Standard Risk Scores Research Articles

Sedentary time in late childhood and cardiometabolic risk in adolescence.

There is a paucity of prospective evidence examining the links between sedentary time (ST) and cardiometabolic outcomes in youth. We examined the associations between objectively assessed ST and moderate to vigorous physical activity (MVPA) in childhood with cardiometabolic risk in adolescence. The study included 4639 children (47% male) aged 11 to 12 years at baseline whose mothers were enrolled in ALSPAC (Avon Longitudinal Study of Parents and Children) during their pregnancy in the early 1990s. A total of 2963 children had valid blood samples at age 15 to 16 years. Associations with baseline ST and MVPA were examined for BMI, waist circumference, body fat mass, lean body mass, systolic and diastolic blood pressure, fasting triglycerides, total cholesterol, low-density lipoprotein and high-density lipoprotein (HDL) cholesterol, glucose, insulin, C-reactive protein, and a clustered standardized cardiometabolic risk score (CMscore). Baseline ST was not associated deleteriously with any cardiometabolic markers. MVPA was beneficially associated with the 3 adiposity indicators, lean body mass, systolic blood pressure, triglycerides, C-reactive protein, insulin, HDL cholesterol, and CMscore; once the models were adjusted for baseline levels of these markers, these associations remained for body fat mass (mean difference per 10 minutes of MVPA: -0.320 [95% confidence interval (CI): -0.438 to -0.203]; P < .001), HDL cholesterol (0.006 logged mmol/L [95% CI: 0.001 to 0.011]; P = .028), insulin (-0.024 logged IU/L [95% CI: -0.036 to -0.013]; P < .001), and CMscore (-0.014 [95% CI: -0.025 to -0.004]; P = .009). We found no evidence linking ST in late childhood with adverse cardiometabolic outcomes in adolescence. Baseline MVPA was beneficially linked to broad cardiometabolic health in adolescence.

Metabolic risk score and cancer risk: pooled analysis of seven cohorts.

Background: There are few data on the joint influence of metabolic factors on risk of separate cancers.Methods: We analysed data on body mass index, blood pressure and plasma levels of glucose, total cholesterol and triglycerides from seven European cohorts comprising 564 596 men and women with a mean age of 44 years. We weighted those factors equally into a standardized metabolic risk score [MRS, mean = 0, standard deviation (SD) = 1], with an individual’s level indicated as SDs from the sex- and cohort-specific means. Cancer hazard ratios were calculated by Cox regression with age as timescale and with relevant adjustments including smoking status. All statistical tests were two-sided.Results: During a mean follow-up of 12 years, 21 593 men and 14 348 women were diagnosed with cancer. MRS was linearly and positively associated with incident cancer in total and at sites (P < 0.05). In men, risk per SD MRS was increased by 43% (95% confidence interval: 27–61) for renal cell cancer, 43% (16–76) for liver cancer, 29% (20–38) for colon cancer, 27% (5–54) for oesophageal cancer, 20% (9–31) for rectal cancer, 19% (4–37) for leukaemias, 15% (1–30) for oral cancer and 10% (2–19) for bladder cancer. In women, risk increases per SD MRS were 56% (42–70) for endometrial cancer, 53% (29–81) for pancreatic cancer, 40% (16–67) for renal cell cancer, 27% (9–47) for cervical cancer and 17% (3–32) for rectal cancer.Conclusion: This largest study to date on the joint influence of metabolic factors on risk of separate cancers showed increased risks for several cancers, in particular renal cell and liver cancer in men and endometrial and pancreatic cancer in women.

Relationship between neutrophil-to-lymphocyte ratio and electrocardiographic ischemia grade in STEMI.

BackgroundNeutrophil-to-lymphocyte ratio (NLR) has been found to be a good predictor of future adverse cardiovascular outcomes in patients with ST-segment elevation myocardial infarction (STEMI). Changes in the QRS terminal portion have also been associated with adverse outcomes following STEMI.ObjectiveTo investigate the relationship between ECG ischemia grade and NLR in patients presenting with STEMI, in order to determine additional conventional risk factors for early risk stratification.MethodsPatients with STEMI were investigated. The grade of ischemia was analyzed from the ECG performed on admission. White blood cells and subtypes were measured as part of the automated complete blood count (CBC) analysis. Patients were classified into two groups according to the ischemia grade presented on the admission ECG, as grade 2 ischemia (G2I) and grade 3 ischemia (G3I).ResultsPatients with G3I had significantly lower mean left ventricular ejection fraction than those in G2I (44.58 ± 7.23 vs. 48.44 ± 7.61, p = 0.001). As expected, in-hospital mortality rate increased proportionally with the increase in ischemia grade (p = 0.036). There were significant differences in percentage of lymphocytes (p = 0.010) and percentage of neutrophils (p = 0.004), and therefore, NLR was significantly different between G2I and G3I patients (p < 0.001). Multivariate logistic regression analysis revealed that only NLR was the independent variable with a significant effect on ECG ischemia grade (odds ratio = 1.254, 95% confidence interval 1.120–1.403, p < 0.001).ConclusionWe found an association between G3I and elevated NLR in patients with STEMI. We believe that such an association might provide an additional prognostic value for risk stratification in patients with STEMI when combined with standardized risk scores.

The Importance of Non-Coronary Atherosclerosis

Coronary atherosclerosis leading to coronary heart disease (CHD) is now responsible for the largest burden of morbid and mortal disease in developed countries, and this is increasing so in developing countries around the world. It is now well recognized that computed tomography (CT) scans can quantitatively assess coronary artery calcium (CAC), a direct marker of coronary atherosclerosis, and CAC can substantially aid in risk prediction of both CHD and other cardiovascular disease (CVD) outcomes. Of course, this might be expected since CAC is actually a direct measure of coronary atherosclerosis, as opposed to a risk factor for CHD such as cigarette smoking or dyslipidemia. Atherosclerosis is a generalized disease and as such also affects other arterial beds throughout the body. This observation raises the question as to whether measurement of atherosclerosis outside of the coronary arteries is of value in risk prediction or disease prognosis for CHD or CVD. Extensive research has shown that the answer is yes; that is, selected measurements of non-coronary atherosclerosis provide incremental and independent information beyond both standardized risk scores employing risk factors, as well as beyond measurement of CAC. Thus, measurements of non-coronary atherosclerosis, both subclinical and clinical, can aid in the prediction of, and determining prognosis for, CHD as well as other CVD events. The epidemiologic and clinical value of non-coronary atherosclerosis will be illustrated with data from research into four selected non-coronary atherosclerosis measures. These measures are the ankle-brachial index (ABI), which is the ratio of the systolic blood pressure at the ankle to that in the arm; subclavian stenosis (SS), which is determined by a significant systolic blood pressure difference between the left and right arms; renal artery calcification (RAC) assessed by CT scan, and abdominal aortic calcification (AAC) assessed by CT scan. Data to be presented come from both US and international studies, and will address the significance of these four measure both in persons without known CVD and in persons with a clinical diagnosis of CVD.

Prognostic value of coronary computed tomography angiography during 5 years of follow-up in patients with suspected coronary artery disease

Coronary computed tomography angiography (CCTA) has a high accuracy for detection of obstructive coronary artery disease (CAD). Several studies also showed a good predictive value for subsequent cardiac events. However, the follow-up period of these studies was limited to ~2 years and long-term follow-up data on prognosis out to 5 years are very limited. This study is based on 1584 patients with suspected CAD undergoing CCTA between December 2003 and November 2006. Among other CCTA parameters, the total plaque score defined as number of abnormal segments (having either a non-obstructive plaque or a stenosis) and the most severe stenosis were recorded. The primary endpoint was a composite of death and non-fatal myocardial infarction. Revascularization procedures later than 90 days after the CT study were assessed as secondary endpoints. During a median follow-up of 5.6 years (IQR: 5.1-6.3 years) 61 patients suffered death or myocardial infarction and 52 underwent late revascularization. The severity of CAD and the total plaque score were the best predictors of death and non-fatal myocardial infarction, both significantly improving prediction over standard clinical risk scores (multivariate c-index 0.60 and 0.66, respectively, P = 0.002 and <0.0001, respectively). The annual event rate ranged from 0.24% for patients with no CAD to 1.1% for patients with obstructive CAD and 1.5% for patients with CAD and extensive plaque load (>5 segments). Both parameters also improved prediction of need for subsequent revascularization (c-index 0.72 and 0.63, respectively, P < 0.0001 and P = 0.0013, respectively). Data from CCTA predict both death and myocardial infarction as well as need for subsequent revascularizations out to 5 years. CCTA imaging may be a valuable tool in the assessment of long-term prognosis in patients with suspected CAD.

Combined use of a standardized risk score and d-dimer to rule out acute aortic dissection in the emergency department

Combined use of a standardized risk score and d-dimer to rule out acute aortic dissection in the emergency department

GW24-e3013 Risk Factors for Cardiovascular Events and estimated risk by risk prediction models at first year after kidney transplantation

ObjectivesTo determine the related risk factors for cardiovascular complication in first-year post-transplantation, and assess the ability of two standard cardiovascular risk scores developed for predicting cardiovascular events (CVE) in non-transplant...

Relations between pregnancy risk, infant growth and cognition

Visual information processing, heart rate attention and growth were assessed in 132 infants at 3, 6 and 9 months of age. The infants’ mothers were predominately white, well‐educated and married; and all infants were predominately breastfed at 3 months of age. There were three groups of infants based on changes in attention termination and encoding speed over the study period. Pregnancy risk was assessed using a standardized questionnaire and risk scores were developed based on maternal response when the infants were 3 months of age. Performance did not differ between groups based on scores associated with pre‐pregnant health (p = .07); pregnancy health problems (p=.21) or late term pregnancy complications (p=.96). The three groups were significantly different in weight for length z‐ scores at 3 months of age (p= .006). In conclusion, cogitative performance on these tasks did not differ based on maternal health just prior to or during pregnancy but did differ based on early growth in this low‐risk sample.

Study on the infectious risk model of AIDS among men who have sex with men in Guangzhou

To develop a human immune deficiency virus (HIV) infection risk appraisal model suitable for men who has sex with men (MSM) in Guangzhou, and to provide tools for follow-up the outcomes on health education and behavior intervention. A cros-sectional study was conducted in Guangzhou from 2008 to 2010. Based on the HIV surveillance data, the main risk factors of HIV infection among MSM were screened by means of logistic regression. Degree on relative risk was transformed into risk scores by adopting the statistics models. Individual risk scores, group risk scores and individual infection risk in comparison with usual MSM groups could then be calculated according to the rate of exposure on those risk factors appeared in data from the surveillance programs. Risk factors related to HIV infection among MSM and the quantitative assessment standard (risk scores and risk scores table of population groups) for those factors were set up by multiple logistic regression, including age, location of registered residence, monthly income, major location for finding their sexual partners, HIV testing in the past year, age when having the first sexual intercourse, rate of condom use in the past six months, symptoms related to sexually transmitted diseases (STDs) and syphilis in particular. The average risk score of population was 6.06, with risk scores for HIV positive and negative as 3.10 and 18.08 respectively (P < 0.001). The rates of HIV infection for different score groups were 0.9%, 2.0%, 7.0%, 14.4% and 33.3%, respectively. The sensitivity and specificity on the prediction of scores were 54.4% and 75.4% respectively, with the accuracy rate as 74.2%. HIV infection risk model could be used to quantify and classify the individual's infectious status and related factors among MSM more directly and effectively, so as to help the individuals to identify their high-risk behaviors as well as lifestyles. We felt that it could also serve as an important tool used for personalized HIV health education and behavior intervention programs.

New and evolving indications for transcatheter aortic valve therapy

Transcatheter aortic valve therapy (TAVI) is an important therapeutic strategy for patients with severe aortic stenosis who are considered ‘high-risk’ for conventional surgery. Traditionally, this has been defined as a logistic EUROSCORE of >20 (subsequently reduced to >15) or a Society of Thoracic Surgeons score of >10. Despite the increasing numbers of patients undergoing treatment (>50,000 to date, worldwide), it remains a relatively new technology. It has become increasingly clear that there are a number of patients who do not fulfill ‘conventional’ criteria for TAVI, who have undergone successful implantation. These include patients who do not meet these standard risk scores, patients with ‘nonstandard’ aortic valve anatomy and those who have undergone previous bioprosthetic surgical valve replacement. Furthermore, a number of patients are unsuitable for standard forms of vascular access and this has prompted the development of several novel access sites. This review summarizes the current use of the...

Added predictive ability of the information on job strain beyond the standard Framingham risk score

16.35 expected cases) published by the Committee on Medical Aspects of Radiation in the Environment (COMARE) differ from those used by Korblein. Of note, COMARE reported a combined SIR of 1.07 (95% CI 0.92–1.26) from a random-effects metaanalysis of 37 estimates from five countries. Korblein rightly points out that the 95% CI of the rate ratio estimate from the main analysis of childhood leukaemia in 0to 4-year olds just includes the point estimate (2.19) of the German KiKK study. However, there is in fact considerable disagreement between the two studies. Assuming that the true IRR for leukaemia in 0to 4-year olds comparing the 0to 5-km zone with the 415-km zone around NPPs is indeed 2.2 (as estimated in the KIKK study), the probability of observing an IRR of 1.2 (as in our study) is 0.03 (Figure 1) and the power of rejecting the null hypothesis of no association at the 5% significance level is 76%. Chirga argues that estimates of mean annual radiation doses originating from nuclear power plants (NPPs) are uncertain and that actual doses might fluctuate over time. He suggests that short spikes in emissions could increase the incidence of childhood cancer. Whereas we cannot exclude this possibility, we reiterate that our study provides little evidence that the rate of childhood cancer is higher in the proximity of NPPs. The few cases of cancer occurring in excess of the expected number of cases among children living in the 5-km zone around Swiss NPPs are well within statistical uncertainty, and so is the deficit of cases a few kilometres further afield. We agree with Chirga that our main exposure measure, Euclidean distance of place of residence to nearest NPP, was crude and can only serve as a proxy for true radiation exposure.

Article Commentary: Screening for cardiovascular disease using age alone: reflections on a paper Peer-Reviewed as both ‘radical’ and ‘unsurprising’

Article Commentary: Screening for cardiovascular disease using age alone: reflections on a paper Peer-Reviewed as both ‘radical’ and ‘unsurprising’

Surgical Candidacy and Selection Biases in Nonemergent Left Main Stenting: Implications for Observational Studies

This study sought to characterize reasons for surgical ineligibility in patients undergoing nonemergent unprotected left main (ULM) percutaneous coronary intervention (PCI) and to assess the potential for these reasons to confound comparative effectiveness studies of coronary revascularization. Although both PCI and coronary artery bypass graft surgery are treatments for ULM disease, some patients are not eligible for both treatments, which may result in treatment selection biases. In 101 consecutive patients undergoing nonemergent ULM PCI, mixed methods were used to determine the prevalence of treatment selection dictated by surgical ineligibility and to identify the reasons cited for avoiding coronary artery bypass graft surgery. We then determined whether these reasons were captured by the ACC-NCDR (American College of Cardiology-National Cardiovascular Data Registry) Cath-PCI dataset to assess the ability of this registry to account for biases in treatment selection. Finally, the association of surgical eligibility with long-term outcomes after ULM PCI was assessed. Treatment selection was dictated by surgical ineligibility in over half the ULM PCI cohort with the majority having reasons for ineligibility not captured by the ACC-NCDR. Surgical ineligibility was a significant predictor of mortality after adjustment for Society of Thoracic Surgeons (hazard ratio [HR]: 5.4, 95% confidence interval [CI]: 1.2 to 25), EuroSCORE (European System for Cardiac Operative Risk Evaluation) (HR: 5.9, 95% CI: 1.3 to 27), or NCDR mortality scores (HR: 6.2, 95% CI: 1.4 to 27). Surgical ineligibility dictating treatment selection is common in patients undergoing nonemergent ULM PCI, occurs on the basis of risk factors not captured by the ACC-NCDR, and is independently associated with worse long-term outcomes after adjusting for standard risk scores.

Relationship Between Trajectories of Trunk Fat Mass Development in Adolescence and Cardiometabolic Risk in Young Adulthood

To examine developmental trajectories of trunk fat mass (FM) growth of individuals categorized as either low or high for cardiometabolic risk at 26 years, a total of 55 males and 76 females from the Saskatchewan Pediatric Bone Mineral Accrual Study (1991-2007) were assessed from adolescence (11.5 ± 1.8 years) to young adulthood (26.2 ± 2.2 years) (median of 11 visits per individual) and had a measure of cardiometabolic risk in young adulthood. Participants were categorized as low or high for blood pressure and cardiometabolic risk as adults using a sex-specific median split of continuous standardized risk scores. Individual trunk FM trajectories of participants in each risk group were analyzed using multilevel random effects models. Males and females in the high blood pressure group had significantly steeper (accelerated) trajectories of trunk FM development (0.61 ± 0.14 and 0.52 ± 0.10log g, respectively) than those in the low blood pressure group for females in the high cardiometabolic risk group trajectory of trunk FM was significantly steeper (0.52 ± 0.10log g) than those females in the low cardiometabolic risk group. Dietary fat was positively related (0.01 ± 0.003g/1,000kcal) and physical activity negatively related (-0.16 ± 0.05 physical activity score) to trunk FM development in males. Young adults with high cardiometabolic risk, compared to low, have greater trunk FM as early as 8 years of age, which supports the need for early intervention.

Does adding information on job strain improve risk prediction for coronary heart disease beyond the standard Framingham risk score? The Whitehall II study

Background Guidelines for coronary heart disease (CHD) prevention recommend using multifactorial risk prediction algorithms, particularly the Framingham risk score. We sought to examine whether adding information on job strain to the Framingham model improves its predictive power in a low-risk working population.Methods Our analyses are based on data from the prospective Whitehall II cohort study, UK. Job strain among 5533 adults (mean age 48.9 years, 1666 women) was ascertained in Phases 1 (1985–88), 2 (1989–90) and 3 (1991–93). Variables comprising the Framingham score (blood lipids, blood pressure, diabetes and smoking) were measured at Phase 3. In men and women who were CHD free at baseline, CHD mortality and non-fatal myocardial infarction (MI) were ascertained from 5-yearly screenings and linkage to mortality and hospital records until Phase 7 (2002–04).Results A total of 160 coronary deaths and non-fatal MIs occurred during the mean follow-up period of 11.3 years. The addition of indicators of job strain to the Framingham score increased the C-statistics from 0.725 [95% confidence intervals (95% CIs): 0.575–0.854] to only 0.726 (0.577–0.855), corresponding to a net reclassification improvement of 0.7% (95% CIs: −4.2 to 5.6%). The findings were similar after inclusion of definite angina in the CHD outcome (352 total cases) and when using alternative operational definitions for job strain.Conclusion In this middle-aged low-risk working population, job strain was associated with an increased risk of CHD. However, when compared with the Framingham algorithm, adding job strain did not improve the model's predictive performance.

Value of the SYNTAX score in patients treated by primary percutaneous coronary intervention for acute ST-elevation myocardial infarction: The MI SYNTAXscore study

The aims of this study were to evaluate the SYNTAX score (SXscore) calculated at 2 stages during a primary percutaneous intervention (PPCI), that is, SXscore I (diagnostic) and SXscore II (postwiring), and assess its additional value to standard clinical risk scores in acute myocardial infarction. SXscores I and II were applied to 736 consecutive acute ST-elevation myocardial infarction patients referred for PPCI between November 2006 and February 2008. SXscore changed significantly before (I: 16, interquartile range 9.5-23) and after wiring (II: 11, interquartile range 6-19), P < .001. Kaplan-Meier methods were used to compare the primary end point major adverse coronary events (MACE; composite of repeat MI, target vessel revascularization [TVR], and mortality) and secondary end point mortality at 1.5 years in tertiles of SXscore I and SXscore II. Major adverse coronary event was highest in the higher SXscore I tertile (11% vs 15% vs 23%, log-rank <0.01), driven primarily by increased rate of mortality (9% vs 11% vs 17%, log-rank 0.02). Major adverse coronary event was also highest in SXscore II tertile, by a combination of increased mortality and also TVR (TVR rate 2% vs 3% vs 9%, log-rank <0.01). Predictive Cox regression models for mortality and MACE were significantly and similarly improved by the addition of either SXscore I or SXscore II (hazard ratio 1.63, 95% CI 1.18-2.26, P < .01 for MACE) with respective c indices of 0.61 and 0.63 for MACE and 0.60 and 0.61 for mortality. SXscore during PPCI is a useful tool that provides additional risk stratification to known risk factors of long-term mortality and MACE in patients with ST-elevation myocardial infarction.

Incidence of cardiovascular events after kidney transplantation and cardiovascular risk scores: study protocol

BackgroundCardiovascular disease (CVD) is the major cause of death after renal transplantation. Not only conventional CVD risk factors, but also transplant-specific risk factors can influence the development of CVD in kidney transplant recipients.The main objective of this study will be to determine the incidence of post-transplant CVD after renal transplantation and related factors. A secondary objective will be to examine the ability of standard cardiovascular risk scores (Framingham, Regicor, SCORE, and DORICA) to predict post-transplantation cardiovascular events in renal transplant recipients, and to develop a new score for predicting the risk of CVD after kidney transplantation.Methods/DesignObservational prospective cohort study of all kidney transplant recipients in the A Coruña Hospital (Spain) in the period 1981-2008 (2059 transplants corresponding to 1794 patients).The variables included will be: donor and recipient characteristics, chronic kidney disease-related risk factors, pre-transplant and post-transplant cardiovascular risk factors, routine biochemistry, and immunosuppressive, antihypertensive and lipid-lowering treatment. The events studied in the follow-up will be: patient and graft survival, acute rejection episodes and cardiovascular events (myocardial infarction, invasive coronary artery therapy, cerebral vascular events, new-onset angina, congestive heart failure, rhythm disturbances and peripheral vascular disease).Four cardiovascular risk scores were calculated at the time of transplantation: the Framingham score, the European Systematic Coronary Risk Evaluation (SCORE) equation, and the REGICOR (Registre Gironí del COR (Gerona Heart Registry)), and DORICA (Dyslipidemia, Obesity, and Cardiovascular Risk) functions.The cumulative incidence of cardiovascular events will be analyzed by competing risk survival methods. The clinical relevance of different variables will be calculated using the ARR (Absolute Risk Reduction), RRR (Relative Risk Reduction) and NNT (Number Needed to Treat).The ability of different cardiovascular risk scores to predict cardiovascular events will be analyzed by using the c index and the area under ROC curves. Based on the competing risks analysis, a nomogram to predict the probability of cardiovascular events after kidney transplantation will be developed.DiscussionThis study will make it possible to determine the post-transplant incidence of cardiovascular events in a large cohort of renal transplant recipients in Spain, to confirm the relationship between traditional and transplant-specific cardiovascular risk factors and CVD, and to develop a score to predict the risk of CVD in these patients.

Regular Physical Activity Moderates Cardiometabolic Risk in Alzheimer's Caregivers

Dementia caregivers have an increased risk of cardiovascular disease, and it is possible that metabolic disturbances contribute to this risk. Regular physical exercise reduces cardiometabolic risk, but caregivers may have less opportunity to engage in such activity. We hypothesized that regular physical activity would moderate cardiometabolic risk in dementia caregivers. One hundred and fifteen Alzheimer's caregivers and 54 noncaregiving controls were assessed for medical history and health habits. Physical activity was defined as the number of days per week participants performed light (score = 0-4), moderate (score = 0-4), or vigorous (score = 0-4) exercise (total score = 0-12). A cardiometabolic risk score was calculated by adding standardized z-scores of five metabolic syndrome components: body mass index, triglycerides, HDL cholesterol, systolic blood pressure, and glucose. Caregivers were less physically active than noncaregivers (mean ± SD = 5.1 ± 3.0 vs 6.3 ± 2.7, P = 0.008). A significant caregiver status × physical activity interaction was found for the standardized cardiometabolic risk score controlling for gender, age, education, smoking, alcohol consumption, health problems, cholesterol-lowering medication, negative affect, role overload, and fasting state (P = 0.035). Among participants with low levels of physical activity, caregivers had greater cardiometabolic risk score than noncaregivers (0.58 ± 0.31 vs -1.23 ± 0.54, P = 0.017); no group difference emerged in participants with high levels of physical activity (P = 0.81). Cardiometabolic risk was particularly high in caregivers reporting reduced levels of regular physical activity. Intervention studies aimed at increasing physical activity in caregivers seem warranted to examine whether that would possibly lower cardiometabolic risk to the level of noncaregivers.

All Trauma Surgeons Are Not Created Equal: Asymmetric Distribution of Malpractice Claims Risk

Trauma surgery is perceived to have high malpractice risk. Unsolicited patient complaints (UPCs) can predict increased malpractice risk. An ex ante analysis of UPCs was performed to determine the risk profile for trauma surgeons compared with nontrauma surgeons. UPCs from 14 health systems over 4 years were retrospectively studied. Surgeons were divided into nontrauma surgeons (NTS) and trauma surgeons (TS). Inclusion criteria for TS were practice at a Level I or geographically isolated Level II adult trauma center and either surgical critical care certification or American Association for the Surgery of Trauma, Eastern Association for the Surgery of Trauma, or Western Trauma Association membership. Standardized risk scores were generated using a weighted sum algorithm from UPC data. Mann-Whitney U test, Kolvogorov-Smirnov two-sample test for distribution, χ for linear trend, and relative risk analysis were performed. A total of 16,518 UPCs were filed against 4,244 surgeons, including 55 TS. 18% of TS and 57% of NTS had 0 UPCs. Mean risk score was higher for TS (29.2 ± 29.0 vs. 10.2 ± 19.5, p < 0.001), and more TS (20.0% vs. 3.15%) were at moderate (score 50-69) or at high risk (score >70) (7.27% vs. 2.57%; p < 0.001), reflecting a shifted risk distribution (p < 0.001) compared with NTS. TS have a relative risk of 6.17 (95% CI: 3.36-11.33) for score >50. TS are at increased risk of UPCs compared with NTS, but this risk is still largely borne by a minority of TS. UPCs seem to be a reasonable proxy for malpractice risk, so targeted interventions for TS associated with disproportionate shares of UPCs may reduce patient dissatisfaction and, perhaps, malpractice claims.

Estimating Lung Resection Risk: A Pilot Study of Trainee and Practicing Surgeons

Most surgeons believe that experience-based risk estimates for major lung resection are reliable. Elements that influence such estimates are poorly understood. Clinical vignettes were created for patients who underwent lung resection; 48 patients who had major complications were matched to 48 patients without complications. Ten senior surgical trainees and 9 practicing thoracic surgeons blinded to outcomes estimated the risk of complications using a seven-point scale (uninformed estimates). After review of a calculated risk score, risk was again estimated (informed estimates). Risk estimates did not differentiate between patient groups with and without complications (4.8 versus 4.9; p=0.94 for trainees; 4.5 versus 4.2; p=0.21 for practicing surgeons). The accuracy of predicting complications was only fair, but was better for practicing surgeons than for trainees (58% versus 51%; p=0.041). Risk estimates correlated moderately well with baseline pulmonary function and possibly with age, but not with performance status or extent of resection. Knowledge of a calculated risk score resulted in more frequent alterations of trainee risk scores, improved interobserver agreement in both groups, and aligned trainee and practicing surgeon estimates more closely. Surgeon estimates are not accurate in predicting lung resection complications using vignette-based, matched-pair methodology. Practicing surgeons and trainees base risk estimates on limited objective clinical data. Trainee estimates are more susceptible to modification by a standard risk score than are estimates of practicing surgeons. Prospective studies are necessary to further explore the etiology, accuracy, and utility of surgeon risk estimates.