title: Recursive and non-linear logistic regression: moving on from the original EuroSCORE and EuroSCORE II methodologies.
abstract: OBJECTIVE
  EuroSCORE II, despite improving on the original EuroSCORE system, has not solved all the calibration and predictability issues. Recursive, non-linear and mixed recursive and non-linear regression analysis were assessed with regard to sensitivity, specificity and predictability of the original EuroSCORE and EuroSCORE II systems.
  
  
  METHODS
  The original logistic EuroSCORE, EuroSCORE II and recursive, non-linear and mixed recursive and non-linear regression analyses of these risk models were assessed via receiver operator characteristic curves (ROC) and Hosmer-Lemeshow statistic analysis with regard to the accuracy of predicting in-hospital mortality. Analysis was performed for isolated coronary artery bypass grafts (CABGs) (n = 2913), aortic valve replacement (AVR) (n = 814), mitral valve surgery (n = 340), combined AVR and CABG (n = 517), aortic (n = 350), miscellaneous cases (n = 642), and combinations of the above cases (n = 5576).
  
  
  RESULTS
  The original EuroSCORE had an ROC below 0.7 for isolated AVR and combined AVR and CABG. None of the methods described increased the ROC above 0.7. The EuroSCORE II risk model had an ROC below 0.7 for isolated AVR only. Recursive regression, non-linear regression, and mixed recursive and non-linear regression all increased the ROC above 0.7 for isolated AVR. The original EuroSCORE had a Hosmer-Lemeshow statistic that was above 0.05 for all patients and the subgroups analysed. All of the techniques markedly increased the Hosmer-Lemeshow statistic. The EuroSCORE II risk model had a Hosmer-Lemeshow statistic that was significant for all patients (P < 0.0001), and very close to significant for isolated CABG (P = 0.05) and for isolated AVR (P = 0.06). Non-linear regression failed to improve on the original Hosmer-Lemeshow statistic. The mixed recursive and non-linear regression using the EuroSCORE II risk model was the only model that produced an ROC of 0.7 or above for all patients and procedures and had a Hosmer-Lemeshow statistic that was highly non-significant.
  
  
  CONCLUSIONS
  The original EuroSCORE and the EuroSCORE II risk models do not have adequate ROC and Hosmer-Lemeshow statistics to allow accurate assessment of cardiac surgeons in the modern era. A mixed recursive and non-linear regression model utilizing the EuroSCORE II risk model improves both the ROC and Hosmer-Lemeshow statistics.
authors.affiliation: Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK mpoullis@hotmail.com.
authors.forename: Michael
authors.initials: M
authors.lastname: Poullis
mesh_terms: D000368:Aged; D006348:Cardiac Surgical Procedures / Q000379:methods / Q000706:statistics & numerical data*; D005260:Female; D006305:Health Status Indicators; D006331:Heart Diseases / Q000401:mortality / Q000601:surgery*; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000401:mortality*; D012372:ROC Curve; D015203:Reproducibility of Results; D018570:Risk Assessment / Q000379:methods*; D006113:United Kingdom / Q000453:epidemiology
keywords: EuroSCORE; Risk modelling