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J Thorac Cardiovasc Surg 2007;133:88-96
© 2007 The American Association for Thoracic Surgery

General Thoracic Surgery

Risk-adjusted morbidity and mortality models to compare the performance of two units after major lung resections

Alessandro Brunelli, MDa,*, Nicholas J. Morgan-Hughes, MDb, Majed Refai, MDa, Michele Salati, MDa, Armando Sabbatini, MDa, Gaetano Rocco, MDc

a Unit of Thoracic Surgery, Umberto I° Regional Hospital, Ancona, Italy
b Department of Anaesthesiology, Sheffield Teaching Hospital, Sheffield, United Kingdom
c Division of Thoracic Surgery, National Cancer Institute, Pascale Foundation, Naples, Italy.

Read at the Eighty-sixth Annual Meeting of The American Association for Thoracic Surgery, Philadelphia, Pa, April 29-May 3, 2006.

Received for publication April 22, 2006; revisions received August 13, 2006; accepted for publication August 31, 2006.

* Address for reprints: Alessandro Brunelli, MD, Via S Margherita 23, Ancona 60129, Italy. (Email: alexit_2000{at}yahoo.com).

OBJECTIVE: We sought to develop risk-adjusted morbidity and mortality models to compare the performance of 2 different thoracic surgery units in patients submitted to major lung resections.

METHODS: Seven hundred forty-three patients (551 male and 192 female patients) who underwent lobectomy (n = 611) or pneumonectomy (n = 132) from January 2000 through August 2004 at 2 European thoracic units (519 patients in unit A and 224 patients in unit B) were analyzed. Risk-adjusted models of 30-day or in-hospital cardiopulmonary morbidity and mortality were developed by using stepwise logistic regression analyses and validated by means of bootstrap analysis. Preoperative and operative variables were initially screened by using univariate analysis. Those with a P value of less than .10 were used as independent variables in the regression analyses. The regression equations were then used to estimate the risk of outcome, and the observed and predicted outcome rates of the 2 units were compared by using the z test for comparison of proportions.

RESULTS: The following regression models were developed. Predicted morbidity: Formula (Hosmer-Lemeshow statistic = 6.1 [P = .6], c index = 0.65). Predicted mortality: Formula (Hosmer-Lemeshow statistic = 2.99 [P = .9], c index = 0.77). The models proved to be stable at bootstrap analyses. No differences were noted between observed and predicted outcome rates within each unit, despite an apparent unadjusted better performance of unit B.

CONCLUSIONS: The use of risk-adjusted outcome models avoided misleading information derived from the unadjusted analysis of performance. Risk modeling is essential for the evaluation of the quality of care.

Abbreviations and Acronyms DLCO = carbon monoxide lung diffusion capacity; FEV1 = forced expiratory volume in 1 second; ppoDLCO = predicted postoperative carbon monoxide lung diffusion capacity; ppoFEV1 = predicted postoperative forced expiratory volume in 1 second; VO 2max = maximum oxygen consumption


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Discussion
J. Thorac. Cardiovasc. Surg. 2007 133: 95-96. [Extract] [Full Text] [PDF]



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