Ann Thorac Surg
2017;104:1755–62
References
1. Shi H, Fang Q, Peng L, Han Y. Should immediate post-
operative oral nutrition following esophagectomy be
generalized immediately? (letter). Ann Thorac Surg 2017;104:
1756.
2. Weijs TJ, Berkelmans GHK, Nieuwenhuijzen GAP, et al. Im-
mediate postoperative oral nutrition following esoph-
agectomy: a multicenter clinical trial. Ann Thorac Surg
2016;102:1141–8.
3. van Workum F, van der Maas J, van den Wildenberg FJ, et al.
Improved functional results after minimally invasive esoph-
agectomy: intrathoracic versus cervical anastomosis. Ann
Thorac Surg 2017;103:267–73.
4. Weijs TJ, Nieuwenhuijzen GA, Ruurda JP, et al. Study proto-
col for the nutritional route in oesophageal resection trial: a
single-arm feasibility trial (NUTRIENT trial). BMJ Open
2014;4:e004557.
5. Weijs TJ, Kumagai K, Berkelmans GH, et al. Nasogastric
decompression following esophagectomy: a systematic liter-
ature review and meta-analysis. Dis Esophagus 2016 Sep 15:
http://dx.doi.org/10.1111/dote.12530 [Epub ahead of print].
6. Berkelmans GH, Wilts BJ, Kouwenhoven EA, et al. Nutritional
route in oesophageal resection trial II (NUTRIENT II): study
protocol for a multicentre open-label randomised controlled
trial. BMJ Open 2016;6:e011979.
Validity of a Score Created to Predict the Risk of
Readmission After Adult Cardiac Operations
To the Editor:
We read with great interest the article by Kilic and colleagues [1]
regarding the ability of a newly created score to predict the risk
of readmission after adult cardiac operations. They stated that
a score to predict the risk of readmission after adult cardiac
operations has been successfully developed and validated in
their study, underlining the capability of the created score to
identify high-risk populations.
However, the reported discriminative power of the new score
(tested on a validation cohort) is extremely disappointing (c-index
of 0.64). Discrimination measures the capacity of the model to
distinguish between patients who will experience an event (in this
case, readmission after adult cardiac operations) and those who
will not [2]. If most of the events occur in the patients who the
model correctly identifies as at high risk, the model has good
discrimination. Discrimination can be assessed by the area
under the receiver operative characteristic curve (AUC). The
AUC is a percentage of randomly drawn pairs (meaning 1
patient readmitted and 1 patient not readmitted) for which it is
true that a patient who was readmitted had a higher risk score
than a patient who was not readmitted [2]. The discriminative
power is thought to be excellent if the AUC is greater than 0.80,
very good if it is greater than 0.75, and good (acceptable) if it is
greater than 0.70 [2]. Kilic and colleagues [1] reported
disappointing discriminative power (AUC ¼ 0.64); therefore, this
risk stratification model cannot be used to predict the risk of
readmission after adult cardiac operations. Although the
Hosmer-Lemeshow test confirmed good calibration (p ¼ 0.57),
it would be of interest to present the observed to expected mor-
tality ratio, especially in each risk group. Ideally, this ratio equals 1
(the observed mortality equals expected mortality; thus the pre-
dictive model is perfectly calibrated). If the 95% confidence in-
terval of the observed to expected mortality ratio includes the
value of 1.0, the model is well calibrated [3]. Surprisingly, nowhere
in the article was the number of patients included in the low-,
moderate-, and high-risk groups mentioned (neither in the
training nor in the validation cohort).
Ó 2017 by The Society of Thoracic Surgeons
Published by Elsevier Inc.
CORRESPONDENCE 1757
Dusko Nezic, MD, PhD
Ivana Petrovic, MD, PhD
Slobodan Micovic, MD, PhD
Department of Cardiac Surgery
“Dedinje” Cardiovascular Institute
M. Tepica 1
11000 Belgrade, Serbia
email: nezic@eunet.rs
References
1. Kilic A, Magruder JT, Grimm JC, et al. Development and
validation of a score to predict the risk of readmission
after adult cardiac operations. Ann Thorac Surg 2017;103:
66–73.
2. Nezic D. eComment. The additive EuroSCORE: an abandoned
risk stratification model in cardiac surgery. Interact Car-
diovasc Thorac Surg 2015;21:434.
3. Nezic D, Borzanovic M, Spasic T, et al. Calibration of the
EuroSCORE II risk stratification model: is the Hosmer-
Lemeshow test acceptable any more? Eur J Cardiothoracic
Surg 2013;43:206.
Reply
To the Editor:
We thank Nezic and colleagues [1] for their comments
regarding our article [2] about a readmission risk score after
adult cardiac surgical procedures. The development of
predictive indices for readmission after cardiac operations has
historically proved to be difficult. A primary reason for this
challenge stems from the fact that most registries do not
MISCELLANEOUS
capture all of the potential risk factors for readmission. For
instance, physical proximity to the hospital, compliance with
medications and follow-up, access to and responsiveness of the
surgeon’s team or office, and social and family support all likely
contribute to some degree to readmission risk; however, these are
not available in our institutional registry, and we suspect they
would not be available in most registries. Therefore, it is not
entirely unexpected that our c-index was comparable to that of
other similar readmission analyses in cardiac surgical procedures,
such as that evaluating 30-day readmission after coronary artery
bypass grafting by use of the Society for Thoracic Surgeons Na-
tional Database (c ¼ 0.648) [3].
Another issue that makes predicting readmission difficult is
our ability to fully capture the primary endpoint. Patients are
often readmitted to hospitals that are different from the index
hospital where the operation was performed. With this in mind,
we performed a follow-up analysis (to be presented at the
American Association for Thoracic Surgery Centennial Annual
Meeting) that used a statewide Maryland database to more fully
capture readmissions. The predictive risk index we derived
using this more robust database yielded slightly improved re-
sults, with a c-index of 0.68. The inability to substantially
improve the predictive yield even with a more robust dataset
raises the question whether readmission should be used as a
quality metric.
Despite these challenges, there are several important im-
plications of our study. Although the c-index may not be above
0.70, we still argue that our model is reliable enough to identify
high-risk patients, with a true and substantial difference in
readmission risk between the low and high ends of the score
spectrum. Readmission risk varied widely from 5.9% to 54.7%
in patients with a score of 0 versus 20, respectively. In the
current era of cost-effective medicine, having such a risk
stratification tool can help in directing resources and
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