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Canadian Journal of Cardiology

A Clinical Risk Scoring Tool to Predict Readmission After Cardiac Surgery: An Ontario Administrative and Clinical Population Database Study

  • Derrick Y. Tam
    Affiliations
    Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada

    Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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  • Jiming Fang
    Affiliations
    Cardiovascular Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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  • Andrew Tran
    Affiliations
    Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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  • Author Footnotes
    † Died May 30, 2018.
    Jack V. Tu
    Footnotes
    † Died May 30, 2018.
    Affiliations
    Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada

    Cardiovascular Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada

    Division of Cardiology, Schulich Heart Centre, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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  • Dennis T. Ko
    Affiliations
    Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada

    Cardiovascular Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada

    Division of Cardiology, Schulich Heart Centre, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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  • Saswata Deb
    Affiliations
    Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada

    Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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  • Stephen E. Fremes
    Correspondence
    Corresponding author: Dr Stephen E. Fremes, Dr. Bernard S. Goldman Chair in Cardiovascular Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Room H4 05, Toronto, Ontario M4N 3M5, Canada. Tel.: +1-416-480-6073.
    Affiliations
    Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada

    Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
    Search for articles by this author
  • Author Footnotes
    † Died May 30, 2018.
Published:September 21, 2018DOI:https://doi.org/10.1016/j.cjca.2018.09.004

      Abstract

      Background

      Reducing readmission after cardiac surgery remains a quality improvement priority yet most readmission risk models examine only coronary artery bypass grafting (CABG). Our objective was to develop a predictive risk score for readmission after discharge in cardiac surgery.

      Methods

      All adults > 18 years undergoing isolated CABG, isolated/multiple valve, or combined CABG/valve surgery from 2008 to 2016 in Ontario were eligible. Risk factors for 30-day readmission after discharge were obtained through linkages of the CorHealth Ontario Cardiac Registry to other administrative health databases. Hazard ratios (HR) for risk factors were calculated using Cox proportional hazards regression with 95% confidence intervals (95% CI). We developed a clinical risk scoring tool weighted by beta coefficients from the final model. Discrimination and calibration was performed using c-statistics and comparing the predicted with observed probabilities across deciles of predicted risk.

      Results

      A total of 63,336 patients underwent CABG and/or valve surgery from 2008 to 2016. The 30-day readmission rate was 11.5% overall. Patients who were readmitted were older with higher incidences of cardiac comorbidities compared with nonreadmitted patients. Significant risk factors for readmission from the final model were prolonged length of stay (HR: 1.45; 95% CI: 1.57, 1.86; P < 0.0001), isolated valve surgery (HR: 1.35; 95% CI: 1.26, 1.44; P < 0.0001), in-hospital complications of sepsis (HR: 1.47; 95% CI: 1.05, 2.07; P = 0.024), and acute myocardial infarction (HR: 1.36; 95% CI: 1.09, 1.71; P = 0.007). A clinical risk scoring tool with 22 variables was derived that delineated patients into 1 of 5 risk quintiles. The c-statistic for the overall model was 0.63.

      Conclusions

      Readmission after cardiac surgery is common and moderately predictable in this contemporary cohort.

      Résumé

      Introduction

      La diminution des réadmissions après les chirurgies cardiaques au cœur demeure une priorité pour l’amélioration de la qualité. Toutefois, la plupart des modèles sur le risque de réadmission permettent seulement d’étudier le pontage aortocoronarien (PAC). Notre objectif était d’élaborer un score de prédiction du risque de réadmission après la sortie de l’hôpital suivant une chirurgie cardiaque.

      Méthodes

      Tous les adultes > 18 ans qui ont subi un PAC isolé, une chirurgie valvulaire multiple/isolée ou une chirurgie valvulaire combinée au PAC de 2008 à 2016 en Ontario étaient admissibles. Les facteurs de risque de réadmission dans les 30 jours après la sortie de l’hôpital étaient obtenus grâce aux liens entre le registre des soins cardiaques du CorHealth Ontario et d’autres banques de données administratives de santé. Les ratios d’incidence approchés (RIA) des facteurs de risque étaient calculés à l’aide de la régression de Cox (modèle à risques proportionnels) avec des intervalles de confiance à 95 % (IC à 95 %). Nous avons élaboré un outil clinique de cotation des risques pondéré en fonction des coefficients bêta d’un modèle final. La discrimination et la calibration étaient réalisées en utilisant les statistiques C et en comparant les probabilités prédites aux réponses observées dans les déciles de risque prédit.

      Résultats

      Un total de 63 336 patients ont subi un PAC et/ou une chirurgie valvulaire de 2008 à 2016. Le taux de réadmission dans les 30 jours était dans l’ensemble de 11,5 %. Les patients réadmis étaient plus âgés et montraient une incidence plus élevée de maladies cardiaques associées que les patients non réadmis. Les facteurs de risque importants de réadmission du modèle final étaient la durée de séjour prolongée (RIA : 1,45; IC à 95 % : 1,57, 1,86; P < 0,0001), la chirurgie valvulaire isolée (RIA : 1,35; IC à 95 % : 1,26, 1,44; P < 0,0001), les complications septiques à l’hôpital (RIA : 1,47; IC à 95 % : 1,05, 2,07; P = 0,024) et l’infarctus du myocarde aigu (RIA : 1,36; IC à 95 % : 1,09, 1,71; P = 0,007). Il ressort de l’outil clinique de cotation des risques à 22 variables de classifier les patients dans 1 des 5 quintiles de risque. Les statistiques C de l’ensemble du modèle étaient de 0,63.

      Conclusions

      Les réadmissions après les chirurgies cardiaques sont fréquentes et modérément prévisibles dans cette cohorte contemporaine.
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      References

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      Linked Article

      • A Clinical Risk Scoring Tool to Predict Readmission After Cardiac Surgery: A Methodological Issue
        Canadian Journal of CardiologyVol. 34Issue 12
        • Preview
          We read with interest the article published recently in the Canadian Journal of Cardiology entitled “A Clinical Risk Scoring Tool to Predict Readmission After Cardiac Surgery: An Ontario Administrative and Clinical Population Database Study.” The aim of the authors was to develop a predictive risk score for readmission after discharge in cardiac surgery.1
        • Full-Text
        • PDF
      • Limiting Readmissions Following Cardiac Surgery—A “Common Sense” Solution
        Canadian Journal of CardiologyVol. 34Issue 12
        • Preview
          In this issue of the Canadian Journal of Cardiology, Tam et al.1 report the results of their review of readmissions after cardiac surgery. In this study involving patients in Ontario from 2008 to 2016, the 30-day readmission rate after isolated coronary artery bypass graft (CABG) surgery, isolated and multiple valve surgery, or combined CABG-valve surgery was 11.5%. They identified 5 factors associated with an increased risk for readmission: prolonged length of stay, isolated valve surgery, sepsis, an acute myocardial infarction, and concomitant CABG + valve surgery.
        • Full-Text
        • PDF