2. Motivation How well did we do? From our experience, how is
your operation risk?
3. Solution A: Past data B: Data analysis A + B = Clinical
database!
4. Database Example 4
5. Data Variables (Computer) Text Number Date Administrative
data
6. Data Variables (Epidemiology) X1, X2, ..., Xn -> Y
Predictor: Xi Outcome: Y
7. Data Variables (Statistics) Scale: Continuous. eg. body
weight Ordinal: Grading. eg. severity Nominal: Category. eg.
side
8. Data Variables (Surgery) Demographics Baseline Preop Op
Postop Outcome
9. Variable Definition Yes / No Timing Category
Measurement
10. Database Example 10
11. Paperwork Question Chart review Paper writing Data key-in
Analysis
12. Hospital Information System (HIS) Help from IT Variable
definitions SQL (Structured Query Language) SELECT [X1], [X2] FROM
[DB] WHERE [X3] ? [X4] Xi? DB?
13. Data Collection from HIS Diagnosis: ICD9 Operation: NHI
Procedures: NHI IABP, MV, HD,... Drugs: ?
14. Cheng-Hsin General Hospital ICD-9 Codes and Diagnoses
DM=250.* COPD=490-492.* or 496 PAOD=443.*-444.* CVA 434.91 or
434.11 or 997.02 Acute renal failure=584.* Chronic renal
failure=586.*-588.* Critical=785.51 or shock or IABP or ECMO
UA=413.* or angina LV dysfunction = 428.* or critical or CHF or
ICMP AMI=410.* or AMI or infarction PHT=416.* or pulmonary
hypertension IE=424.*
15. Cheng-Hsin General Hospital Natl Health Insurance Codes
Operations Postop Course CABG*1= 68023 CABG+LIMA= 68023X1/2
CABG*2=68024 CABG*3=68025 MVA/TVA=68015 AVR/MVR/TVR=68016 DVR=68017
AVR+MVR+TVR=68018 Redo=68003 Ventilator=57001 IABP=33079 HD=58001
CVVH=58014 Text data-mining
16. Database Steps Data collection Data validation Data
analysis
23. EuroScore Calculator http://www.euroscore.org Nashef SA et
al: European system for cardiac operative risk evaluation
(EuroSCORE). Eur J Cardiothorac Surg 1999 Jul;16(1):9-13
24. EuroScore Calculator, Additive http://www.euroscore.org
Nashef SA et al: European system for cardiac operative risk
evaluation (EuroSCORE). Eur J Cardiothorac Surg 1999
Jul;16(1):9-13
25. EuroScore Calculator, Logistic Nashef SA et al: European
system for cardiac operative risk evaluation (EuroSCORE). Eur J
Cardiothorac Surg 1999 Jul;16(1):9-13 Roques F et al: The logistic
EuroSCORE. Eur Heart J. 2003 May;24(9):882-3
26. EuroScore since 1995, 15 years old 36 Questions Patient
details Patient Heart Operation Outcome EuroScore 2010
27. Commercial Package Interface Data Entry Data Analysis
28. Customization Which variables Possible questions
29. People Factors Work-flow Work-load Motivations
30. Cheng-Hsin General Hospital ICD-9 Codes and Diagnoses
DM=250.* COPD=490-492.* or 496 PAOD=443.*-444.* CVA 434.91 or
434.11 or 997.02 Acute renal failure=584.* Chronic renal
failure=586.*-588.* Critical=785.51 or shock or IABP or ECMO
UA=413.* or angina LV dysfunction = 428.* or critical or CHF or
ICMP AMI=410.* or AMI or infarction PHT=416.* or pulmonary
hypertension IE=424.*
31. Cheng-Hsin General Hospital Natl Health Insurance Codes
Operations Postop Course CABG*1= 68023 CABG+LIMA= 68023X1/2
CABG*2=68024 CABG*3=68025 MVA/TVA=68015 AVR/MVR/TVR=68016 DVR=68017
AVR+MVR+TVR=68018 Redo=68003 Ventilator=57001 IABP=33079 HD=58001
CVVH=58014 Text data-mining
32. Cheng-Hsin General Hospital Definition of Isolated CABG 1.
CABG without any cardiac procedures such as valvular, aortic, Af
ablation, etc. 2. Excluding redo-CABG 3. Not excluding pacemaker
implantation or vascular procedures such as carotid endarterectomy
or PAOD bypass.
33. Cheng-Hsin General Hospital Results: Overall From 2006-01-1
to 2008-12-31 CABG-included operations N=1066 Combined cardiac
procedures: 22.0% Concomitant double-valve replacement, Bentalls
operation, heart transplantation, redo, etc. 22% 78% N=1,066
Combined CABG only
34. Cheng-Hsin General Hospital Results: Isolated CABG Included
Isolated CABG N=757 EuroScore (additive)= 3.1 (2.9~3.2) EuroScore
(logistic)= 3.3% (2.9%~3.6%) Early graft failure: N=3 (0.4%) Redo
CABG within the 3-year period On-pump arrest method: N=703 (92.9%)
Off-pump or on-pump beating method: N=54 (7.1%)
35. Cheng-Hsin General Hospital On-pump Arrest CABGPreop Data
First-time on-pump arrest CABG: N=703 EuroScore (additive)= 2.9
(2.7~3.1) EuroScore (logistic)= 3.0% (2.7%~3.2%) Female: 23.8%
(20.6%~26.9%) Age at operation: 63.910.3 years (63.1~64.6)
Concomitant carotid endarterectomy: 2.4% (1.3%~3.6%) Emergent: 8.7%
(6.6%~10.8%) LM-involved disease: 16.1% (13.4%~18.8%).
36. Cheng-Hsin General Hospital On-pump Arrest CABG--Op Data
LIMA use: 68.9% (65.4%~72.3%) No. of distal anastomosis: 3.71.0
(median=4, range=1~7) Op time : 8.01.5 hr (7.9~8.1) Pumping time:
135.044.2 min (131.7~138.3) Ischemic time: 83.230.0 min
(81.0~85.4)
37. Cheng-Hsin General Hospital On-pump Arrest CABG--Postop
Data New postop IABP: 2.7% (1.5%~3.9%) Lung complication
(atelectasis infection): 9.5% (7.3%~11.7%) Reopen for bleeding:
1.9% (0.9%~2.8%) New-onset CVA (symptomatic): 2.3% (1.2%~3.4%)
New-onset acute renal failure (hemodialysis): 3.7% (2.3%~5.1%)
38. Cheng-Hsin General Hospital On-pump Arrest CABG--Postop
Data Surgical mortality (within 30 days): 1.6% (0.6%~2.5%) Hospital
mortality (in the same in-hospital course): 1.9% (0.9%~2.8%)
Excluding surgical mortality and postop CVA (N=703) Off ventilator
within 24 hr: 67.1% (63.7%~70.6%) Median ICU stay: 5 days Median
hospital stay: 15 days.
39. Cheng-Hsin General Hospital On-pump Arrest CABG--All- Cause
Mortality Kaplan-Meier curve for freedom from all-cause mortality
1-year: 97.3% (95.7%~98.3%) 2-year: 96.8% (94.7%~98.1%) 3-year:
96.2% (93.6%~97.7%)
40. Cheng-Hsin General Hospital Variables for EuroScores Age
Unstable angina Gender LV dysfunction COPD Recent MI PAOD Pulm. HTN
CVA Redo Emergent op Renal insufficiency Combined proc. IE Op on
thoracic Ao Preop critical Post. Infarct VSR
42. Cheng-Hsin General Hospital Variables Included in the
Regression Analyses EuroScore (additive) EuroScore (logistic) LM
disease Carotid procedure Operation time Ischemia time Pumping time
No. of distal anastomoses LIMA use (elective cases)
43. Cheng-Hsin General Hospital Predictors for Surgical
Mortality (Within 30 Days) Predictor OR 95% CI P-value EuroScore
(additive) 1.3 1.1~1.6 0.003 EuroScore (logistic)% 1.1 1.04~1.2
0.002
44. Cheng-Hsin General Hospital Predictors for Hospital
Mortality (Same Hosp. Course) Predictor OR 95% CI P-value EuroScore
(additive) 1.6 1.3~1.9
