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Pediatric Risk Stratification Is Improved by Integrating Both Patient Comorbidities and Intrinsic Surgical Risk
Viviane G Nasr1, Steven J Staffa, David Zurakowski
1From the Division of Cardiac Anesthesia (V.G.N., J.A.D.) Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts (S.J.S., D.Z.) the Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario Canada (D.F).
Insights
This study developed a new pediatric surgical risk model incorporating procedure risk and patient comorbidities to predict 30-day mortality. The model accurately stratifies risk, improving patient care discussions and resource allocation.
Area of Science:
- Pediatric surgery
- Surgical outcomes research
- Risk stratification
Background:
- Current pediatric perioperative mortality risk models focus on patient comorbidities.
- These models often overlook the intrinsic risk associated with specific surgical procedures.
Purpose of the Study:
- To develop and validate a risk stratification model for pediatric perioperative mortality.
- The model incorporates both patient comorbidities and the intrinsic risk of surgical procedures.
Main Methods:
- Retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program Pediatric database.
- Multivariable logistic regression used to identify predictors of 30-day mortality.
- Internal and external validation of the developed risk model.
Main Results:
- Analysis of 367,065 pediatric surgical cases revealed a 30-day mortality rate of 0.34%.
- Intrinsic surgical risk, categorized by Current Procedural Terminology risk quartiles, significantly predicted mortality (P < 0.001).
- The validated model demonstrated excellent discrimination (c-index = 0.95) for predicting 30-day mortality.
Conclusions:
- Accurate perioperative risk estimation requires considering both patient comorbidities and surgical procedure risk.
- This enhanced risk model can facilitate better patient-family-provider discussions.
- The model may aid in cost analysis and resource allocation in pediatric surgery.
What We Already Know About This Topic:
Risk stratification models to predict perioperative mortality in pediatric surgical populations are based on patient comorbidities, but do not take into consideration the intrinsic risk of the surgical procedures.
What This Article Tells Us That Is New:
Surgical procedures identified by specialty are not independent risk factors for perioperative mortality in pediatric patients. However, in multivariable predictive algorithms, the interaction of patient comorbidities with the intrinsic risk of the surgical procedure strongly predicts 30-day mortality.
Background:
Recently developed risk stratification models for perioperative mortality incorporate patient comorbidities as predictors but fail to consider the intrinsic risk of surgical procedures. In this study, the authors used the American College of Surgeons National Surgical Quality Improvement Program Pediatric database to demonstrate the relationship between the intrinsic surgical risk and 30-day mortality and develop and validate an accessible risk stratification model that includes the surgical procedures in addition to the patient comorbidities and physical status.
Methods:
A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program Pediatric database was performed. The incidence of 30-day mortality was the primary outcome. Surgical Current Procedural Terminology codes with at least 25 occurrences were included. Multivariable logistic regression model was used to determine the predictors for mortality including patient comorbidities and intrinsic surgical risk. An internal validation using bootstrap resampling, and an external validation of the model were performed.
Results:
The authors analyzed 367,065 surgical cases encompassing 659 unique Current Procedural Terminology codes with an incidence of overall 30-day mortality of 0.34%. Intrinsic risk of surgical procedures represented by Current Procedural Terminology risk quartiles instead of broad categorization was significantly associated with 30-day mortality (P < 0.001). Predicted risk of 30-day mortality ranges from 0% with no comorbidities to 4.7% when all comorbidities are present among low-risk surgical procedures and from 0.07 to 46.7% among high-risk surgical procedures. Using an external validation cohort of 110,474 observations, the multivariable predictive risk model displayed good calibration and excellent discrimination with area under curve (c-index) equals 0.95 (95% CI, 0.94 to 0.96; P < 0.001).
Conclusions:
Understanding and accurately estimating perioperative risk by accounting for the intrinsic risk of surgical procedures and patient comorbidities will lead to a more comprehensive discussion between patients, families, and providers and could potentially be used to conduct cost analysis and allocate resources.
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