title: Monitoring risk-adjusted outcomes in congenital heart surgery: does the appropriateness of a risk model change with time?
abstract: BACKGROUND
  Risk adjustment of outcomes in pediatric congenital heart surgery is challenging due to the great diversity in diagnoses and procedures. We have previously shown that variable life-adjusted display (VLAD) charts provide an effective graphic display of risk-adjusted outcomes in this specialty. A question arises as to whether the risk model used remains appropriate over time.
  
  
  METHODS
  We used a recently developed graphic technique to evaluate the performance of an existing risk model among those patients at a single center during 2000 to 2003 originally used in model development. We then compared the distribution of predicted risk among these patients with that among patients in 2004 to 2006. Finally, we constructed a VLAD chart of risk-adjusted outcomes for the latter period.
  
  
  RESULTS
  Among 1083 patients between April 2000 and March 2003, the risk model performed well at predicted risks above 3%, underestimated mortality at 2% to 3% predicted risk, and overestimated mortality below 2% predicted risk. There was little difference in the distribution of predicted risk among these patients and among 903 patients between June 2004 and October 2006. Outcomes for the more recent period were appreciably better than those expected according to the risk model. This finding cannot be explained by any apparent bias in the risk model combined with changes in case-mix.
  
  
  CONCLUSIONS
  Risk models can, and hopefully do, become out of date. There is scope for complacency in the risk-adjusted audit if the risk model used is not regularly recalibrated to reflect changing standards and expectations.
authors.affiliation: Cardiac Unit, Great Ormond Street Hospital, London, United Kingdom. tsangv@gosh.nhs.uk
authors.forename: Victor T
authors.initials: VT
authors.lastname: Tsang
authors.forename: Katherine L
authors.initials: KL
authors.lastname: Brown
authors.forename: Mats Johanssen
authors.initials: MJ
authors.lastname: Synnergren
authors.forename: Nicholas
authors.initials: N
authors.lastname: Kang
authors.forename: Marc R
authors.initials: MR
authors.lastname: de Leval
authors.forename: Steve
authors.initials: S
authors.lastname: Gallivan
authors.forename: Martin
authors.initials: M
authors.lastname: Utley
mesh_terms: D006348:Cardiac Surgical Procedures / Q000379:methods* / Q000401:mortality; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D006330:Heart Defects, Congenital / Q000175:diagnosis / Q000401:mortality* / Q000601:surgery*; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008485:Medical Audit; D008991:Monitoring, Physiologic; D009520:New Zealand; D011183:Postoperative Complications / Q000401:mortality; D012189:Retrospective Studies; D020379:Risk Adjustment; D016019:Survival Analysis; D013997:Time Factors; D017749:Total Quality Management; D016896:Treatment Outcome