On-line variable live-adjusted displays with internal and external risk-adjusted mortalities. A valuable method for benchmarking and early detection of unfavourable trends in cardiac surgery

Objective: Benchmarking and early detection of unfavourable trends. Methods: We implemented a dedicated project-orientated data warehouse, which continuously supplies data for on-line computing of the variable live-adjusted displays (VLADs). To calculate the expected cumulative mortality, we used the multi-variate logistic regression model of the EuroSCORE model. In addition to the external EuroSCORE standard, we calculated a centre-specific risk score for internal standards by analysing the data of 9135 patients, which enables both internal and external comparisons. The VLADs are embedded into the multi-purpose web-based information portal, so that the physicians can investigate several types of VLADs interactively: performance of different types of surgery and individual surgeons for different time intervals. We investigated clinically important events such as modification of operative techniques and personnel changes of the team by the VLADs. Results: We found transient declines in the performance curves during major changes in patient management, indicating that systemic-rather than accidental or patient related factors-were involved in the mortality risk. The internal standard line represents these clusters more clearly than the external line. We evaluated examples of how periods of increased risk could be monitored by the VLAD curves: (1) the introduction of OPCAB surgery; (2) training of surgeons; (3) staff changes and staff-related management. Conclusions: On-line VLADs based on a day-to-day updated database, displaying both internal and external standards, are a helpful visualisation tool for earlier detection of unfavourable trends. They enable the surgeon teams and clinical management to take countermeasures at an early stage. (C) 2003 Elsevier B.V. All rights reserved.