Congenital Heart Surgery Case Mix Across North American Centers and Impact on Performance Assessment

Abstract

Background Performance assessment in congenital heart surgery is challenging due to wide heterogeneity of disease. We describe current case-mix across centers, evaluate methodology inclusive of all cardiac operations vs. the more homogeneous subset of STS benchmark operations, and describe implications regarding performance assessment. Methods Centers (n=119) participating in the STS Congenital Heart Surgery Database (2010–2014) were included. Index operation type and frequency across centers were described. Center performance (risk-adjusted operative mortality) was evaluated and classified when including the benchmark vs. all eligible operations. Results Overall, 207 types of operations were performed during the study period (112,140 total cases). Few operations were performed across all centers; only 25% were performed at least once by 75% or more of centers. There was 7.9-fold variation across centers in the proportion of total cases comprised of high-complexity cases (STAT 5). In contrast, the benchmark operations comprised 36% of cases, and all but 2 were performed by ≥90% of centers. When evaluating performance based on benchmark vs. all operations, 15% of centers changed performance classification; 85% remained unchanged. Benchmark methodology was associated with lower power (35% vs. 78% of centers met sample size requirements). Conclusions There is wide variation in congenital heart surgery case-mix across centers. Metrics based on benchmark vs. all operations are associated with strengths (less heterogeneity) and weaknesses (lower power), and lead to differing performance classification for some centers. These findings have implications for ongoing efforts to optimize performance assessment, including choice of target population and appropriate interpretation of reported metrics.

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