as well as in the isolated CABG subset (Table 5).


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  		Table 5. Discriminatory power of EuroSCORE mortality prediction in STS database patients

 

   4. Discussion
Top
 Abstract
 1. Introductions
 2. Methods
 3. Results
 4. Discussion
Appendix A. Conference...
 References
 
The originators and custodians of both the STS national database and of the EuroSCORE project share a strongly held conviction in the importance of data collection and risk stratification for proper quality assessment and outcome improvement in cardiac surgery. Multicentre databases are the cornerstone on which the quality assessment structure can be built, and centralised, risk stratified data are the essential building blocks on which analysis of quality, meaningful comparison of outcomes and, finally, improvements in outcomes can be based. This information is now an integral part of the practice of cardiac surgery. It forms part of risk assessment, surgical decision-making and the process of informed consent. Knowledge of risk and comparative outcomes is no longer an ‘optional extra’ in cardiac surgery: it is, and should be, as essential to the surgeon as the knowledge of surgical anatomy and techniques.

The choice of a risk model must necessarily depend on the unit and the audit resources to which it has access. Currently, hospitals range from those without even rudimentary data about numbers and types of procedures to those with full risk-stratified outcome data and the ability to perform complex Bayesian and regression analysis of outcomes. Whatever the available resources, inter-hospital and international evaluation of outcomes would strongly benefit from a universal and easily applicable risk model that can be understood by all. The simple additive EuroSCORE model has been shown to work well in both coronary surgery [8], valve surgery [9] and in overall cardiac surgery across many European countries [10]. The STS database algorithms remain proprietary and confidential. The reasons given for this are the protection of intellectual property and the encouragement of data submission. This paper demonstrates that EuroSCORE performs remarkably well in North American cardiac surgery despite substantial differences in demographic, risk and surgical characteristics between European and American patients. This performance is sustained across years, types of surgery and risk groups.

The additive EuroSCORE model, by virtue of its nature, tends to underestimate risk in very high-risk patients. This is not readily seen in analyses of large, multicentre databases. Some very high-risk patients may be better assessed, for individual risk prediction, by using the full logistic EuroSCORE model (www.euroscore.org).

In an ideal future world, there will be an international database of cardiac surgery to which all units will contribute data. The resources for complex and comprehensive risk analysis will be available to all, and accurate and individualised risk assessment will be within reach of every surgeon and every patient. In the meantime, there is a need for an international risk standard which can be used as a benchmark for risk assessment in inter-hospital and international studies. This study, together with previous work in Europe and elsewhere, demonstrates that EuroSCORE can provide that standard.


   Footnotes
 
Presented at the joint 15th Annual Meeting of the European Association for Cardio-thoracic Surgery and the Annual Meeting of the European Society of Thoracic Surgeons, Lisbon, Portugal, Septermber 16–19, 2001

1 For the EuroSCORE Project Group. Back


   Appendix A. Conference discussion
Top
 Abstract
 1. Introductions
 2. Methods
 3. Results
 4. Discussion
 Appendix A. Conference...
References
 
Dr B. Osswald (Heidelberg, Germany): The EuroSCORE has three classes for risk stratification. Did you also divide the patient groups into those three different score groups, and how did they differ from the published predictions?

Dr Nashef: I believe you are referring to the original paper in which we divided patients into three equal groups in order to validate and calibrate the system. We did not really intend these divisions to be in tablets of stone. We think the most important thing is to produce groups that are statistically comparable. For example, there is not much point in having a group of a EuroSCORE 15 and above in a single hospital because the numbers of patients would be very small and the confidence interval around any kind of prediction would be extremely wide. On this occasion, we just took the patients and divided them into five equal groups across the risk spectrum, and there is no rule that says you cannot divide them into three, four or five risk groups. The original three risk groups were purely for calibration.

Dr U. Herold (Essen, Germany): I would like to ask you a question about your statement that you think that the American patients are sicker, but how can you explain the circumstance that the European patients have to be operated more upon the heart? Endocarditis doesn't explain these concerns from my point of view.

Dr Nashef: I am sorry, I don't think I understood the question. Could you just repeat the question?

Dr Herold: You stated that the American patients are termed to be sicker than the European ones.

Dr Nashef: Yes.

Dr Herold: But how can you explain the circumstance that European patients have to be operated upon the heart more often than the Americans? Your explanation of endocarditis doesn't fit to this.

Dr Nashef: Yes. The European patients in general have more valve surgery; valve surgery as a group represents a higher percentage in European surgery than it does in American surgery. There is more isolated coronary artery bypass grafting in the American database, but there are more redos in America. Understandably, if you have a large population of valve patients, then a substantial number of these, well, at least a slightly larger proportion of these, would have endocarditis compared with the American group.


   References
Top
 Abstract
 1. Introductions
 2. Methods
 3. Results
 4. Discussion
 Appendix A. Conference...
 References
 

  1. Roques F., Nashef S.A., 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 Cardiothorac Surg 1999;15:816-822.[Abstract/Free Full Text]
  2. Nashef S.A., Roques F., Michel P., Gauducheau E., Lemeshow S., Salamon R. European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg 1999;16:9-13.[Abstract/Free Full Text]
  3. Clarke R.E., The S.T.S. Cardiac Surgery National Database: an update. Ann Thorac Surg 1995;59:1841-1844.
  4. Ferguson T.B., Jr, Dziuban S.W., Edwards F.H., Eiken M.C., Shroyer A.L., 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]
  5. Clark R.E. The development of The Society of Thoracic Surgeons voluntary national database system: genesis, issues, growth, and status. Best Pract Benchmarking Healthc 1996;1:62-69.[Medline]
  6. Clark R.E. The STS Cardiac Surgery National Database: an update. Ann Thorac Surg 1995;59:1376-1380.[Abstract/Free Full Text]
  7. Shroyer A.L., Plomondon M.E., Grover F.L., Edwards F.H. The 1996 coronary artery bypass risk model: the Society of Thoracic Surgeons Adult Cardiac National Database. Ann Thorac Surg 1999;67:1205-1208.[Abstract/Free Full Text]
  8. 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 European system for cardiac operative risk evaluation database. Eur J Cardiothorac Surg 2000;17:396-399.[Abstract/Free Full Text]
  9. Roques F., Nashef S.A.M., Michel P., the EuroSCORE Study Group. Risk factors for early mortality after valve surgery in Europe in the 990s: lessons from the EuroSCORE pilot program. J Heart Valve Dis 2001;10(5):572-577.[Medline]
  10. Roques F., Nashef S.A.M., Michel P., Pinna Pintor P., David M., Baudet E. The EuroSCORE Study Group Does EuroSCORE work in individual European countries?. Eur J Cardiothorac Surg 2000;18:27-30.[Abstract/Free Full Text]



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F. Biancari, O.-P. Kangasniemi, J. Luukkonen, S. Vuorisalo, J. Satta, R. Pokela, and T. Juvonen
EuroSCORE predicts immediate and late outcome after coronary artery bypass surgery.
Ann. Thorac. Surg., July 1, 2006; 82(1): 57 - 61.
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 Eur. J. Cardiothorac. Surg.Home page
C.-J. Jakobsen, P. Torp, and E. Sloth
Assessment of left ventricular ejection fraction may invalidate the reliability of EuroSCORE.
Eur. J. Cardiothorac. Surg., June 1, 2006; 29(6): 978 - 982.
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 Eur. J. Cardiothorac. Surg.Home page
F. Seccareccia, C. A. Perucci, P. D'Errigo, and D. Fusco
Concerning the Editorial comment by Dr Menicanti.
Eur. J. Cardiothorac. Surg., May 1, 2006; 29(5): 858 - 859.
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 Eur. J. Cardiothorac. Surg.Home page
C.-H. Yap, C. Reid, M. Yii, M. A. Rowland, M. Mohajeri, P. D. Skillington, S. Seevanayagam, and J. A. Smith
Validation of the EuroSCORE model in Australia.
Eur. J. Cardiothorac. Surg., April 1, 2006; 29(4): 441 - 446.
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 Eur. J. Cardiothorac. Surg.Home page
P. Gersbach, H. Tevaearai, J.-P. Revelly, P. Bize, R. Chiolero, and L. K. von Segesser
Are there accurate predictors of long-term vital and functional outcomes in cardiac surgical patients requiring prolonged intensive care?
Eur. J. Cardiothorac. Surg., April 1, 2006; 29(4): 466 - 472.
[Abstract] [Full Text] [PDF]

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 Ann. Thorac. Surg.Home page
N. Luciani, G. Nasso, A. Anselmi, F. Glieca, M. Gaudino, F. Girola, M. Piscitelli, M. Perisano, L. Martinelli, and G. Possati
Repeat Valvular Operations: Bench Optimization of Conventional Surgery
Ann. Thorac. Surg., April 1, 2006; 81(4): 1279 - 1283.
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 Eur Heart JHome page
J. Nilsson, L. Algotsson, P. Hoglund, C. Luhrs, and J. Brandt
Comparison of 19 pre-operative risk stratification models in open-heart surgery
Eur. Heart J., April 1, 2006; 27(7): 867 - 874.
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 J Am Coll CardiolHome page
M. J. Price, E. Cristea, N. Sawhney, J. A. Kao, J. W. Moses, M. B. Leon, R. A. Costa, A. J. Lansky, and P. S. Teirstein
Serial Angiographic Follow-Up of Sirolimus-Eluting Stents for Unprotected Left Main Coronary Artery Revascularization
J. Am. Coll. Cardiol., February 21, 2006; 47(4): 871 - 877.
[Abstract] [Full Text] [PDF]