Advertisement

Pediatric Cardiology

, 30:1117 | Cite as

Stratification of Complexity Improves the Utility and Accuracy of Outcomes Analysis in a Multi-Institutional Congenital Heart Surgery Database: Application of the Risk Adjustment in Congenital Heart Surgery (RACHS-1) and Aristotle Systems in the Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database

  • Jeffrey P. Jacobs
  • Marshall L. Jacobs
  • Francois G. Lacour-Gayet
  • Kathy J. Jenkins
  • Kimberlee Gauvreau
  • Emile Bacha
  • Bohdan Maruszewski
  • David R. Clarke
  • Christo I. Tchervenkov
  • J. William Gaynor
  • Thomas L. Spray
  • Giovanni Stellin
  • Sean M. O’Brien
  • Martin J. Elliott
  • Constantine Mavroudis
Original Article

Abstract

Quality-of-care evaluation must take into account variations in “case mix.” This study reviewed the application of two case-mix complexity-adjustment tools in the Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database: the Aristotle Basic Complexity (ABC) score and the Risk Adjustment in Congenital Heart Surgery (RACHS-1) method. The 2006 STS Congenital Heart Surgery Database Report, the first STS report to incorporate both methods, included 45,635 operations from 47 centers. Each operation was assigned an ABC score in a range from 1.5 (lowest complexity) to 15 (highest complexity), an ABC level in a range from 1 (lowest complexity) to 4 (highest complexity), and a RACHS-1 category in a range from 1 (lowest risk) to 6 (highest risk). The overall discharge mortality was 3.9% (1,222/31,719 eligible cardiac index operations). Of the eligible cardiac index operations, 85.8% (27,202/31,719) were eligible for analysis by the RACHS-1 method, and 94.0% (29,813/31,719) were eligible for analysis by the ABC approach. With both RACHS-1 and ABC, as complexity increases, discharge mortality also increases. The ABC approach allows classification of more operations, whereas the RACHS-1 discriminates better at the higher end of complexity. Complexity stratification is a useful method for analyzing the impact of case mix on pediatric cardiac surgical outcomes. Both the RACHS-1 and ABC methods facilitate complexity stratification in the STS database.

Keywords

Congenital heart disease Database Patient safety Pediatric heart surgery Registry Surgical outcomes 

Notes

Acknowledgments

We thank the Children’s Heart Foundation (http://www.childrensheartfoundation.org/) for financial support of this research.

References

  1. 1.
    Al-Radi OO, Harrell FE Jr, Caldarone CA, McCrindle BW, Jacobs JP, Williams MG, Van Arsdell GS, Williams WG (2007) Case complexity scores in congenital heart surgery: a comparative study of the Aristotle Basic Complexity score and the Risk Adjustment in Congenital Heart Surgery (RACHS-1) system. J Thorac Cardiovasc Surg 133:865–875Google Scholar
  2. 2.
    Boethig D, Jenkins KJ, Hecker H, Thies WR, Breymann T (2004) The RACHS-1 risk categories reflect mortality and length of hospital stay in a large German pediatric cardiac surgery population. Eur J Cardiothorac Surg 26:12–17CrossRefPubMedGoogle Scholar
  3. 3.
    Clarke DR, Lacour-Gayet F, Jacobs JP, Jacobs ML, Maruszewski B, Pizarro C, Edwards FH, Mavroudis C (2008) The assessment of complexity in congenital cardiac surgery based on objective data. Cardiol Young 18(Suppl 2):169–176CrossRefPubMedGoogle Scholar
  4. 4.
    Jacobs JP, Mavroudis C, Jacobs ML et al (2004) Lessons learned from the data analysis of the second harvest (1998–2001) of the Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database. Eur J Cardiothorac Surg 26:18–37CrossRefPubMedGoogle Scholar
  5. 5.
    Jacobs JP, Lacour-Gayet FG, Jacobs ML et al (2005) Initial application in the STS congenital database of complexity adjustment to evaluate surgical case mix and results. Ann Thorac Surg 79:1635–1649 (discussion 1635–1649)CrossRefPubMedGoogle Scholar
  6. 6.
    Jacobs JP, Jacobs ML, Maruszewski B et al (2005) Current status of the European Association for Cardio-Thoracic Surgery and the Society of Thoracic Surgeons Congenital Heart Surgery Database. Ann Thorac Surg 80:2278–2283 (discussion 2283–2284)CrossRefPubMedGoogle Scholar
  7. 7.
    Jacobs JP, Mavroudis C, Jacobs ML, Maruszewski B, Tchervenkov CI, Lacour-Gayet FG, Clarke DR, Yeh T, Walters HLIII, Kurosawa H, Stellin G, Ebels T, Elliott MJ (2006) What is operative mortality? Defining death in a surgical registry database: a report from the STS Congenital Database Taskforce and the Joint EACTS-STS Congenital Database Committee. Ann Thorac Surg 81:1937–1941CrossRefPubMedGoogle Scholar
  8. 8.
    Jacobs JP, Jacobs ML, Mavroudis C, Maruszewski B, Tchervenkov CI, Lacour-Gayet FG, Clarke DR, Yeh T, Walters HLIII, Kurosawa H, Stellin G, Ebels T, Elliott MJ, Vener DF, Barach P, Benavidez OJ, Bacha EA (2007) What is operative morbidity? Defining complications in a surgical registry database: a report from the STS Congenital Database Task Force and the Joint EACTS-STS Congenital Database Committee. Ann Thorac Surg 84:1416–1421CrossRefGoogle Scholar
  9. 9.
    Jacobs JP, Mavroudis C, Jacobs ML, Maruszewski B, Tchervenkov CI, Lacour-Gayet FG, Clarke DR, Gaynor JW, Spray TL, Kurosawa H, Stellin G, Ebels T, Bacha EA, Walters HL, Elliott MJ (2007) Nomenclature and databases: the past, the present, and the future: a primer for the congenital heart surgeon. Pediatr Cardiol 28:105–115 (Epub 4 May 2007)CrossRefPubMedGoogle Scholar
  10. 10.
    Jacobs JP, Jacobs ML, Mavroudis C, Backer CL, Lacour-Gayet FG, Tchervenkov CI, Franklin RCG, Béland MJ, Jenkins KJ, Walters HIII, Bacha EA, Maruszewski B, Kurosawa H, Clarke DR, Gaynor JW, Spray TL, Stellin G, Ebels T, Krogmann ON, Aiello VD, Colan SD, Weinberg P, Giroud JM, Everett A, Wernovsky G, Martin J. Elliott MJ, Edwards FH (2008) Nomenclature and databases for the surgical treatment of congenital cardiac disease: an updated primer and an analysis of opportunities for improvement. Cardiol Young 18(Suppl 2):38–62CrossRefPubMedGoogle Scholar
  11. 11.
    Jacobs JP, Benavidez OJ, Bacha EA, Walters HLIII, Jacobs ML (2008) The nomenclature of safety and quality of care for patients with congenital cardiac disease: a report of the Society of Thoracic Surgeons Congenital Database Taskforce Subcommittee on Patient Safety. Cardiol Young 18(Suppl. 2):81–91CrossRefPubMedGoogle Scholar
  12. 12.
    Jacobs JP, Jacobs ML, Mavroudis C, Lacour-Gayet FG (2002) Executive Summary: The Society of Thoracic Surgeons Congenital Heart Surgery Database—Second Harvest (1998–2001) Beta Site Test. The Society of Thoracic Surgeons (STS) and Duke Clinical Research Institute (DCRI), Duke University Medical Center, Durham, NC, USA, Fall 2002 HarvestGoogle Scholar
  13. 13.
    Jacobs JP, Jacobs ML, Mavroudis C, Lacour-Gayet FG (2003) Executive Summary: The Society of Thoracic Surgeons Congenital Heart Surgery Database—Third Harvest (1998–2002). The Society of Thoracic Surgeons (STS) and Duke Clinical Research Institute (DCRI), Duke University Medical Center, Durham, NC, USA, Spring 2003 HarvestGoogle Scholar
  14. 14.
    Jacobs JP, Jacobs ML, Mavroudis C, Lacour-Gayet FG (2004) Executive Summary: The Society of Thoracic Surgeons Congenital Heart Surgery Database—Fourth Harvest (2002–2003). The Society of Thoracic Surgeons (STS) and Duke Clinical Research Institute (DCRI), Duke University Medical Center, Durham, NC, USA, Spring 2004 HarvestGoogle Scholar
  15. 15.
    Jacobs JP, Jacobs ML, Mavroudis C, Lacour-Gayet FG (2005) Executive Summary: The Society of Thoracic Surgeons Congenital Heart Surgery Database—Fifth Harvest (2002–2004). The Society of Thoracic Surgeons (STS) and Duke Clinical Research Institute (DCRI), Duke University Medical Center, Durham, NC, USA, Spring 2005 HarvestGoogle Scholar
  16. 16.
    Jacobs JP, Jacobs ML, Mavroudis C, Lacour-Gayet FG, Tchervenkov CI (2006) Executive Summary: The Society of Thoracic Surgeons Congenital Heart Surgery Database—Sixth Harvest (2002–2005). The Society of Thoracic Surgeons (STS) and Duke Clinical Research Institute (DCRI), Duke University Medical Center, Durham, NC, USA, Spring 2006 HarvestGoogle Scholar
  17. 17.
    Jacobs JP, Jacobs ML, Mavroudis C, Lacour-Gayet FG, Tchervenkov CI (2007) Executive Summary: The Society of Thoracic Surgeons Congenital Heart Surgery Database—Seventh Harvest (2003–2006). The Society of Thoracic Surgeons (STS) and Duke Clinical Research Institute (DCRI), Duke University Medical Center, Durham, NC, USA, Spring 2007 HarvestGoogle Scholar
  18. 18.
    Jacobs JP, Jacobs ML, Mavroudis C, Lacour-Gayet FG, Tchervenkov CI (2008) Executive Summary: The Society of Thoracic Surgeons Congenital Heart Surgery Database—Eighth Harvest (1 January 2004–31 December 2007). The Society of Thoracic Surgeons (STS) and Duke Clinical Research Institute (DCRI), Duke University Medical Center, Durham, NC, USA, Spring 2008 HarvestGoogle Scholar
  19. 19.
    Jacobs JP, Jacobs ML, Mavroudis C, Lacour-Gayet FG, Tchervenkov CI (2009) Executive Summary: The Society of Thoracic Surgeons Congenital Heart Surgery Database—Tenth Harvest (1 January 2005–31 December 2008). The Society of Thoracic Surgeons (STS) and Duke Clinical Research Institute (DCRI), Duke University Medical Center, Durham, NC, USA, Spring 2009 HarvestGoogle Scholar
  20. 20.
    Jacobs ML, Mavroudis C, Jacobs JP, Tchervenkov CI, Pelletier GJ (2006) Report of the 2005 STS Congenital Heart Surgery Practice and Manpower Survey: a report from The STS Workforce on Congenital Heart Surgery. Ann Thorac Surg 82:1152–1158, 1159e1–1159e5, discussion 1158–1159Google Scholar
  21. 21.
    Jacobs ML, Jacobs JP, Jenkins KJ, Gauvreau K, Clarke DR, Lacour-Gayet FL (2008) Stratification of complexity: the risk adjustment for congenital heart surgery-1 method and The Aristotle Complexity Score—past, present, and future. Cardiol Young 18(Suppl 2):163–168CrossRefPubMedGoogle Scholar
  22. 22.
    Jenkins KJ, Gauvreau K, Newburger JW, Spray TL, Moller JH, Iezzoni LI (2002) Consensus-based method for risk adjustment for surgery for congenital heart disease. J Thorac Cardiovasc Surg 123:110–118CrossRefPubMedGoogle Scholar
  23. 23.
    Jenkins KJ (2004) Risk adjustment for congenital heart surgery: the RACHS-1 method. Semin Thorac Cardiovasc Surg Pediatr Cardiac Surg Annu 7:180–184CrossRefGoogle Scholar
  24. 24.
    Kang N, Cole T, Tsang V et al (2004) Risk stratification in paediatric open heart surgery. Eur J Cardiothorac Surg 26:3–11CrossRefPubMedGoogle Scholar
  25. 25.
    Lacour-Gayet F (2002) Risk stratification theme for congenital heart surgery. Semin Thorac Cardiovasc Surg Pediatr Cardiac Surg Annu 5:148–152CrossRefGoogle Scholar
  26. 26.
    Lacour-Gayet FG, Clarke D, Jacobs JP, Comas J, Daebritz S, Daenen W, Gaynor JW, Hamilton L, Jacobs ML, Maruszewski B, Pozzi M, Spray T, Stellin G, Tchervenkov CI, Mavroudis C, the Aristotle Committee (2004) The Aristotle Score: a complexity-adjusted method to evaluate surgical results. Eur J Cardiothorac Surg 25:911–924CrossRefPubMedGoogle Scholar
  27. 27.
    Lacour-Gayet FG, Clarke D, Jacobs JP, Gaynor JW, Hamilton L, Jacobs ML, Maruszewski B, Pozzi M, Spray T, Tchervenkov CI, Mavroudis C, the Aristotle Committee (2004) The Aristotle Score for Congenital Heart Surgery. Semin Thorac Cardiovasc Surg Pediatr Cardiac Surg Annu 7:185–191CrossRefGoogle Scholar
  28. 28.
    Mavroudis C, Jacobs JP (eds) (2000) International Congenital Heart Surgery Nomenclature and Database Project. Ann Thorac Surg 69(Supp 1):1–372Google Scholar
  29. 29.
    O’Brien SM, Jacobs JP, Clarke DR, Maruszewski B, Jacobs ML, Walters HLIII, Tchervenkov CI, Welke KF, Tobota Z, Stellin G, Mavroudis C, Hamilton JR, Gaynor JW, Pozzi M, Lacour-Gayet FG (2007) Accuracy of the Aristotle Basic Complexity Score for classifying the mortality and morbidity potential of congenital heart surgery operations. Ann Thorac Surg 84:2027–2037CrossRefPubMedGoogle Scholar
  30. 30.
    O’Brien SM, Clarke DR, Jacobs JP, Jacobs ML, Lacour-Gayet FG, Pizarro C, Welke KF, Maruszewski B, Tobota Z, Miller WJ, Hamilton L, Peterson ED, Mavroudis C, Edwards FH An empirically based tool for analyzing outcomes of congenital heart surgery. J Thorac Cardiovasc Surg accepted for publication (in press)Google Scholar
  31. 31.
    Shroyer AL, Coombs LP, Peterson ED et al (2003) The Society of Thoracic Surgeons: 30-day operative mortality and morbidity risk models. Ann Thorac Surg 75:1856–1864 (discussion 1864–1865)CrossRefPubMedGoogle Scholar
  32. 32.
    Welke KF, Jacobs JP, Jenkins KJ (2005) Evaluation of quality of care for congenital heart disease. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 8:157–167CrossRefGoogle Scholar
  33. 33.
    Welke KF, Shen I, Ungerleider RM (2006) Current assessment of mortality rates in congenital cardiac surgery. Ann Thorac Surg 82:164–171CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  • Jeffrey P. Jacobs
    • 1
  • Marshall L. Jacobs
    • 2
  • Francois G. Lacour-Gayet
    • 3
  • Kathy J. Jenkins
    • 4
  • Kimberlee Gauvreau
    • 4
  • Emile Bacha
    • 4
  • Bohdan Maruszewski
    • 5
  • David R. Clarke
    • 6
  • Christo I. Tchervenkov
    • 7
  • J. William Gaynor
    • 8
  • Thomas L. Spray
    • 8
  • Giovanni Stellin
    • 9
  • Sean M. O’Brien
    • 10
  • Martin J. Elliott
    • 11
  • Constantine Mavroudis
    • 2
  1. 1.The Congenital Heart Institute of Florida (CHIF), Division of Thoracic and Cardiovascular SurgeryAll Children’s Hospital and Children’s Hospital of Tampa, University of South Florida College of Medicine, Cardiac Surgical Associates of Florida (CSAoF)Saint PetersburgUSA
  2. 2.The Cleveland Clinic Children’s Hospital, Center for Pediatric and Adult Congenital Heart DiseasesClevelandUSA
  3. 3.Children’s Hospital at MontefioreNew YorkUSA
  4. 4.Boston Children’s HospitalHarvard UniversityBostonUSA
  5. 5.Children’s Memorial Health InstituteWarsawPoland
  6. 6.The Children’s Hospital, University of Colorado Denver School of MedicineAuroraUSA
  7. 7.Montreal Children’s HospitalMcGill UniversityMontrealCanada
  8. 8.The Cardiac Center at The Children’s Hospital of PhiladelphiaPhiladelphiaUSA
  9. 9.University of Padova Medical SchoolPadovaItaly
  10. 10.Duke University Medical CenterDurhamUSA
  11. 11.Great Ormond Street Hospital for ChildrenLondonUK

Personalised recommendations