Know the score

WARNING: You may find this post to be somewhat disturbing. I stumbled across it quite unintentionally, looking for something else.

Have you ever heard of the Aristotle Complexity Score?

Since 1999, Congenital Heart Procedures have been assigned a score based on how complex the operation is. To calculate the Basic Score, you assign points to three different factors, then add those factors together. Since the low number on each scale as a 1 and the high is a 5, the Basic Score is a range between 3.0 and 15.0.

The reason for the Aristotle system is not to claim “bragging rights” over other surgeons (and I certainly hope it is not used for that!) but rather to improve patient care. If the Operating Room calls the Cardiac Critical Care Unit and tells them that a patient is coming down who just had surgery, and the Aristotle Score is a 10, then CCCU knows to keep their eyes open. This patient just had a major operation and they are very ill. And just by quoting that one number, every Cardiac caregiver down the line will know exactly how fragile their patient’s health is.

The first factor used in the Basic Score is mortality. Based on previous research, this takes into account the chances that the patient will die during the operation or shortly afterward. 1 point is given for an expected mortality of less than 1%, while 20% or greater earns a maximum of 5 points.

The next factor is morbidity. A simple definition for morbidity is “a diseased state or symptom.” The Aristotle system bases the morbidity score on the lengh of time spent in the ICU. Less than 24 hours is one point, longer than 2 weeks is five points.

The third factor is the perceived difficulty of the operation. No heart surgery is simple, of course, but fixing an ASD is less complicated than completing a Bi-directional Glenn Shunt. So an operation of the least perceived complexity is again worth one point, and the most difficult is worth five points.

There are other factors that can influence the Basic Score higher or lower – patient’s age, gender, overall health, etc. – but just looking at the Basic Scores can be informative…. and scary!

The “simplest” operation is an ASD repair, rated 3.0.

My Classic Glenn Shunt (a “unidirectional cavopulmonary anastomosis”) is rated a 7.0.

The Modified Blalock-Taussig Shunt (using an artificial conduit) is a 6.3, while a Blalock-Taussig done with a rerouted artery is a 6.8.

The Norwood Procedure (Which is actually three separate operations, but considered one corrective procedure) is the 2nd most complex operation with a 14.5 rating. The only thing more difficult is an HLHS Biventricular Repair, which rates the highest possible Basic Score, 15.0.

We all know Heart Surgery is serious, and knowledge of the Aristotle System only gives us a glimpse of just how serious it is. A surgeon is literally walking into a minefield, and how many of us would consent to an operation (for ourselves or our child) if we knew the true amount of skill that is required?

You can’t just be good and be a Congenital Heart Surgeon… you need to be among the best!

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5 Responses to “Know the score”

  1. Christina Davis Says:

    Jacob’s Arterial Switch Operation has a basic score of 10.0. So interesting. Thanks for the info!

  2. automatthias Says:

    I think the scoring system creates an unnecessary layer of complexity. Aristotle score creators used somewhat arbitrary numbers, and then argued that the numbers are correlated with actual mortality rates as calculated from the EACTS Congenital database. Isn’t it simpler and more accurate to use the mortality rates directly?

    Totally agree on the last sentence. It’s hard to even imagine how difficult it is to work with an open living heart.

  3. Steve Says:

    I honestly don’t know. As I mentioned right at the beginning of the post, I actually stumbled across this looking for something else entirely. And since I have no formal medical training – all I know is what I have learned by *having* a Heart Defect – I really don’t even know how to begin answering that question.

    All I was able to find was the Basic Score, not any kind of guide that explains how other factors could “adjust” the score higher or lower. So I’m also using incomplete information. This is one of those times (and they occur fairly often!) where I just have to say “I don’t know!”

  4. automatthias Says:

    It’s a question not as much for a person with medical training, as to a statistician or a data analyst. I have a feeling that people behind the Aristotle Score are not trained in statistics.

    By the way, you might find it interesting to visit EACTS Congenital Database website. If you hover over “Results”, you’ll see a link to a report called Mortality vs Procedure. The data comes from Europe and other parts of the world as well, except for the US. It shows mortality rates for specific procedures.

  5. RHONDA Says:

    HEY STEVE,
    I ENJOY READING YOUR BLOG…I AM DOING WELL!! I REALIZED JUST HOW HUMAN DOCTORS ARE WHEN I WORKED IN THE ER SEVERAL YEARS AGO AS A PHLEBOTOMIST….IT IS SCARY WHEN YOU REALIZE THAT DRS ARE REAL PEOPLE JUST LIKE YOU AND ME..BUT THEY HAVE TO REALLY KNOW WHAT THEY ARE DOING…SO MAYBE THIS SCORE SYSTEM WORKS FOR THEM, IT WOULD MAKE ME MORE NERVOUS.
    ANYWAYS…
    I HOPE YOU HAVE A WONDERFUL CHRISTMAS AND CAN GET BACK TO YOUR WALKING ROUTINE SOON! THANKS FOR THE ENCOURAGEMENT ON MY BLOG..
    GOD BLESS!
    RHONDA

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