External validity of a mortality prediction model in patients after open abdominal aortic aneurysm repair using multi-level methodology.
Hadjianastassiou VG., Tekkis PP., Athanasiou T., Muktadir A., Young JD., Hands LJ.
OBJECTIVES: Evaluation of the prognostic ability of the APACHE-AAA model in an independent group of post-operative (open) Abdominal Aortic Aneurysm (AAA) patients. METHODS: The model was applied to predict in-hospital mortality in 541 patients (325 elective and 216 emergencies; 489 from Oxford; 52 from Lewisham). Multi-level modelling was used to adjust for both the local structure and process of care and patient case-mix. Model performance was assessed using goodness-of-fit and subgroup analyses. RESULTS: The model's predictive ability to discriminate between dead and alive patients was very good (ROC area=0.84). The model achieved a good fit across all strata of risk (Hosmer-Lemeshow C-test (8, N=476)=7.777, p=0.456) and in all subgroups. The model was able to rank the ICUs according to their performance independently of the patient case-mix. CONCLUSION: The APACHE-AAA model accurately predicted in-hospital mortality in a population of patients independent of the one used to develop it, confirming its validity. The multi-level methodology employed has shown that patient outcome is not only a function of the patient case-mix but instead predictive models should also adjust for the individual hospital-related factors (structure and process of care).