Sergeant P, Blackstone E, Meyns B
Cardiac Surgery Department, Gasthuisberg University Hospital, Leuven, Belgium.
Eur J Cardiothorac Surg. 1997 Jan;11(1):2-9. doi: 10.1016/s1010-7940(96)01032-9.
To test prospectively the unsubstantiated claim that patient-specific predictions of time-related outcome after coronary artery bypass grafting (CABG) from multivariable parametric equations are reliable for medical decision making and for intra- and interdepartmental quality control in surgical training and practice.
3720 survival curves were generated prospectively for all primary, isolated CABG patients operated upon at the Katholieke Universiteit (KU) Leuven between July, 1987 and January, 1992 using the published AHA/ACC guidelines multivariable equation derived from prior KU Leuven experience. The average of these curves (risk-adjusted predicted survival) was compared to the Kaplan-Meier (actual) estimates, overall and for patient subsets. Variables associated with systematic deviation of actual from predicted number of deaths were sought by multivariable residual risk analysis.
Actual overall survival was less good than predicted (P = 0.03) and the excess risk was distributed uniformly across time. The excess risk was not attributable to substantial changes in prevalence of known risk factors. It was attributable largely to a small subset of patients (n = 292) with low-prevalence, but important risk factors not accounted for by the equation (P = 0.7, for difference in survival among the remaining 3428 patients).
Within the confines of a single institution, patient-specific predictions of outcome after CABG can be made reliably in most patients using multivariable equations developed from a heterogeneous experience, despite changes in prevalence of risk factors. New subsets of high-risk patients, failure or inability to account for important rare risk factors or for institutional changes, may lead to systematic errors of prediction. Under these limitations it is an excellent tool for medical decision making and audit of surgical training and practice.
前瞻性地检验一个未经证实的说法，即通过多变量参数方程对冠状动脉搭桥术（CABG）后与时间相关的结果进行患者特异性预测，对于医疗决策以及手术培训和实践中的部门内和部门间质量控制是可靠的。
使用从鲁汶大学（KU）先前经验得出的已发表的美国心脏协会/美国心脏病学会（AHA/ACC）指南多变量方程，前瞻性地为1987年7月至1992年1月在鲁汶大学（KU）进行手术的所有原发性、孤立性CABG患者生成了3720条生存曲线。将这些曲线的平均值（风险调整后的预测生存率）与Kaplan-Meier（实际）估计值进行比较，包括总体比较和患者亚组比较。通过多变量残余风险分析寻找与实际死亡人数与预测死亡人数的系统偏差相关的变量。
实际总体生存率低于预测值（P = 0.03），且额外风险在整个时间内均匀分布。额外风险并非归因于已知风险因素患病率的实质性变化。它主要归因于一小部分患者（n = 292），这些患者患病率低，但存在该方程未考虑的重要风险因素（其余3428名患者的生存率差异P = 0.7）。
在单一机构的范围内，尽管风险因素患病率有所变化，但使用从异质性经验得出的多变量方程，大多数患者的CABG后结果的患者特异性预测可以可靠地进行。新的高风险患者亚组、未能或无法考虑重要的罕见风险因素或机构变化，可能导致预测的系统误差。在这些限制下，它是医疗决策以及手术培训和实践审核的一个优秀工具。
