Categorizing BMI may lead to biased results in studies investigating in-hospital mortality after isolated CABG

Abstract 

Objective

To investigate how categorizing body mass index (BMI) into weight classes can impact the assessment of the relationship between BMI and in-hospital mortality after coronary artery bypass graft (CABG) surgery.

Study Design and Setting

BMI–mortality (in-hospital) relationship was assessed in 5,762 patients who underwent isolated CABG at Baylor University Medical Center (Dallas, TX) from January 1, 1997 to November 30, 2003. Different ways of modeling BMI were used to investigate this association in a propensity-adjusted model, controlling for risk factors identified by the Society of Thoracic Surgeons (STS) and other clinical/nonclinical details.

Results

A highly significant (P=0.003) association between BMI (modeled with a restricted cubic spline) and mortality was found. Reduced risk of in-hospital mortality was observed for subjects with BMI in the low-30s as compared with patients with BMI in the mid-20s or over 40kg/m². Results were strongly affected by the way BMI was specified in the multivariable model. Only five of the 10 BMI categorizations considered produced significant results, and these results did not fully determine the effect of BMI on mortality.

Conclusions

BMI categorization critically impacts study results. Conceivably, findings of other studies investigating BMI and adverse outcomes after CABG may be similarly affected. Investigators should consider smoothing techniques to avoid categorization.

Keywords: Body mass index, Coronary artery bypass, Postoperative adverse outcomes, In-hospital mortality, Epidemiologic methods, Smoothing methods