Current quality reporting methods are not adequate for salvage cardiac operations

Objectives: Outcomes in cardiac surgery are benchmarked against national Society of Thoracic Surgeons (STS) data and include patients undergoing elective, urgent, emergent, and salvage operations. This practice relies on accurate risk adjustment to avoid risk-averse behavior. We hypothesize that the STS risk calculator does not adequately characterize the risk of salvage operations because of their heterogeneity and infrequent occurrence. Methods: Data on all cardiac surgery patients with an STS predicted risk score (2002-2017) were extracted from a regional database of 19 cardiac surgery centers. Patients were stratified according to operative status for univariate analysis. Observed-to-expected (O:E) ratios for mortality and composite morbidity/mortality were calculated and compared among elective, urgent, emergent, and salvage patients. Results: A total of 76,498 patients met inclusion criteria. The O:E mortality ratios for elective, urgent, and emergent cases were 0.96, 0.98, and 0.93, respectively (all P values > .05). However, mortality rate was significantly higher than expected for salvage patients (O:E ratio, 1.41; P = .04). Composite morbidity/mortality rate was lower than expected in elective (O:E ratio, 0.81; P = .0001) and urgent (O:E ratio, 0.93; P = .0001) cases but higher for emergent (O:E ratio, 1.13; P = .0006) and salvage (O:E ratio, 1.24; P = .01). O:E ratios for salvage mortality were highly variable among each of the 19 centers. Conclusions: The current STS risk models do not adequately predict outcomes for salvage cardiac surgery patients. On the basis of these results, we recommend more detailed reporting of salvage outcomes to avoid risk aversion in these potentially life-saving operations.