HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pinna Pintor, P. Articles by Diena, M. Search for Related Content PubMed PubMed Citation Articles by Pinna Pintor, P. Articles by Diena, M. Related Collections Cardiac - other Coronary disease

Eur J Cardiothorac Surg 2003;23:595-598
© 2003 Elsevier Science NL

Can EuroSCORE predict direct costs of cardiac surgery?

^a Arturo Pinna Pintor Foundation, Via Vespucci 61, 10129 Turin, Italy
^b Monzino Foundation Heart Center, Milan, Italy
^c Cardioteam, Turin, Italy

Received 28 September 2002; received in revised form 17 December 2002; accepted 22 December 2002.

^* Corresponding author. Tel.: +30-011-5802365; fax: +30-011-5683893
e-mail: fondazione{at}pinnapintor.it
e-mail: http://www.pinnapintor.it

	Abstract

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

 
Objective: The aim of this study is to determine if a preoperative risk stratification model can identify different surgical costs. Methods: Four hundred and eighty-eight patients undergoing open heart surgery between March 2000 and March 2001 were classified with the EuroSCORE model. Direct variable costs were prospectively collected, surgical team costs excluded. The multivariate analysis was used to find variables independently associated with costs. Results: Of the 488 patients enrolled 342 (70%) were males, mean age 65±10 years, 57 (12%) had myocardial infarction, 20 (4%) had ejection fraction <30%, 56 (11%) were operated in emergency, 26 (5%) had a re-operation. 113 (23.2%) were operated for valvular disease, 30 (6.1%) were operated for thoracic aortic surgery, one (0.2%) was operated for interatrial septal defect, 79 (16.2%) were operated for other intervention in addition to coronary bypass and 265 (54.3%) for isolated coronary bypass. The mean intensive care unit length of stay (ICU-LOS) was 2.3±4.1 days and the postoperative LOS was 8.2±5.3 days. According to EuroSCORE, 117 patients (24%) were at low, 187 (38%) at medium, and 184 (38%) at high risk. Costs were significantly and directly correlated with preoperative risk model with a correlation coefficient of 0.47 and an increase of costs of 3.5% (95% CI 2.3–4.7, P<0.0001) for each single rise of risk score. The relationship EuroSCORE vs. direct costs is, respectively: EuroSCORE 0–2 6863±861 €; 3–4 8292±3714 €; 5–6 8908±3480 €; 7–8 10,462±6123 €; 9–10 13,711±12,634 €; >10 21,353±18,507 €. Excluding EuroSCORE from the preoperative logistic model, age, preoperative creatinine, critical condition, ejection fraction, re-operation and sex were independently correlated with costs. Conclusions: From our data the EuroSCORE model developed to predict (30-day postoperative) hospital mortality could be used to predict direct operative costs and identify patients with different levels of resource consumption.

Key Words: Costs • Risk models • Cardiac surgery

	1. Introduction

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

 
During the last two decades a major case-mix evolution has been observed in cardiac surgery [1], both in North America and in Europe.

Despite an increase of average perioperative mortality risk¹,², since older patients, more acute, and with more co-morbidity, are referred to cardiac surgery³, the hospital mortality was unchanged or slightly reduced¹ [2,3]. Meanwhile an increase of postoperative complications led to an increase of surviving patients, but at the cost of a higher rate of complications [4], of prolonged intensive care unit (ICU) length of stay (LOS) [5–7] and of a remarkable increase of individual costs [8,9].

The identification of candidates to cardiac surgery at risk of prolonged stay in ICU and relative higher costs may be useful in order to allocate limited resources both for budgetary reasons and for negotiating the prospective charges with public and private financing institutions. At present there are no available statistical models, specifically validated, to predict individual costs in cardiac surgery.

In order to assess whether a preoperative predictive model, designed to identify the mortality risk in cardiac surgery, can also be applied to predict costs, we compared in our population the preoperative risk stratification obtained using the EuroSCORE model [10], or the single variables of the EuroSCORE model, with costs.

	2. Materials and methods

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

 
From March 2000 to March 2001 488 patients underwent cardiac surgery at our institution. For each patient selected, demographic and clinical preoperative characteristics were used to calculate the EuroSCORE: a risk stratification model, widely validated on the European population and already diffused and used in the cardiac surgery centers also in Italy [11] for quality assurance of outcome.

The direct variable costs (disposable materials, diagnostic tests, drugs, laboratory test and blood components) were prospectively collected. We decided to exclude hospital fixed costs and surgical team costs because they are related to specific activities and it is not possible to generalize them to other Institutions. The EuroSCORE subdivides patients in three main risk groups (low, medium, and high risk). In order to have a more detailed analysis of the relationship between costs and the EuroSCORE we decided to divide the preoperative mortality risk of patients in six groups of increasing risk and then we calculated the mean costs.

A linear regression analysis with the log-transformed direct costs was used to explore the association of the EuroSCORE model and its variables with costs. A covariance analysis (ANCOVA) using direct costs as dependent variable was used with two models: the first one including only clinical and operative variables in the explanatory model and the second including also the EuroSCORE.

	3. Results

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

 
Of the 488 patients enrolled 342 (70%) were males, mean age 65±10 years, 113 (23.2%) were operated for valvular disease, 30 (6.1%) were operated for thoracic aortic surgery, one (0.2%) was operated for interatrial septal defect, 79 (16.2%) were operated for other intervention in addition to coronary bypass and 265 (54.3%) for isolated coronary artery bypass graft (CABG).

Table 1 describes the variables used to calculate the EuroSCORE of our population and the operating and follow-up characteristics. According to EuroSCORE 117 (24%) were at low, 187 (38%) at medium, and 184 (38%) at high risk. The mean ICU-LOS was 2.3±4.1 days and the postoperative LOS was 8.2±5.3 days. The overall crude 30 day mortality was 4.7% (23 patients).

View larger version (15K): [in this window] [in a new window]   Fig. 1. Linear regression analysis: Euroscore vs. log-transformed direct costs; increase of costs 3.5% (95% CI 2.3–4.7), P<0.0001 for each single rise of risk score.

	4. Discussion

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

Furthermore, some of the variables included in the EuroSCORE model showed an independent association with costs. This should be kept in mind when it should be decided whether to refer a patient to cardiac surgery, because patients with these risk factors, alone or differently combined, could have higher costs, lower cost-benefit relation and probably longer ICU-LOS in addition to higher mortality risk. Thus, it would be desirable that another form of medical or surgical treatment will be suggested in this subset of higher risk patients. If our data are confirmed by other investigations, cardiologists, and cardiac surgeons will have more information to include into the decision model. We should be aware that the decision to refer a patient to cardiac surgery should not be confined only to the risk of death, but also to the risk of long and costly hospital stays that are translated into a painful anguish for either the patient or his/her relatives. Shortly, all European centers will be able to automatically calculate the preoperative EuroSCORE of each patient, so that surgeons will have a simple tool to check their performance and to improve their outcome not only in terms of mortality but also of quality of life for their own patients.

	Acknowledgments

 
The authors thank warmly Mrs Piera Colonna and Mrs Maddalena Caviglia for their skilful secretarial assistance and Mrs Agnese Cremaschi for her careful data collection.

	Footnotes

 
Presented at the 16th Annual Meeting of the European Association for Cardio-thoracic Surgery, Monte Carlo, Monaco, September 22–25, 2002.

¹ From http://www.clevelandclinic.org/heartcenter/pub/about/default.asp

² From http://www.scts.org/doc/5483

³ From http://space.tin.it/salute/ppinnapi/symp2000/edwards.htm

	Appendix A. Conference discussion

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

 
Dr T. Wahlers (Jena, Germany): I think it is a very important study concerning the changing pattern of patients we are dealing with, and, in our opinion, you can identify the costs mostly on the length of the ICU stay. So my question is, have you looked with a mean of 2.6 days ICU stay whether you find a direct correlation with the ICU stay in this model with regard to the costs, because the costs, in my opinion, mainly depend, aside from the surgery, on the ICU performance of the patient?

Dr Pintor: Is it a comment or a question?

Dr Wahlers: The length of the ICU stay, because you have given only the mean of all your patients, and the relation to the EuroSCORE.

Dr Pintor: The length of stay is 2.5 days.

Dr Wahlers: Right, and my question is whether you have looked up if the ICU stay is proportional, longer, in the patients with the higher EuroSCORE.

Dr Pintor: Yes, in another study, that was not presented here, we found a statistically significant correlation between the EuroSCORE and the ICU and postoperative length of stay.

	References

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

 

1. Pinna Pintor P., Colangelo S., Bobbio S. Evolution of case-mix in heart surgery: from mortality risk to complication risk. Eur J Cardiothorac Surg 2002;22(6):920-926.
2. Parsonnet V., Bernstein A.D., Gera M. Clinical usefulness of risk-stratified outcome analysis in cardiac surgery in New Jersey. Ann Thorac Surg 1996;61:S8-S11.
3. Ferguson T.B., Jr, Dziuban S.W., Jr, 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 millenium. Ann Thorac Surg 2000;69:680-691.[Abstract/Free Full Text]
4. Warner C.D., Weintraub W.S., Craver J.M., Jones E.L., Gott J.P., Guyton R.A. Effect of cardiac surgery patient characteristics on patient outcomes from 1981 through 1995. Circulation 1997;96:1575-1579.[Abstract/Free Full Text]
5. Staat P., Cucherat M., George M., Lehot J.J., Jegaden O., Andre-Fouet X., Beaune J. Severe morbidity after coronary artery surgery: development and validation of a simple predictive clinical score. Eur Heart J 1999;20:960-966.[Abstract/Free Full Text]
6. Tu J.V., Mazer C.D., Levinton C., Armstrong P.W., Naylor C.D. A predictive index for length of stay in the intensive care unit following cardiac surgery. Can Med Assoc J 1994;151:177-185.[Abstract]
7. Kurki T.S.O., Kataja M. Preoperative prediction of postoperative morbidity in coronary artery bypass grafting. Ann Thorac Surg 1996;61:1740-1745.[Abstract/Free Full Text]
8. Weintraub W.S., Jones E.L., Craver J., Guyton R., Cohen C. Determinants of prolonged length of hospital stay after coronary bypass surgery. Circulation 1989;80:276-284.[Abstract/Free Full Text]
9. Lazar H.L., Fitzgerald C., Gross S., Heeren T., Aldea G.S., Shemin R.J. Determinants of length of stay after coronary artery bypass graft surgery. Circulation 1995;92(Suppl):II20-II24.
10. Nashef S.A.M., Roques F., Michel F., Gauducheau E., Lemeshow S., Salamon R. The EruoScore study group: European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg 1999;16:9-13.[Abstract/Free Full Text]
11. Roques F., Nashef S.A.M., Michel P., Pinna Pintor P., David M., Baudet E. Does EuroSCORE work in individual European countries. Eur J Cardiothorac Surg 1999;18:27-30.
12. Sokolovic E., Schmidlin D., Schmid E.R., Turina M., Ruef C., Schwenkglenks M., Szucs T.D. Determinants of costs and resource utilization associated with open heart surgery. Eur Heart J 2002;23:574-578.[Abstract/Free Full Text]

This article has been cited by other articles:

				A. Haneya, A. Philipp, C. Schmid, C. Diez, R. Kobuch, S. Hirt, W. Zink, and T. Puehler Minimised versus conventional cardiopulmonary bypass: outcome of high-risk patients Eur. J. Cardiothorac. Surg., November 1, 2009; 36(5): 844 - 848. [Abstract] [Full Text] [PDF]

				N. Messaoudi, J. De Cocker, B. A. Stockman, L. L. Bossaert, and I. E.R. Rodrigus Is EuroSCORE useful in the prediction of extended intensive care unit stay after cardiac surgery? Eur. J. Cardiothorac. Surg., July 1, 2009; 36(1): 35 - 39. [Abstract] [Full Text] [PDF]

				F. Versaci, B. Reimers, C. Del Giudice, J. Schofer, A. Giacomin, S. Sacca, R. Gandini, R. Albiero, A. Pellegrino, F. Bertoldo, et al. Simultaneous Hybrid Revascularization by Carotid Stenting and Coronary Artery Bypass Grafting: The SHARP Study J. Am. Coll. Cardiol. Intv., May 1, 2009; 2(5): 393 - 401. [Abstract] [Full Text] [PDF]

				P. Loponen, M. Luther, J. Nissinen, J.-O. Wistbacka, F. Biancari, J. Laurikka, H. Sintonen, and M. R. Tarkka EuroSCORE predicts health-related quality of life after coronary artery bypass grafting Interactive CardioVascular and Thoracic Surgery, August 1, 2008; 7(4): 564 - 568. [Abstract] [Full Text] [PDF]

				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. [Abstract] [Full Text] [PDF]

				P. Kolh Importance of risk stratification models in cardiac surgery Eur. Heart J., April 1, 2006; 27(7): 768 - 769. [Full Text] [PDF]

				I. K. Toumpoulis, C. E. Anagnostopoulos, S. K. Toumpoulis, J. J. DeRose Jr, and D. G. Swistel EuroSCORE Predicts Long-Term Mortality After Heart Valve Surgery Ann. Thorac. Surg., June 1, 2005; 79(6): 1902 - 1908. [Abstract] [Full Text] [PDF]

				I. K. Toumpoulis, C. E. Anagnostopoulos, D. G. Swistel, and J. J. DeRose Jr Does EuroSCORE predict length of stay and specific postoperative complications after cardiac surgery? Eur. J. Cardiothorac. Surg., January 1, 2005; 27(1): 128 - 133. [Abstract] [Full Text] [PDF]

				J. Nilsson, L. Algotsson, P. Hoglund, C. Luhrs, and J. Brandt EuroSCORE Predicts Intensive Care Unit Stay and Costs of Open Heart Surgery Ann. Thorac. Surg., November 1, 2004; 78(5): 1528 - 1534. [Abstract] [Full Text] [PDF]

				J. Nilsson, L. Algotsson, P. Hoglund, C. Luhrs, and J. Brandt Early mortality in coronary bypass surgery: the EuroSCORE versus The Society of Thoracic Surgeons risk algorithm Ann. Thorac. Surg., April 1, 2004; 77(4): 1235 - 1239. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pinna Pintor, P. Articles by Diena, M. Search for Related Content PubMed PubMed Citation Articles by Pinna Pintor, P. Articles by Diena, M. Related Collections Cardiac - other Coronary disease