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Use of hierarchical models to evaluate performance of cardiac surgery centres in the Italian CABG outcome study

Paola D'Errigo1*, Maria E Tosti1, Danilo Fusco2, Carlo A Perucci2, Fulvia Seccareccia1 and the research group of the Italian CABG Outcome Study3

Author Affiliations

1 National Center for Epidemiology, Surveillance and Health Promotion, Istituto Superiore di Sanità, Rome, Italy

2 Department of Epidemiology, ASL RME, Rome, Italy

3 See Appendix

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BMC Medical Research Methodology 2007, 7:29  doi:10.1186/1471-2288-7-29

Published: 3 July 2007



Hierarchical modelling represents a statistical method used to analyze nested data, as those concerning patients afferent to different hospitals. Aim of this paper is to build a hierarchical regression model using data from the "Italian CABG outcome study" in order to evaluate the amount of differences in adjusted mortality rates attributable to differences between centres.


The study population consists of all adult patients undergoing an isolated CABG between 2002–2004 in the 64 participating cardiac surgery centres.

A risk adjustment model was developed using a classical single-level regression. In the multilevel approach, the variable "clinical-centre" was employed as a group-level identifier. The intraclass correlation coefficient was used to estimate the proportion of variability in mortality between groups. Group-level residuals were adopted to evaluate the effect of clinical centre on mortality and to compare hospitals performance. Spearman correlation coefficient of ranks (ρ) was used to compare results from classical and hierarchical model.


The study population was made of 34,310 subjects (mortality rate = 2.61%; range 0.33–7.63). The multilevel model estimated that 10.1% of total variability in mortality was explained by differences between centres. The analysis of group-level residuals highlighted 3 centres (VS 8 in the classical methodology) with estimated mortality rates lower than the mean and 11 centres (VS 7) with rates significantly higher. Results from the two methodologies were comparable (ρ = 0.99).


Despite known individual risk-factors were accounted for in the single-level model, the high variability explained by the variable "clinical-centre" states its importance in predicting 30-day mortality after CABG.