Peer-reviewedCC BY-NC-ND 4.0Journal of Cardiothoracic Surgery5 Aug 2026

Assessing the prevalence of risk factors not included in the EuroSCORE II and their impact on hospital benchmarking in cardiac surgery: using the Netherlands Heart Registration as an example

Maaike M. Roefs¹
Edgar J. Daeter²
Maaike S.Y. Thio^3,4
Fabiano Porta⁵
Dennis van Veghel¹

5 affiliations

¹Netherlands Heart Registration, Moreelsepark 1, Utrecht, 3511 EP Netherlands
²Department of Cardiac Surgery, St Antonius Hospital, Koekoekslaan 1, Nieuwegein, 3435 CM Netherlands
³Department of Anaesthesiology and Intensive Care, Amphia Hospital, Molengracht 21, 4818 CK Breda, Netherlands
⁴Department of Anaesthesiology, Intensive Care and Pain management, St. Antonius Hospital, Koekoekslaan 1, Nieuwegein, 3435 CM Netherlands
⁵Department of Cardiothoracic Surgery, Frisius MC, Henri Dunantweg 2, Leeuwarden, 8934 AD The Netherlands

Abstract

Objectives: Quality registries often use risk-adjusted benchmarking of mortality to assess hospital performance. The Netherlands Heart Registration (NHR) uses the EuroSCOREII to adjust for hospital differences. However, EuroSCOREII does not include all risk factors that increase mortality risk. Suboptimal benchmarking may have significant negative consequences for all stakeholders. This study aims to assess risk factors not included in EuroSCOREII and their impact on risk-adjusted benchmarking in the Netherlands.

Methods: This retrospective nationwide cohort study used data from the NHR. Patients undergoing coronary artery bypass grafting and/or surgical aortic valve replacement were included. Patients with surgical mortality were assessed for any additional risk factor not included in the EuroSCOREII by a cardiothoracic surgeon and marked as additional high-risk or not. Risk-adjusted benchmarking was performed using EuroSCOREII. The influence of additional high-risk on benchmarking was assessed through exclusion of additional high-risk patients and through correction for additional high-risk.

Results: 8,480 patients were included of which 156 died within 30-days, 60 out of 156 (38.5%) patients with surgical mortality were classified as additional high-risk. Most frequently mentioned non-cardiac risk factor was high body mass index, cardiac risk factors were ongoing acute myocardial infarction, porcelain aorta and previous unsuccessful revascularization. Both exclusion and correction for additional high-risk led to altered benchmarking positions of hospitals, both improving and degrading hospital rankings.

Conclusion: 38.5% of patients suffer from risk factors not covered in EuroSCOREII, including cardiac, non-cardiac and life-style factors. Including these factors as additional high-risk in the benchmarking process alters the hospital benchmarking positions, indicating that this process may be improved.

Graphical abstract:

Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1186/s13019-026-04639-z.

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BibTeX RIS

BibTeX

@article{roefs2026assessing,
  title = {{Assessing the prevalence of risk factors not included in the EuroSCORE II and their impact on hospital benchmarking in cardiac surgery: using the Netherlands Heart Registration as an example}},
  author = {Maaike M. Roefs and Edgar J. Daeter and Maaike S.Y. Thio and Fabiano Porta and Dennis van Veghel},
  journal = {Journal of Cardiothoracic Surgery},
  year = {2026},
  month = aug,
  doi = {10.1186/s13019-026-04639-z},
  url = {https://doi.org/10.1186/s13019-026-04639-z},
  note = {CC BY-NC-ND 4.0},
}

RIS

TY  - JOUR
TI  - Assessing the prevalence of risk factors not included in the EuroSCORE II and their impact on hospital benchmarking in cardiac surgery: using the Netherlands Heart Registration as an example
AU  - Maaike M. Roefs
AU  - Edgar J. Daeter
AU  - Maaike S.Y. Thio
AU  - Fabiano Porta
AU  - Dennis van Veghel
PY  - 2026
DA  - 2026/08/05
JO  - Journal of Cardiothoracic Surgery
DO  - 10.1186/s13019-026-04639-z
UR  - https://doi.org/10.1186/s13019-026-04639-z
AB  - Objectives: Quality registries often use risk-adjusted benchmarking of mortality to assess hospital performance. The Netherlands Heart Registration (NHR) uses the EuroSCOREII to adjust for hospital differences. However, EuroSCOREII does not include all risk factors that increase mortality risk. Suboptimal benchmarking may have significant negative consequences for all stakeholders. This study aims to assess risk factors not included in EuroSCOREII and their impact on risk-adjusted benchmarking in the Netherlands.  Methods: This retrospective nationwide cohort study used data from the NHR. Patients undergoing coronary artery bypass grafting and/or surgical aortic valve replacement were included. Patients with surgical mortality were assessed for any additional risk factor not included in the EuroSCOREII by a cardiothoracic surgeon and marked as additional high-risk or not. Risk-adjusted benchmarking was performed using EuroSCOREII. The influence of additional high-risk on benchmarking was assessed through exclusion of additional high-risk patients and through correction for additional high-risk.  Results: 8,480 patients were included of which 156 died within 30-days, 60 out of 156 (38.5%) patients with surgical mortality were classified as additional high-risk. Most frequently mentioned non-cardiac risk factor was high body mass index, cardiac risk factors were ongoing acute myocardial infarction, porcelain aorta and previous unsuccessful revascularization. Both exclusion and correction for additional high-risk led to altered benchmarking positions of hospitals, both improving and degrading hospital rankings.  Conclusion: 38.5% of patients suffer from risk factors not covered in EuroSCOREII, including cardiac, non-cardiac and life-style factors. Including these factors as additional high-risk in the benchmarking process alters the hospital benchmarking positions, indicating that this process may be improved.  Graphical abstract:  Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1186/s13019-026-04639-z.
SN  - 1749-8090
ER  -

Abstract

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