Author + information
- Received November 12, 2018
- Revision received June 25, 2019
- Accepted July 2, 2019
- Published online October 7, 2019.
- Mark Tacey, MBiostat, BSca,b,c,
- Diem T. Dinh, PhD, BAppSc (Hons)a,∗ (, )@Monash_SPHPM,
- Nick Andrianopoulos, MBBS, MBiostata,
- Angela L. Brennan, RN, BSca,
- Dion Stub, MBBS, PhDa,d,
- Danny Liew, MBBS, PhDa,
- Christopher M. Reid, PhD, MSc, DipEda,e,
- Stephen J. Duffy, MBBS, PhDa,d and
- Jeffrey Lefkovits, MBBSa,f
- aCentre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- bNorthern Health, Epping, Australia
- cDepartment of Medicine, University of Melbourne, Parkville, Australia
- dDepartment of Cardiology, Alfred Health, Melbourne, Australia
- eDepartment of NHMRC, Centre of Research Excellence & Cardiovascular Outcomes Improvement & Health Research, Data Analytics Hub, School of Public Health, Curtin University, Perth, Australia
- fDepartment of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- ↵∗Address for correspondence:
Dr. Diem T. Dinh, Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Victoria 3004, Australia.
Objectives This study sought to determine the most risk-adjustment model for 30-day all-cause mortality in order to report risk-adjusted outcomes. The study also explored whether the exclusion of extreme high-risk conditions of cardiogenic shock, intubated out-of-hospital cardiac arrest (OHCA), or the need for mechanical ventricular support affected the model’s predictive accuracy.
Background Robust risk-adjustment models are a critical component of clinical quality registries, allowing outcomes to be reported in a fair and meaningful way. The Victorian Cardiac Outcomes Registry encompasses all 30 hospitals in the state of Victoria, Australia, that undertake percutaneous coronary intervention.
Methods Data were collected on 27,544 consecutive percutaneous coronary intervention procedures from 2014 to 2016. Twenty-eight patient risk factors and procedural variables were considered in the modeling process. The multivariable logistic regression analysis considered derivation and validation datasets, along with a temporal validation period.
Results The model included risk-adjustment for cardiogenic shock, intubated OHCA, estimated glomerular filtration rate, left ventricular ejection fraction, angina type, mechanical ventricular support, ≥80 years of age, lesion complexity, percutaneous access site, and peripheral vascular disease. The C-statistic for the derivation dataset was 0.921 (95% confidence interval: 0.905 to 0.936), with C-statistics of 0.931 and 0.934 for 2 validation datasets reflecting the 2014 to 2016 and 2017 periods. Subgroup modeling excluding cardiogenic shock and intubated OHCA provided similar risk-adjusted outcomes (p = 0.32).
Conclusions Our study has developed a highly predictive risk-adjustment model for 30-day mortality that included high-risk presentations. Therefore, we do not need to exclude high-risk cases in our model when determining risk-adjusted outcomes.
The Victorian Department of Health and Human Services and Victorian Cardiac Clinical Network have provided startup and ongoing funding for Victorian Cardiac Outcomes Registry. Startup funding was also provided by Medibank Private before its privatization. Prof. Duffy’s work is supported by a National Health and Medical Research Council (NHMRC) grant (reference no. 1111170). Prof. Reid is supported by a NHMRC Senior Research Fellowship (reference no. 1045862). A/Prof. Stub is supported by a joint NHMRC/National Heart Foundation early career fellowship (reference no. 1090302/100516) and a Viertel Foundation Clinical Investigator award. Prof. Duffy has served as a proctor for Medtronic. Prof. Liew has received consulting honoraria and research grant support from Abbvie, Astellas, AstraZeneca, Bristol-Myers Squibb, CSL-Behring, Novartis, Pfizer, Sanofi, and Shire. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received November 12, 2018.
- Revision received June 25, 2019.
- Accepted July 2, 2019.
- 2019 American College of Cardiology Foundation
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