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Updating an Empirically Based Tool for Analyzing Congenital Heart Surgery Mortality
Marshall L Jacobs1, Jeffrey P Jacobs2, Dylan Thibault3
1Department of Surgery, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Insights
The updated STAT 2020 Score and Categories provide a more accurate assessment of congenital heart surgery case mix by reflecting contemporary outcomes and including more procedures. These new metrics demonstrate good discrimination in predicting patient mortality.
Area of Science:
- Cardiovascular Surgery
- Health Services Research
Background:
- The STAT Mortality Categories, developed in 2009, stratify congenital heart surgery procedures by mortality risk to characterize provider case mix.
- An update was needed to reflect contemporary outcomes and expand the scope of procedures analyzed.
Purpose of the Study:
- To update the STAT Mortality Score and Categories using contemporary data from the Society of Thoracic Surgeons Congenital Heart Surgery Database.
- To empirically derive new risk scores and category assignments for congenital heart surgery procedures, including those with multiple components.
Main Methods:
- Analysis of cardiovascular surgical operations from January 1, 2010, to June 30, 2017.
- Bayesian modeling was used to estimate the mortality risk of individual procedures and combinations, assuming risk is determined by the highest-risk component.
- Risk estimates were rescaled to STAT 2020 Scores (0.1–5.0), and categories were assigned to minimize within-category and maximize between-category variation.
Main Results:
- The STAT 2020 update includes 235 unique STAT Scores for procedure combinations, a 58% increase from the 2009 metrics.
- Mortality risk estimates ranged from 0.2% in Category 1 to 38.7% in Category 5.
- The STAT 2020 Scores and Categories showed good discrimination in an independent validation sample (C-statistic = 0.791 for Score, 0.779 for Category).
Conclusions:
- The updated STAT 2020 metrics accurately reflect current congenital heart surgery practice and outcomes.
- The expanded set of empirically based scores and categories, accounting for multi-component operations, facilitates precise case-mix assessment.
- Regular updates of STAT metrics are crucial for maintaining accurate case-mix characterization in congenital heart surgery.
Objectives:
STAT Mortality Categories (developed 2009) stratify congenital heart surgery procedures into groups of increasing mortality risk to characterize case mix of congenital heart surgery providers. This update of the STAT Mortality Score and Categories is empirically based for all procedures and reflects contemporary outcomes.
Methods:
Cardiovascular surgical operations in the Society of Thoracic Surgeons Congenital Heart Surgery Database (January 1, 2010 - June 30, 2017) were analyzed. In this STAT 2020 Update of the STAT Mortality Score and Categories, the risk associated with a specific combination of procedures was estimated under the assumption that risk is determined by the highest risk individual component procedure. Operations composed of multiple component procedures were eligible for unique STAT Scores when the statistically estimated mortality risk differed from that of the highest risk component procedure. Bayesian modeling accounted for small denominators. Risk estimates were rescaled to STAT 2020 Scores between 0.1 and 5.0. STAT 2020 Category assignment was designed to minimize within-category variation and maximize between-category variation.
Results:
Among 161,351 operations at 110 centers (19,090 distinct procedure combinations), 235 types of single or multiple component operations received unique STAT 2020 Scores. Assignment to Categories resulted in the following distribution: STAT 2020 Category 1 includes 59 procedure codes with model-based estimated mortality 0.2% to 1.3%; Category 2 includes 73 procedure codes with mortality estimates 1.4% to 2.9%; Category 3 includes 46 procedure codes with mortality estimates 3.0% to 6.8%; Category 4 includes 37 procedure codes with mortality estimates 6.9% to 13.0%; and Category 5 includes 17 procedure codes with mortality estimates 13.5% to 38.7%. The number of procedure codes with empirically derived Scores has grown by 58% (235 in STAT 2020 vs 148 in STAT 2009). Of the 148 procedure codes with empirically derived Scores in 2009, approximately one-half have changed STAT Category relative to 2009 metrics. The New STAT 2020 Scores and Categories demonstrated good discrimination for predicting mortality in an independent validation sample (July 1, 2017-June 30, 2019; sample size 46,933 operations at 108 centers) with C-statistic = 0.791 for STAT 2020 Score and 0.779 for STAT 2020 Category.
Conclusions:
The updated STAT metrics reflect contemporary practice and outcomes. New empirically based STAT 2020 Scores and Category designations are assigned to a larger set of procedure codes, while accounting for risk associated with multiple component operations. Updating STAT metrics based on contemporary outcomes facilitates accurate assessment of case mix.
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