Comparison of a clinical score with individual clinician judgment for assigning priority for heart valve surgery

Abstract, European Society of Cardiology Congress, Stockholm, Sweden, 2010, European Heart Journal 31 (suppl 1), 71

R A H Stewart (1), A Hamer (2), B Mahon (3), P Ruygrok (4), N Kang (4), A Sasse (3), R Fischer (5), R Luke (6), A Barber (7), R Naden (7)

(1) The University of Auckland, Auckland; (2) Nelson Hospital, Nelson; (3) Wellington Hospital, Wellington; (4) Auckland City Hospital, Auckland; (5) Hamilton Hospital, Hamilton; (6) Hastings Hospital, Hastings; (7) Ministry of Health, Wellington, New Zealand

Background: Priority for cardiac surgery is usually based on a clinician’s judgment of the degree of urgency. Point systems have the potential to improve the accuracy and consistency of this assessment. A working group of New Zealand Cardiologists and Cardiac Surgeons developed a Clinical Priority Score (CPS) for assigning priority for surgery for heart valve disease based on current guidelines of the AHA/ACC and ESC. Categories scored include the severity of the valve lesion, symptoms related to the valve lesion, the presence and amount of cardiac dysfunction, risk of progression and the presence of an additional AHA/ACC/ESC class 1 indication for surgery. Clear definitions relevant to individual valve lesions were used within each category. Points were assigned using decision analysis software which calculates weights based on the consensus ‘expert’ responses to a series of choices. The aim of this study was to compare the CPS with individual clinician judgment for assigning priority for heart valve surgery.

Methods: 25 vignettes of cases referred for a broad range of heart valve surgery were independently ranked for urgency by 8 cardiologists or cardiac surgeons. A clinical consensus rank (1 to 25) was then agreed by first determining the average rank then re-ranking cases after group discussion. The final consensus rank was compared to the rank assigned from the CPS and with the initial rank of each clinician.

Results: There was a close correlation between the CPS score and final consensus judgment (r= 0.91), which on average was better than for individual clinicians (mean r=0.74, SD 0.13). For CPS and individual clinicians respectively the proportion of cases where agreement was very good (≤2 rank places different) was 60% and 37%, good (2.5 to 4) 24% and 28%, modest (4 to 8) 16% and 25%, and poor (>8 rank places different) 0% and 14.5%, p=0.008.

Conclusion: Priority for surgery for heart valve disease assigned by a systematic point score was consistent with consensus clinical judgment. In contrast individual clinician judgment was variable and more likely to assign a priority inconsistent with the consensus judgment.