Value of risk scores in the decision to palliate patients with ruptured abdominal aortic aneurysm

M. J. Sweeting, P. Ulug, J. Roy, R. Hultgren, R. Indrakusuma, R. Balm, M. M. Thompson, R. J. Hinchliffe, S. G. Thompson, J. T. Powell, the Ruptured Aneurysm Collaborators, including IMPROVE, AJAX, ECAR and STAR collaborators

Research output: Contribution to journalArticleAcademicpeer-review

Abstract

Background: The aim of this study was to develop a 48-h mortality risk score, which included morphology data, for patients with ruptured abdominal aortic aneurysm presenting to an emergency department, and to assess its predictive accuracy and clinical effectiveness in triaging patients to immediate aneurysm repair, transfer or palliative care. Methods: Data from patients in the IMPROVE (Immediate Management of the Patient With Ruptured Aneurysm: Open Versus Endovascular Repair) randomized trial were used to develop the risk score. Variables considered included age, sex, haemodynamic markers and aortic morphology. Backwards selection was used to identify relevant predictors. Predictive performance was assessed using calibration plots and the C-statistic. Validation of the newly developed and other previously published scores was conducted in four external populations. The net benefit of treating patients based on a risk threshold compared with treating none was quantified. Results: Data from 536 patients in the IMPROVE trial were included. The final variables retained were age, sex, haemoglobin level, serum creatinine level, systolic BP, aortic neck length and angle, and acute myocardial ischaemia. The discrimination of the score for 48-h mortality in the IMPROVE data was reasonable (C-statistic 0·710, 95 per cent c.i. 0·659 to 0·760), but varied in external populations (from 0·652 to 0·761). The new score outperformed other published risk scores in some, but not all, populations. An 8 (95 per cent c.i. 5 to 11) per cent improvement in the C-statistic was estimated compared with using age alone. Conclusion: The assessed risk scores did not have sufficient accuracy to enable potentially life-saving decisions to be made regarding intervention. Focus should therefore shift to offering repair to more patients and reducing non-intervention rates, while respecting the wishes of the patient and family.
Original languageEnglish
Pages (from-to)1135-1144
JournalBritish Journal of Surgery
Volume105
Issue number9
DOIs
Publication statusPublished - 2018

Cite this

Sweeting, M. J., Ulug, P., Roy, J., Hultgren, R., Indrakusuma, R., Balm, R., ... the Ruptured Aneurysm Collaborators, including IMPROVE, AJAX, ECAR and STAR collaborators (2018). Value of risk scores in the decision to palliate patients with ruptured abdominal aortic aneurysm. British Journal of Surgery, 105(9), 1135-1144. https://doi.org/10.1002/bjs.10820
Sweeting, M. J. ; Ulug, P. ; Roy, J. ; Hultgren, R. ; Indrakusuma, R. ; Balm, R. ; Thompson, M. M. ; Hinchliffe, R. J. ; Thompson, S. G. ; Powell, J. T. ; the Ruptured Aneurysm Collaborators, including IMPROVE, AJAX, ECAR and STAR collaborators. / Value of risk scores in the decision to palliate patients with ruptured abdominal aortic aneurysm. In: British Journal of Surgery. 2018 ; Vol. 105, No. 9. pp. 1135-1144.
@article{c6b4964194bd4c31b5fc7de8289611e3,
title = "Value of risk scores in the decision to palliate patients with ruptured abdominal aortic aneurysm",
abstract = "Background: The aim of this study was to develop a 48-h mortality risk score, which included morphology data, for patients with ruptured abdominal aortic aneurysm presenting to an emergency department, and to assess its predictive accuracy and clinical effectiveness in triaging patients to immediate aneurysm repair, transfer or palliative care. Methods: Data from patients in the IMPROVE (Immediate Management of the Patient With Ruptured Aneurysm: Open Versus Endovascular Repair) randomized trial were used to develop the risk score. Variables considered included age, sex, haemodynamic markers and aortic morphology. Backwards selection was used to identify relevant predictors. Predictive performance was assessed using calibration plots and the C-statistic. Validation of the newly developed and other previously published scores was conducted in four external populations. The net benefit of treating patients based on a risk threshold compared with treating none was quantified. Results: Data from 536 patients in the IMPROVE trial were included. The final variables retained were age, sex, haemoglobin level, serum creatinine level, systolic BP, aortic neck length and angle, and acute myocardial ischaemia. The discrimination of the score for 48-h mortality in the IMPROVE data was reasonable (C-statistic 0·710, 95 per cent c.i. 0·659 to 0·760), but varied in external populations (from 0·652 to 0·761). The new score outperformed other published risk scores in some, but not all, populations. An 8 (95 per cent c.i. 5 to 11) per cent improvement in the C-statistic was estimated compared with using age alone. Conclusion: The assessed risk scores did not have sufficient accuracy to enable potentially life-saving decisions to be made regarding intervention. Focus should therefore shift to offering repair to more patients and reducing non-intervention rates, while respecting the wishes of the patient and family.",
author = "Sweeting, {M. J.} and P. Ulug and J. Roy and R. Hultgren and R. Indrakusuma and R. Balm and Thompson, {M. M.} and Hinchliffe, {R. J.} and Thompson, {S. G.} and Powell, {J. T.} and {the Ruptured Aneurysm Collaborators, including IMPROVE, AJAX, ECAR and STAR collaborators} and R. Balm and Koelemay, {M. J. W.} and Idu, {M. M.} and C. Kox and Legemate, {D. A.} and {van Lienden}, {K. P.} and Reimerink, {J. J.} and {van Beek}, {S. C.} and J. Bosma and Visser, {M. J. T.} and W. Wisselink and Hoksbergen, {A. W. J.} and Blankensteijn, {J. D.} and Coveliers, {H. M. E.} and Nederhoed, {J. H.} and {van den Berg}, {F. G.} and {van der Meijs}, {B. B.} and {van den Oever}, {M. L. P.} and Lely, {R. J.} and Meijerink, {M. R.} and Wiersema, {A. M.} and {van der Elst}, A. and Legemate, {D. A.} and {van Lienden}, {K. P.} and Reimerink, {J. J.} and {van Beek}, {S. C.} and J. Bosma and Visser, {M. J. T.} and W. Wisselink and Hoksbergen, {A. W. J.} and Blankensteijn, {J. D.} and Coveliers, {H. M. E.} and Nederhoed, {J. H.} and {van den Berg}, {F. G.} and {van der Meijs}, {B. B.} and {van den Oever}, {M. L. P.} and Lely, {R. J.} and Meijerink, {M. R.} and Wiersema, {A. M.} and {van der Elst}, A.",
year = "2018",
doi = "10.1002/bjs.10820",
language = "English",
volume = "105",
pages = "1135--1144",
journal = "British Journal of Surgery",
issn = "0007-1323",
publisher = "John Wiley and Sons Ltd",
number = "9",

}

Sweeting, MJ, Ulug, P, Roy, J, Hultgren, R, Indrakusuma, R, Balm, R, Thompson, MM, Hinchliffe, RJ, Thompson, SG, Powell, JT & the Ruptured Aneurysm Collaborators, including IMPROVE, AJAX, ECAR and STAR collaborators 2018, 'Value of risk scores in the decision to palliate patients with ruptured abdominal aortic aneurysm' British Journal of Surgery, vol. 105, no. 9, pp. 1135-1144. https://doi.org/10.1002/bjs.10820

Value of risk scores in the decision to palliate patients with ruptured abdominal aortic aneurysm. / Sweeting, M. J.; Ulug, P.; Roy, J.; Hultgren, R.; Indrakusuma, R.; Balm, R.; Thompson, M. M.; Hinchliffe, R. J.; Thompson, S. G.; Powell, J. T.; the Ruptured Aneurysm Collaborators, including IMPROVE, AJAX, ECAR and STAR collaborators.

In: British Journal of Surgery, Vol. 105, No. 9, 2018, p. 1135-1144.

Research output: Contribution to journalArticleAcademicpeer-review

TY - JOUR

T1 - Value of risk scores in the decision to palliate patients with ruptured abdominal aortic aneurysm

AU - Sweeting, M. J.

AU - Ulug, P.

AU - Roy, J.

AU - Hultgren, R.

AU - Indrakusuma, R.

AU - Balm, R.

AU - Thompson, M. M.

AU - Hinchliffe, R. J.

AU - Thompson, S. G.

AU - Powell, J. T.

AU - the Ruptured Aneurysm Collaborators, including IMPROVE, AJAX, ECAR and STAR collaborators

AU - Balm, R.

AU - Koelemay, M. J. W.

AU - Idu, M. M.

AU - Kox, C.

AU - Legemate, D. A.

AU - van Lienden, K. P.

AU - Reimerink, J. J.

AU - van Beek, S. C.

AU - Bosma, J.

AU - Visser, M. J. T.

AU - Wisselink, W.

AU - Hoksbergen, A. W. J.

AU - Blankensteijn, J. D.

AU - Coveliers, H. M. E.

AU - Nederhoed, J. H.

AU - van den Berg, F. G.

AU - van der Meijs, B. B.

AU - van den Oever, M. L. P.

AU - Lely, R. J.

AU - Meijerink, M. R.

AU - Wiersema, A. M.

AU - van der Elst, A.

AU - Legemate, D. A.

AU - van Lienden, K. P.

AU - Reimerink, J. J.

AU - van Beek, S. C.

AU - Bosma, J.

AU - Visser, M. J. T.

AU - Wisselink, W.

AU - Hoksbergen, A. W. J.

AU - Blankensteijn, J. D.

AU - Coveliers, H. M. E.

AU - Nederhoed, J. H.

AU - van den Berg, F. G.

AU - van der Meijs, B. B.

AU - van den Oever, M. L. P.

AU - Lely, R. J.

AU - Meijerink, M. R.

AU - Wiersema, A. M.

AU - van der Elst, A.

PY - 2018

Y1 - 2018

N2 - Background: The aim of this study was to develop a 48-h mortality risk score, which included morphology data, for patients with ruptured abdominal aortic aneurysm presenting to an emergency department, and to assess its predictive accuracy and clinical effectiveness in triaging patients to immediate aneurysm repair, transfer or palliative care. Methods: Data from patients in the IMPROVE (Immediate Management of the Patient With Ruptured Aneurysm: Open Versus Endovascular Repair) randomized trial were used to develop the risk score. Variables considered included age, sex, haemodynamic markers and aortic morphology. Backwards selection was used to identify relevant predictors. Predictive performance was assessed using calibration plots and the C-statistic. Validation of the newly developed and other previously published scores was conducted in four external populations. The net benefit of treating patients based on a risk threshold compared with treating none was quantified. Results: Data from 536 patients in the IMPROVE trial were included. The final variables retained were age, sex, haemoglobin level, serum creatinine level, systolic BP, aortic neck length and angle, and acute myocardial ischaemia. The discrimination of the score for 48-h mortality in the IMPROVE data was reasonable (C-statistic 0·710, 95 per cent c.i. 0·659 to 0·760), but varied in external populations (from 0·652 to 0·761). The new score outperformed other published risk scores in some, but not all, populations. An 8 (95 per cent c.i. 5 to 11) per cent improvement in the C-statistic was estimated compared with using age alone. Conclusion: The assessed risk scores did not have sufficient accuracy to enable potentially life-saving decisions to be made regarding intervention. Focus should therefore shift to offering repair to more patients and reducing non-intervention rates, while respecting the wishes of the patient and family.

AB - Background: The aim of this study was to develop a 48-h mortality risk score, which included morphology data, for patients with ruptured abdominal aortic aneurysm presenting to an emergency department, and to assess its predictive accuracy and clinical effectiveness in triaging patients to immediate aneurysm repair, transfer or palliative care. Methods: Data from patients in the IMPROVE (Immediate Management of the Patient With Ruptured Aneurysm: Open Versus Endovascular Repair) randomized trial were used to develop the risk score. Variables considered included age, sex, haemodynamic markers and aortic morphology. Backwards selection was used to identify relevant predictors. Predictive performance was assessed using calibration plots and the C-statistic. Validation of the newly developed and other previously published scores was conducted in four external populations. The net benefit of treating patients based on a risk threshold compared with treating none was quantified. Results: Data from 536 patients in the IMPROVE trial were included. The final variables retained were age, sex, haemoglobin level, serum creatinine level, systolic BP, aortic neck length and angle, and acute myocardial ischaemia. The discrimination of the score for 48-h mortality in the IMPROVE data was reasonable (C-statistic 0·710, 95 per cent c.i. 0·659 to 0·760), but varied in external populations (from 0·652 to 0·761). The new score outperformed other published risk scores in some, but not all, populations. An 8 (95 per cent c.i. 5 to 11) per cent improvement in the C-statistic was estimated compared with using age alone. Conclusion: The assessed risk scores did not have sufficient accuracy to enable potentially life-saving decisions to be made regarding intervention. Focus should therefore shift to offering repair to more patients and reducing non-intervention rates, while respecting the wishes of the patient and family.

UR - https://www.scopus.com/inward/record.uri?partnerID=HzOxMe3b&scp=85044944419&origin=inward

UR - https://www.ncbi.nlm.nih.gov/pubmed/30461007

U2 - 10.1002/bjs.10820

DO - 10.1002/bjs.10820

M3 - Article

VL - 105

SP - 1135

EP - 1144

JO - British Journal of Surgery

JF - British Journal of Surgery

SN - 0007-1323

IS - 9

ER -