Surgical Volume and Center Effects on Early Mortality After Pediatric Cardiac Surgery: 25-Year North American Experience From a Multi-institutional Registry

Abstract

Mortality after pediatric cardiac surgery varies among centers. Previous research suggests that surgical volume is an important predictor of this variation. This report characterizes the relative contribution of patient factors, center surgical volume, and a volume-independent center effect on early postoperative mortality in a retrospective cohort study of North American centers in the Pediatric Cardiac Care Consortium (up to 500 cases/center/year). From 1982 to 2007, 49 centers reported 109,475 operations, 85,023 of which were analyzed using hierarchical multivariate logistic regression analysis. Patient characteristics varied significantly among the centers. The adjusted odds ratio (OR) for mortality decreased more than 10-fold during the study period (1982 vs. 2007: OR, 12.27, 95 % confidence interval [CI], 8.52–17.66; p < 0.0001). Surgical volume was associated inversely with odds of death (additional 100 cases/year: OR, 0.84; 95 % CI, 0.78–0.90; p < 0.0001). In the analysis of interactions, this effect was fairly consistent across age groups, risk categories (except the lowest), and time periods. However, a volume-independent center effect contributed substantially more to the risk model than did the volume. The Risk Adjusted Classification for Congenital Heart Surgery, version 1 (RACHS-1) risk category remains the strongest predictor of postoperative mortality through the 25-year study period. In conclusion, center-specific variation exists but is only partially explained by operative volume. Low-risk operations are safely performed at centers in all volume categories, whereas regionalization or other quality improvement strategies appear to be warranted for moderate- and high-risk operations. Potentially preventable mortality occurs at centers in all volume categories studied, so referral or regionalization strategies must target centers by observed outcomes rather than assume that volume predicts quality.

Use of the quality management system "JACIE" and outcome after hematopoietic stem cell transplantation

“…It is therefore likely, with all the limitations of an observational study, that the findings are indeed sufficiently unbiased and robust; these results cannot be reduced to a simple center effect, learning curve, cumulative experience or case load. [31][32][33][34][35] It remains possible that accredited centers were more prone to quality work and that accreditation remains a surrogate marker of quality consciousness. Nevertheless, the data showed a close relationship between the individual steps of the accreditation process and the improvements; they showed a clear difference in speed of improvement over calendar time between accredited and non-accredited centers.…”

Trends in Congenital Heart Disease

“…The complex relationship between procedure volume and outcomes has been identified in congenital cardiovascular procedures, and it continues to be refined ( Figure 9). [126][127][128][129] It has become clear from analyses of these data both that surgical outcomes have improved and that there remains significant variability in outcomes and costs, as well, among hospitals. 108,[130][131][132] In addition to measurement of perioperative surgical mortality and long-term survival, the significance of comorbidities as both measurable outcomes and predictors of other outcomes is increasingly well defined.…”

Factors Affecting Length of Postoperative Hospitalization for Pediatric Cardiac Operations in a Large North American Registry (1982–2007)

“…CHD is a leading cause of infant mortality and morbidity and a significant societal and financial burden [4, 5]. The mortality risk, while significant, has greatly improved over the last 25 years [6]. Compared to infants undergoing surgery in the mid 1980s, infants undergoing surgery in the mid 2000s had 6.5 times lower odds of death after controlling for center surgical volume, risk category, age group, and sex [6].…”

“…The mortality risk, while significant, has greatly improved over the last 25 years [6]. Compared to infants undergoing surgery in the mid 1980s, infants undergoing surgery in the mid 2000s had 6.5 times lower odds of death after controlling for center surgical volume, risk category, age group, and sex [6]. In 2004, the costs for hospitalizations for individuals with CHD in the U.S. was $1.4 billion [7] with estimated costs for a privately insured infant of almost $100,000 [5, 8].…”

“…It has been suggested that if higher-volume pediatric cardiac surgery centers have better outcomes, overall care may be improved by regionalization of some or all pediatric cardiac operations. Vinocur et al found that while surgical volume was a contributing factor, volume-independent center-specific effects were more important for predicting post-operative mortality [6]. This finding suggests that institutional excellence in surgical management is not entirely mediated through surgical volume, but also through other unmeasured center characteristics.…”