Variation in Outcomes for Risk-Stratified Pediatric Cardiac Surgical Operations: An Analysis of the STS Congenital Heart Surgery Database

Abstract

Background. We evaluated outcomes for groups of risk-stratified operations in The Society of Thoracic Surgeons Congenital Heart Surgery Database to provide contemporary benchmarks and examine variation between centers. Methods. Patients undergoing surgery from 2005 to 2009 were included. Centers with more than 10% missing data were excluded. Discharge mortality and postoperative length of stay (PLOS) among patients discharged alive were calculated for groups of risk-stratified operations using the five Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery mortality categories (STAT Mortality Categories). Power for analyzing between-center differences in outcome was determined for each STAT Mortality Category. Variation was evaluated using funnel plots and Bayesian hierarchical modeling. Results. In this analysis of risk-stratified operations, 58,506 index operations at 73 centers were included. Overall discharge mortality (interquartile range among programs with more than 10 cases) was as follows: STAT Category 1 = 0.55% (0% to 1.0%), STAT Category 2 = 1.7% (1.0% to 2.2%), STAT Category 3 = 2.6% (1.1% to 4.4%), STAT Category 4 = 8.0% (6.3% to 11.1%), and STAT Category 5 = 18.4% (13.9% to 27.9%). Funnel plots with 95% prediction limits revealed the number of centers characterized as outliers by STAT Mortality Categories was as follows: Category 1 = 3 (4.1%), Category 2 = 1 (1.4%), Category 3 = 7 (9.7%), Category 4 = 13 (17.8%), and Category 5 = 13 (18.6%). Between-center variation in PLOS was analyzed for all STAT Categories and was greatest for STAT Category 5 operations. Conclusions. This analysis documents contemporary benchmarks for risk-stratified pediatric cardiac surgical operations grouped by STAT Mortality Categories and the range of outcomes among centers. Variation was greatest for the more complex operations. These data may aid in the design and planning of quality assessment and quality improvement initiatives.

Extubation Failure after Neonatal Cardiac Surgery: A Multicenter Analysis

“…We observed a range of extubation failure rates across the seven participating centers in our study, from 8% -23%, also consistent with the data from the PC4 registry, which reported a range of 5% -22% [10]. Further, the only retrospective single center study that focused on a heterogeneous population of neonates who underwent cardiac surgery published an extubation failure rate of 17.5% [11]. This variation in extubation failure occurrence rates across centers suggests an opportunity for institutional quality assurance initiatives aimed at decreasing the occurrence of this frustrating and potentially life-threatening complication.…”

“…Table 2 (online), organized by STAT mortality category. [11,12] The most common operations performed were the arterial switch procedure (n=60) and the Norwood procedure (n=47).…”

“…• Society of Thoracic Surgeons-European Association for Cardio-thoracic Surgery Society Congenital Heart Surgery Mortality Category (STAT mortality category) [11][12] Extubation Failure after Neonatal Cardiac Surgery…”

Infant deaths in the UK community following successful cardiac surgery: building the evidence base for optimal surveillance, a mixed-methods study

“…Paediatricians with expertise in cardiology, however, may not be the first point of contact for the deteriorating infant with CHD, and there may be potential for learning from related secondary care examples, such as scoring tools that have been deployed in A&E and utilised by non-specialist HPs to detect signs of deterioration in presenting children. 146 Finally, at present the focus of national and international audit remains on 30-day mortality rates for paediatric cardiac surgery 68,69,147 and we note that additional audit metrics focusing on the postdischarge stage of the patient journey may be a useful lever for quality improvement in the future.…”

“…68 These early mortality outcomes have improved over time to the current, historically low, levels. 4 However, although important, these outcome measures are relatively limited in scope, and longer-term measures of outcome and metrics such as morbidity or complications are also essential to consider in quality assurance and improvement.…”