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Hickey PA, Pasquali SK, Gaynor JW, He X, Hill KD, Connor JA, Gauvreau K, Jacobs ML, Jacobs JP, Hirsch-Romano JC. Critical Care Nursing's Impact on Pediatric Patient Outcomes. Ann Thorac Surg 2016; 102:1375-80. [PMID: 27173065 DOI: 10.1016/j.athoracsur.2016.03.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 02/11/2016] [Accepted: 03/02/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Previous studies have demonstrated the effect of adult nursing skill mix, staffing ratios, and level of education on patient deaths, complication rates, and failure to rescue (FTR). To date, only one known study had examined the effect of nursing experience and education on postoperative pediatric cardiac operations. METHODS Nursing survey data were linked to The Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database for patients undergoing cardiac operations (2010 to 2011). Logistic regression models were used to estimate associations of nursing education and years of clinical experience with in-hospital mortality rates, complication rates, and FTR. Generalized estimating equations and robust standard error estimates were used to account for within-center correlation of outcomes. RESULTS Among 15,463 patients (29 hospitals), the in-hospital mortality rate was 2.8%, postoperative complications occurred in 42.4%, and the FTR rate was 6.4%. After covariate adjustment, pediatric critical care units with a higher proportion of nurses with a Bachelor of Science degree or higher had lower odds of complication (odds ratio for 10% increase, 0.85; 95% confidence interval, 0.76 to 0.96; p = 0.009). Units with a higher proportion of nurses with more than 2 years of experience had lower mortality rates (odds ratio for 10% increase, 0.92; 95% confidence interval, 0.85 to 0.99; p = 0.025). CONCLUSIONS This is the first study to demonstrate that higher levels of nursing education and experience are significantly associated with fewer complications after pediatric cardiac operations and aligns with our previous findings on their association with reduced deaths. These results provide data for pediatric hospital leaders and reinforce the importance of organization-wide mentoring strategies for new nurses and retention strategies for experienced nurses.
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Affiliation(s)
- Patricia A Hickey
- Department of Nursing Patient Care Services, Boston Children's Hospital, Boston, Massachusetts.
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
| | - J William Gaynor
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Xia He
- Duke Clinical Research Institute, Durham, North Carolina
| | - Kevin D Hill
- Duke Clinical Research Institute, Durham, North Carolina
| | - Jean A Connor
- Department of Nursing Patient Care Services, Boston Children's Hospital, Boston, Massachusetts
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeffrey P Jacobs
- Johns Hopkins Children's Heart Surgery, All Children's Hospital, St. Petersburg, Florida
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Dodge-Khatami A, Chancellor WZ, Gupta B, Seals SR, Ebeid MR, Batlivala SP, Taylor MB, Salazar JD. Achieving Benchmark Results for Neonatal Palliation of Hypoplastic Left Heart Syndrome and Related Anomalies in an Emerging Program. World J Pediatr Congenit Heart Surg 2016; 6:393-400. [PMID: 26180154 DOI: 10.1177/2150135115589605] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Results of surgical management of hypoplastic left heart syndrome (HLHS) and related anomalies are often compared to published benchmark data which reflect the use of a variety of surgical and hybrid protocols. We report encouraging results achieved in an emerging program, despite a learning curve at all care levels. Rather than relying on a single preferred protocol, surgical management was based on matching surgical strategy to individual patient factors. METHODS From 2010 to 2014, a total of 47 consecutive patients with HLHS or related anomalies with ductal-dependent systemic circulation underwent initial surgical palliation, including 30 Norwood stage I, 8 hybrid stage I, and 9 salvage-to-Norwood procedures. True hybrid procedures entailed bilateral pulmonary artery banding and ductal stenting. In the salvage-to-Norwood strategy, ductal stenting was withheld in favor of continued prostaglandin infusion in anticipation of a deferred Norwood procedure. Cardiac comorbidities (obstructed pulmonary venous return, poor ventricular function, and atrioventricular valve regurgitation) and noncardiac comorbidities influenced the choice of treatment strategies and were analyzed as potential risk factors for extracorporeal membrane oxygenation (ECMO) support or in-hospital mortality. RESULTS Overall hospital survival was 81% (Norwood 83.3%, hybrid 88%, "salvage" 67%; P = .4942). Extracorporeal membrane oxygenation support was used for eight (17%) patients with two survivors. For cases with obstructed pulmonary venous return (n = 10, 21%), management choices favored a hybrid or salvage strategy (P = .0026). Aortic atresia (n = 22, 47%) was treated by a Norwood or salvage-to-Norwood. No cardiac, noncardiac, or genetic comorbidities were identified as independent risk factors for ECMO or discharge mortality in a multivariable analysis. CONCLUSIONS Our emerging program achieved outcomes that compare favorably to published benchmark data with respect to hospital survival. These results reflect rigorous interdisciplinary teamwork and a flexible approach to surgical palliation based on matching surgical strategy to patient factors. With major associated cardiac/noncardiac comorbidity and antegrade coronary flow, a true hybrid with ductal stenting was our preferred strategy. For high-risk situations such as aortic atresia with obstructed pulmonary venous return, the salvage hybrid-bridge-to-Norwood strategy may help achieve survival albeit with increased resource utilization.
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Affiliation(s)
- Ali Dodge-Khatami
- Division of Pediatric and Congenital Heart Surgery, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, MS, USA
| | - William Z Chancellor
- Division of Pediatric and Congenital Heart Surgery, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, MS, USA
| | - Bhawna Gupta
- Division of Pediatric and Congenital Heart Surgery, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, MS, USA
| | - Samantha R Seals
- Center of Biostatistics and Bioinformatics, The University of Mississippi Medical Center, Jackson, MS, USA
| | - Makram R Ebeid
- Division of Pediatric Cardiology, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, MS, USA
| | - Sarosh P Batlivala
- Division of Pediatric Cardiology, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, MS, USA
| | - Mary B Taylor
- Division of Pediatric Cardiology, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, MS, USA Division of Pediatric Critical Care, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, MS, USA
| | - Jorge D Salazar
- Division of Pediatric and Congenital Heart Surgery, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, MS, USA
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Oster ME, Kelleman M, McCracken C, Ohye RG, Mahle WT. Association of Digoxin With Interstage Mortality: Results From the Pediatric Heart Network Single Ventricle Reconstruction Trial Public Use Dataset. J Am Heart Assoc 2016; 5:e002566. [PMID: 26764412 PMCID: PMC4859374 DOI: 10.1161/jaha.115.002566] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 11/18/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Mortality for infants with single ventricle congenital heart disease remains as high as 8% to 12% during the interstage period, the time between discharge after the Norwood procedure and before the stage II palliation. The objective of our study was to determine the association between digoxin use and interstage mortality in these infants. METHODS AND RESULTS We conducted a retrospective cohort study using the Pediatric Heart Network Single Ventricle Reconstruction Trial public use dataset, which includes data on infants with single right ventricle congenital heart disease randomized to receive either a Blalock-Taussig shunt or right ventricle-to-pulmonary artery shunt during the Norwood procedure at 15 institutions in North America from 2005 to 2008. Parametric survival models were used to compare the risk of interstage mortality between those discharged to home on digoxin versus those discharged to home not on digoxin, adjusting for center volume, ascending aorta diameter, shunt type, and socioeconomic status. Of the 330 infants eligible for this study, 102 (31%) were discharged home on digoxin. Interstage mortality for those not on digoxin was 12.3%, compared to 2.9% among those on digoxin, with an adjusted hazard ratio of 3.5 (95% CI, 1.1-11.7; P=0.04). The number needed to treat to prevent 1 death was 11 patients. There were no differences in complications between the 2 groups during the interstage period. CONCLUSIONS Digoxin use in infants with single ventricle congenital heart disease is associated with significantly reduced interstage mortality.
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Affiliation(s)
- Matthew E. Oster
- Children's Healthcare of AtlantaGA
- Emory University School of MedicineAtlantaGA
| | | | | | | | - William T. Mahle
- Children's Healthcare of AtlantaGA
- Emory University School of MedicineAtlantaGA
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Ejaz A, Kim Y, Spolverato G, Taylor R, Hundt J, Pawlik TM. Understanding drivers of hospital charge variation for episodes of care among patients undergoing hepatopancreatobiliary surgery. HPB (Oxford) 2015; 17:955-63. [PMID: 26256003 PMCID: PMC4605332 DOI: 10.1111/hpb.12452] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 05/06/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Understanding factors associated with variation in hospital charges may help identify means to increase savings. The aim of the present study was to define potential variation in hospital charges associated with hepatopancreatobiliary(HPB) surgery. METHODS Patients who underwent an HPB procedure between 2009-2013 were identified. Total hospital charges were tabulated for room and board, surgical/anaesthesia services, medications, laboratory/radiology services and other miscellaneous charges. RESULTS Approximately 2545 patients underwent either a pancreas (66.8%) or liver/biliary (33.2%) resection. The mean total charges for all patients were $42,357 ± 33,745 (pancreas: $46,352 ± 34,932 versus the liver: $34,303 ± 29,639; P < 0.001). Morbidity (pancreas, range: 7-18%; liver, range: 9-18%) and observed:expected (O:E) length of stay (LOS)(pancreas, range: 0.67-1.64; liver, range: 1.06-3.35) varied among providers (both P < 0.001). While a peri-operative complication resulted in increased total hospital charges (complication: $66,401 ± 55,124 versus no complication: $39,668 ± 29,250; P < 0.001), total charges remained variable even among patients who did not experience a complication (P < 0.001). Surgeons within the lowest quartile of O:E LOS had lower total charges ($33 879 ± $27 398) versus surgeons in the highest quartile ($49,498 ± 40 971) (P < 0.001). Surgeons with the highest O:E LOS had higher across-the-board charges (operating room, highest quartile: $10,514 ± $4496 versus lowest quartile: $7842 ± $3706; medication, highest quartile: $1796 ± $3799 versus lowest quartile: $925 ± $2211; radiology, highest quartile: $2494 ± $4683 versus lowest quartile: $1424 ± $3247; P = 0.001; laboratory, highest quartile: $4236 ± $5991 versus lowest quartile: $3028 ± $3804; all P < 0.001). CONCLUSIONS After accounting for in-hospital complications, the total mean hospital charges for HPB surgery remained variable by case type and provider. While the variation in charges was associated with LOS, provider-level differences in across-the-board charges were also noted.
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Affiliation(s)
- Aslam Ejaz
- Department of Surgery, University of Illinois Hospital and Health Sciences SystemChicago, IL, USA
| | - Yuhree Kim
- Department of Surgery, The Johns Hopkins HospitalBaltimore, MD, USA
| | - Gaya Spolverato
- Department of Surgery, The Johns Hopkins HospitalBaltimore, MD, USA
| | - Ryan Taylor
- Department of Surgery, The Johns Hopkins HospitalBaltimore, MD, USA
| | - John Hundt
- Department of Surgery, The Johns Hopkins HospitalBaltimore, MD, USA
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins HospitalBaltimore, MD, USA
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105
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Moon-Grady AJ, Morris SA, Belfort M, Chmait R, Dangel J, Devlieger R, Emery S, Frommelt M, Galindo A, Gelehrter S, Gembruch U, Grinenco S, Habli M, Herberg U, Jaeggi E, Kilby M, Kontopoulos E, Marantz P, Miller O, Otaño L, Pedra C, Pedra S, Pruetz J, Quintero R, Ryan G, Sharland G, Simpson J, Vlastos E, Tworetzky W, Wilkins-Haug L, Oepkes D. International Fetal Cardiac Intervention Registry: A Worldwide Collaborative Description and Preliminary Outcomes. J Am Coll Cardiol 2015. [PMID: 26205597 DOI: 10.1016/j.jacc.2015.05.037] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Invasive fetal cardiac intervention (FCI) has been reported in single-institution series, promoting technical and physiologic success. OBJECTIVES This study describes the creation of an international registry of cases presenting for FCI, intended to compile technical and outcome data from a multicenter cohort. METHODS For this initial analysis, the entire database of the International Fetal Cardiac Intervention Registry (IFCIR) was queried for details of diagnoses, procedures, and outcomes. Maternal-fetal dyads from January 2001 through June 2014 were included. RESULTS Eighteen institutions submitted data by data harvest. Of 370 cases entered, 245 underwent FCI: 100 aortic valvuloplasties from a previous single-center report (excluded from additional reporting here), an additional 86 aortic and 16 pulmonary valvuloplasties, 37 atrial septal cases, and 6 unclassified cases. FCI did not appear to affect overall survival to hospital discharge. Among live-born infants with a fetal diagnosis of aortic stenosis/evolving hypoplastic left heart syndrome, more than twice as many were discharged with biventricular circulation after successful FCI versus those meeting institutional criteria but without any or successful FCI (42.8% vs. 19.4%, respectively). When fetal deaths were counted as treatment failures, the percentages were similar: biventricular circulation at discharge was 31.3% versus 18.5% for those discharged with univentricular palliation. Survival to discharge for live-born fetuses with atrial restriction was similar to that of those undergoing technically successful versus unsuccessful FCI (63.6% vs. 46.7%, respectively), although criteria for diagnosis were nonuniform. CONCLUSIONS We describe the contents of the IFCIR and present post-natal data to suggest potential benefit to fetal therapy among pregnancies considered for possible intervention and support proposals for additional work.
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Affiliation(s)
| | | | | | - Ramen Chmait
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Joanna Dangel
- Perinatal Cardiology Clinic, Medical University of Warsaw, Warsaw, Poland
| | | | - Stephen Emery
- Magee Women's Hospital of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Alberto Galindo
- Hospital Universitario 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Sarah Gelehrter
- C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | | | - Sofia Grinenco
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | | | - Edgar Jaeggi
- Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mark Kilby
- University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | | | - Pablo Marantz
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Owen Miller
- Evelina London Children's Hospital, London, United Kingdom
| | - Lucas Otaño
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | | | - Jay Pruetz
- Children's Hospital of Los Angeles, Los Angeles, California
| | - Ruben Quintero
- University of Miami Miller School of Medicine, Miami, Florida
| | - Greg Ryan
- Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - John Simpson
- Evelina London Children's Hospital, London, United Kingdom
| | - Emanuel Vlastos
- SSM Cardinal Glennon Children's Medical Center, St. Louis, Missouri
| | | | | | - Dick Oepkes
- Leiden University Medical Center, Leiden, the Netherlands
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106
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Balachandran R, Kappanayil M, Sen AC, Sudhakar A, Nair SG, Sunil GS, Raj RB, Kumar RK. Impact of the International Quality Improvement Collaborative on outcomes after congenital heart surgery: a single center experience in a developing economy. Ann Card Anaesth 2015; 18:52-7. [PMID: 25566712 PMCID: PMC4900307 DOI: 10.4103/0971-9784.148322] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background: The International Quality Improvement Collaborative (IQIC) for Congenital Heart Surgery in Developing Countries was initiated to decrease mortality and major complications after congenital heart surgery in the developing world. Objective: We sought to assess the impact of IQIC on postoperative outcomes after congenital heart surgery at our institution. Methods: The key components of the IQIC program included creation of a robust worldwide database on key outcome measures and nurse education on quality driven best practices using telemedicine platforms. We evaluated 1702 consecutive patients ≤18 years undergoing congenital heart surgery in our institute from January 2010-December 2012 using the IQIC database. Preoperative variables included age, gender, weight at surgery and surgical complexity as per the RACHS-1 model. The outcome variables included, in- hospital mortality, duration of ventilation, intensive care unit (ICU) stay, bacterial sepsis and surgical site infection. Results: The 1702 patients included 771(45.3%) females. The median age was 8 months (0.03-216) and the median weight was 6.1Kg (1-100). The overall in-hospital mortality was 3.1%, Over the three years there was a significant decline in bacterial sepsis (from 15.1%, to 9.6%, P < 0.001), surgical site infection (11.1% to 2.4%, P < 0.001) and duration of ICU stay from 114(8-999) hours to 72 (18-999) hours (P < 0.001) The decline in mortality from (4.3% to 2.2%) did not reach statistical significance. Conclusions: The inclusion of our institution in the IQIC program was associated with improvement in key outcome measures following congenital heart surgery over a three year period.
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Affiliation(s)
| | | | - Amitabh Chanchal Sen
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Center, Kochi, Kerala, India
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Pike NA, Okuhara CA, Toyama J, Gross BP, Wells WJ, Starnes VA. Reduced pleural drainage, length of stay, and readmissions using a modified Fontan management protocol. J Thorac Cardiovasc Surg 2015; 150:481-7. [DOI: 10.1016/j.jtcvs.2015.06.042] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 06/09/2015] [Accepted: 06/14/2015] [Indexed: 10/23/2022]
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108
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The science of assessing the outcomes and improving the quality of the congenital and paediatric cardiac care. Curr Opin Cardiol 2015; 30:100-11. [PMID: 25469591 DOI: 10.1097/hco.0000000000000133] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Although significant progress has been made in the care of patients with paediatric and congenital cardiac disease, optimization of outcomes remains a constant goal. This review article will discuss the latest advances in the science of assessing the outcomes and improving the quality of the congenital and paediatric cardiac care, and will also review some of the latest associated research. RECENT FINDINGS Important advances continue to be made in each of the following domains: standardized nomenclature; established uniform core dataset; evaluation of case complexity; verification of the completeness and accuracy of the data; collaboration between subspecialties; strategies for longitudinal follow-up; and incorporating quality improvement. In January 2015, the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) will begin voluntary public reporting of programmatic congenital cardiac surgical outcomes using a new risk model that includes both procedural risk (as defined by the procedure itself and STAT Categories) and a number of patient-specific characteristics including age, weight, prior cardiothoracic operation, prematurity, chromosomal abnormalities, syndromes, noncardiac congenital anatomic abnormalities and preoperative factors. Clinical databases have been linked with administrative database to answer questions neither dataset can answer independently, providing new information about long-term mortality, rates of rehospitalization, long-term morbidity, comparative effectiveness of various treatments, and the cost of healthcare. Multiple research initiatives have recently been published using STS-CHSD. SUMMARY The science of assessing the outcomes and improving the quality of congenital and paediatric cardiac care continues to evolve. Recent advances will facilitate the continued evolution of a meaningful method of multiinstitutional outcomes analysis for congenital and paediatric cardiac surgery.
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The Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Risk Model: Part 1-Statistical Methodology. Ann Thorac Surg 2015; 100:1054-62. [PMID: 26245502 DOI: 10.1016/j.athoracsur.2015.07.014] [Citation(s) in RCA: 128] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 07/10/2015] [Accepted: 07/13/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND This study's objective was to develop a risk model incorporating procedure type and patient factors to be used for case-mix adjustment in the analysis of hospital-specific operative mortality rates after congenital cardiac operations. METHODS Included were patients of all ages undergoing cardiac operations, with or without cardiopulmonary bypass, at centers participating in The Society of Thoracic Surgeons Congenital Heart Surgery Database during January 1, 2010, to December 31, 2013. Excluded were isolated patent ductus arteriosus closures in patients weighing less than or equal to 2.5 kg, centers with more than 10% missing data, and patients with missing data for key variables. Data from the first 3.5 years were used for model development, and data from the last 0.5 year were used for assessing model discrimination and calibration. Potential risk factors were proposed based on expert consensus and selected after empirically comparing a variety of modeling options. RESULTS The study cohort included 52,224 patients from 86 centers with 1,931 deaths (3.7%). Covariates included in the model were primary procedure, age, weight, and 11 additional patient factors reflecting acuity status and comorbidities. The C statistic in the validation sample was 0.858. Plots of observed-vs-expected mortality rates revealed good calibration overall and within subgroups, except for a slight overestimation of risk in the highest decile of predicted risk. Removing patient preoperative factors from the model reduced the C statistic to 0.831 and affected the performance classification for 12 of 86 hospitals. CONCLUSIONS The risk model is well suited to adjust for case mix in the analysis and reporting of hospital-specific mortality for congenital heart operations. Inclusion of patient factors added useful discriminatory power and reduced bias in the calculation of hospital-specific mortality metrics.
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110
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Jacobs JP, O'Brien SM, Pasquali SK, Gaynor JW, Mayer JE, Karamlou T, Welke KF, Filardo G, Han JM, Kim S, Quintessenza JA, Pizarro C, Tchervenkov CI, Lacour-Gayet F, Mavroudis C, Backer CL, Austin EH, Fraser CD, Tweddell JS, Jonas RA, Edwards FH, Grover FL, Prager RL, Shahian DM, Jacobs ML. The Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Risk Model: Part 2-Clinical Application. Ann Thorac Surg 2015; 100:1063-8; discussion 1068-70. [PMID: 26245504 DOI: 10.1016/j.athoracsur.2015.07.011] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 04/24/2015] [Accepted: 07/02/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The empirically derived 2014 Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Risk Model incorporates adjustment for procedure type and patient-specific factors. The purpose of this report is to describe this model and its application in the assessment of variation in outcomes across centers. METHODS All index cardiac operations in The Society of Thoracic Surgeons Congenital Heart Surgery Database (January 1, 2010, to December 31, 2013) were eligible for inclusion. Isolated patent ductus arteriosus closures in patients weighing less than or equal to 2.5 kg were excluded, as were centers with more than 10% missing data and patients with missing data for key variables. The model includes the following covariates: primary procedure, age, any prior cardiovascular operation, any noncardiac abnormality, any chromosomal abnormality or syndrome, important preoperative factors (mechanical circulatory support, shock persisting at time of operation, mechanical ventilation, renal failure requiring dialysis or renal dysfunction (or both), and neurological deficit), any other preoperative factor, prematurity (neonates and infants), and weight (neonates and infants). Variation across centers was assessed. Centers for which the 95% confidence interval for the observed-to-expected mortality ratio does not include unity are identified as lower-performing or higher-performing programs with respect to operative mortality. RESULTS Included were 52,224 operations from 86 centers. Overall discharge mortality was 3.7% (1,931 of 52,224). Discharge mortality by age category was neonates, 10.1% (1,129 of 11,144); infants, 3.0% (564 of 18,554), children, 0.9% (167 of 18,407), and adults, 1.7% (71 of 4,119). For all patients, 12 of 86 centers (14%) were lower-performing programs, 67 (78%) were not outliers, and 7 (8%) were higher-performing programs. CONCLUSIONS The 2014 Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Risk Model facilitates description of outcomes (mortality) adjusted for procedural and for patient-level factors. Identification of low-performing and high-performing programs may be useful in facilitating quality improvement efforts.
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Affiliation(s)
- Jeffrey P Jacobs
- Johns Hopkins All Children's Heart Institute, Saint Petersburg, Tampa, and Orlando, Florida; Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Florida Hospital for Children, Orlando, Florida.
| | - Sean M O'Brien
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Sara K Pasquali
- Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - John E Mayer
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery, Benioff Children's Hospital, University of California, San Francisco, San Francisco, California
| | - Karl F Welke
- Section of Congenital Cardiovascular Surgery, University of Illinois College of Medicine at Peoria, Children's Hospital of Illinois, Peoria, Illinois
| | - Giovanni Filardo
- Institute for Health Care Research and Improvement, Baylor Health Care System, Dallas, Texas
| | - Jane M Han
- The Society of Thoracic Surgeons, Chicago, Illinois
| | - Sunghee Kim
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - James A Quintessenza
- Johns Hopkins All Children's Heart Institute, Saint Petersburg, Tampa, and Orlando, Florida; Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Florida Hospital for Children, Orlando, Florida
| | | | | | | | - Constantine Mavroudis
- Johns Hopkins All Children's Heart Institute, Saint Petersburg, Tampa, and Orlando, Florida; Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Florida Hospital for Children, Orlando, Florida
| | - Carl L Backer
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Erle H Austin
- Kosair Children's Hospital, University of Louisville, Louisville, Kentucky
| | - Charles D Fraser
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | | | | | - Fred H Edwards
- University of Florida, College of Medicine-Jacksonville, Jacksonville, Florida
| | | | | | - David M Shahian
- Massachusetts General Hospital Department of Surgery and Center for Quality and Safety, and Harvard Medical School, Boston, Massachusetts
| | - Marshall L Jacobs
- Johns Hopkins All Children's Heart Institute, Saint Petersburg, Tampa, and Orlando, Florida; Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Florida Hospital for Children, Orlando, Florida
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111
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Elevated Aortic Augmentation Index in Children Following Fontan Palliation: Evidence of Stiffer Arteries? Pediatr Cardiol 2015; 36:1232-8. [PMID: 25832849 DOI: 10.1007/s00246-015-1151-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 03/24/2015] [Indexed: 10/23/2022]
Abstract
Children born with a functional single ventricle who undergo Fontan palliation are prone to early pump failure. Whether they develop early arterial stiffness with resultant increase in afterload is not well known. We hypothesized that the aortic stiffness is higher in pediatric Fontan patients when compared to healthy controls. A prospective study was conducted at the Children's Hospital of Michigan. Twenty-two Fontan patients (aged 6-21 years) were compared with 22 healthy controls (aged 9-17 years) selected from children referred to our clinic who had normal cardiac anatomy and function on the echocardiogram. Aortic stiffness was assessed noninvasively by measuring the aortic augmentation index (AAI) using applanation tonometry (Sphygmocor, Atcor, IL). AAI was calculated as AP/PP where augmentation pressure (AP) is the increase in aortic systolic blood pressure (BP) and pulse pressure (PP) is the difference between aortic systolic and diastolic BP. Ten patients (45 %) had hypoplastic left ventricle, and 11 (50 %) had undergone aortic arch surgery. The median AAI was significantly higher in Fontan patients when compared to controls (12.5, IQR 4.8, 17.3 vs 0, IQR -6.3, 5.8; p = 0.0003). History of aortic arch surgery and single ventricle morphology did not have a significant impact on AAI. Pediatric patients who undergo Fontan palliation have significantly higher AAI, a marker of aortic stiffness and increased afterload, compared to healthy controls. Larger longitudinal studies are warranted to elucidate the possible contribution of elevated AAI on pump failure in these patients.
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Affiliation(s)
- Sara K Pasquali
- From Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital Congenital Heart Center, University of Michigan, Ann Arbor.
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113
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Collaborative quality improvement in the cardiac intensive care unit: development of the Paediatric Cardiac Critical Care Consortium (PC4). Cardiol Young 2015; 25:951-7. [PMID: 25167212 PMCID: PMC4344914 DOI: 10.1017/s1047951114001450] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Despite many advances in recent years for patients with critical paediatric and congenital cardiac disease, significant variation in outcomes remains across hospitals. Collaborative quality improvement has enhanced the quality and value of health care across specialties, partly by determining the reasons for variation and targeting strategies to reduce it. Developing an infrastructure for collaborative quality improvement in paediatric cardiac critical care holds promise for developing benchmarks of quality, to reduce preventable mortality and morbidity, optimise the long-term health of patients with critical congenital cardiovascular disease, and reduce unnecessary resource utilisation in the cardiac intensive care unit environment. The Pediatric Cardiac Critical Care Consortium (PC4) has been modelled after successful collaborative quality improvement initiatives, and is positioned to provide the data platform necessary to realise these objectives. We describe the development of PC4 including the philosophical, organisational, and infrastructural components that will facilitate collaborative quality improvement in paediatric cardiac critical care.
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DiBardino DJ, Gomez-Arostegui J, Kemp A, Raviendran R, Hegde S, Devaney EJ, Lamberti JJ, El-Said H. Intermediate Results of Hybrid Versus Primary Norwood Operation. Ann Thorac Surg 2015; 99:2141-7; discussion 2147-9. [DOI: 10.1016/j.athoracsur.2015.02.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Revised: 01/21/2015] [Accepted: 02/06/2015] [Indexed: 11/25/2022]
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Abstract
BACKGROUND Although much is known about morbidity and mortality, there are limited data focussing on the financial aspect of the Norwood operation. Our objective is to characterise the hospitalisation and detail the hospital costs. METHODS We retrospectively studied 86 newborns with hypoplastic left heart syndrome who underwent Norwood palliation between 2008 and 2012. Clinical and financial data were collected. Financial data have been reported for 2011-2012. RESULTS At surgery, median age and weight of the patients were 4 days (range 1-13) and 3 kg (range 2-4.8), respectively. The median time from admission to surgery was 4 days (range 1-10), with the postoperative ICU stay and total length of stay at the hospital being 10 days (range 4-135) and 16 days (range 5-136), respectively. Discharge mortality was 14/86 (16%) patients. For patients operated on between 2011 and 2012 (n=40), median hospital costs, charges, and collections per patient were $117,021, $433,054, and $198,453, respectively, and mean hospital costs, charges, and collections per patient were $322,765, $1,109,500, and $511,271, respectively. A breakdown of total hospital costs (direct and indirect) by department showed that the top four areas of resource utilisation (excluding physician fees) were as follows: the cardiac ICU (35%), laboratory (12%), pharmacy (12%), and operating room (7%). Interestingly, point-of-care laboratory evaluations accounted for almost half of the laboratory total (5%). Extracorporeal membrane oxygenation, although only utilised in eight patients between 2011 and 2012, accounted for 7% of utilisation.General radiology only accounted for 2%, despite numerous radiographs. CONCLUSIONS Limited data are available that detail the hospitalisation and costs associated with the Norwood operation. We hope that this analysis will identify areas for quality and value improvement from both system and patient perspectives.
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Brown KL, Crowe S, Franklin R, McLean A, Cunningham D, Barron D, Tsang V, Pagel C, Utley M. Trends in 30-day mortality rate and case mix for paediatric cardiac surgery in the UK between 2000 and 2010. Open Heart 2015; 2:e000157. [PMID: 25893099 PMCID: PMC4395835 DOI: 10.1136/openhrt-2014-000157] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Revised: 11/28/2014] [Accepted: 01/20/2015] [Indexed: 11/07/2022] Open
Abstract
Objectives To explore changes over time in the 30-day mortality rate for paediatric cardiac surgery and to understand the role of attendant changes in the case mix. Methods, setting and participants Included were: all mandatory submissions to the National Institute of Cardiovascular Outcomes Research (NICOR) relating to UK cardiac surgery in patients aged <16 years. The χ2 test for trend was used to retrospectively analyse the proportion of surgical episodes ending in 30-day mortality and with various case mix indicators, in 10 consecutive time periods, from 2000 to 2010. Comparisons were made between two 5-year eras of: 30-day mortality, period prevalence and mean age for 30 groups of specific operations. Main outcome measure 30-day mortality for an episode of surgical management. Results Our analysis includes 36 641 surgical episodes with an increase from 2283 episodes in 2000 to 3939 in 2009 (p<0.01). The raw national 30-day mortality rate fell over the period of review from 4.3% (95% CI 3.5% to 5.1%) in 2000 to 2.6% (95% CI 2.2% to 3.0%) in 2009/2010 (p<0.01). The case mix became more complex in terms of the percentage of patients <2.5 kg (p=0.05), with functionally univentricular hearts (p<0.01) and higher risk diagnoses (p<0.01). In the later time era, there was significant improvement in 30-day mortality for arterial switch with ventricular septal defect (VSD) repair, patent ductus arteriosus ligation, Fontan-type operation, tetralogy of Fallot and VSD repair, and the mean age of patients fell for a range of operations performed in infancy. Conclusions The raw 30-day mortality rate for paediatric cardiac surgery fell over a decade despite a rise in the national case mix complexity, and compares well with international benchmarks. Definitive repair is now more likely at a younger age for selected infants with congenital heart defects.
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Affiliation(s)
- Katherine L Brown
- Cardiac Unit , Great Ormond Street Hospital for Children , London , UK ; Institute for Cardiovascular Science, University College London, London , UK
| | - Sonya Crowe
- Clinical Operational Research Unit , University College London , London , UK
| | - Rodney Franklin
- Department of Paediatric Cardiology , Royal Brompton and Harefield NHS Foundation Trust , London , UK
| | - Andrew McLean
- Cardiac Surgery Department , The Royal Hospital for Sick Children , Glasgow , UK
| | - David Cunningham
- National Institute for Cardiac Outcomes Research (NICOR), University College London , London , UK
| | - David Barron
- Cardiac Surgery Department , Birmingham Children's Hospital , Birmingham , UK
| | - Victor Tsang
- Cardiac Unit , Great Ormond Street Hospital for Children , London , UK ; Institute for Cardiovascular Science, University College London, London , UK
| | - Christina Pagel
- Clinical Operational Research Unit , University College London , London , UK
| | - Martin Utley
- Clinical Operational Research Unit , University College London , London , UK
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Croatian clinical epidemiological study (2008-2011): the use of standardised risk scores in paediatric congenital cardiac surgery for a case complexity selection and gradual progress of cardiosurgical model in developing countries. Cardiol Young 2015; 25:274-80. [PMID: 25647467 DOI: 10.1017/s1047951113002060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE By employing the widely used and accepted methodologies of case-mix complexity adjustment in congenital cardiac surgery, we tried to evaluate our performance and use the ABC scores for a case complexity selection that may have different outcomes in various centres. METHODS We analysed outcomes of cardiac surgical procedures - with or without cardiopulmonary bypass - performed in our institution between January, 2008 and December, 2011. Data were collected from the European Association for Cardio-Thoracic Surgery database. Together with prospective collection of these data, the data of all patients sent abroad to foreign cardiosurgical centres were recorded. RESULTS During the period of study, 634 operations were performed; among them, 60% were performed in Croatia and 40% in foreign cardiosurgical centres. The number of operations performed in Croatia showed a linear increase: 55, 78, 121, and 126 operations performed in the years 2008, 2009, 2010, and 2011, respectively. Early mortality rates were 1.82%, 5.41%, 3.64%, and 3.48% in 2008, 2009, 2010, and 2011, respectively. The increase in the number of operations was followed by a satisfactory low average mortality rate of 3.85%. The mean ABC score complexity for operations performed in Croatia was 5.77. We determined a linear correlation between ABC score and early mortality, especially for the more complex operations. CONCLUSION The use of standardised risk scores allows selection of complex cardiac diseases, which may have very different outcomes in various centres. In our case, those with higher ABC scores were correctly identified and referred for treatment abroad. In this way, we allowed gradual progress of the cardiosurgical model in Croatia and maintained an enviably low mortality rate.
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Sunstrom RE, Muralidaran A, Gerrah R, Reed RD, Good MK, Armsby LR, Rekito AJ, Zubair MM, Langley SM. A Defined Management Strategy Improves Early Outcomes After the Fontan Procedure: The Portland Protocol. Ann Thorac Surg 2015; 99:148-55. [DOI: 10.1016/j.athoracsur.2014.06.121] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 06/11/2014] [Accepted: 06/13/2014] [Indexed: 11/25/2022]
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Austin EH. Validation accepted, but look at what else was revealed. J Thorac Cardiovasc Surg 2014; 148:2568-9. [PMID: 25433876 DOI: 10.1016/j.jtcvs.2014.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 10/01/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Erle H Austin
- Department of Surgery, University of Louisville, Louisville, Ky.
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120
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Shenoy RU, Parness IA. Hypoplastic Left Heart Syndrome. J Am Coll Cardiol 2014; 64:2036-8. [DOI: 10.1016/j.jacc.2014.09.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Revised: 09/16/2014] [Accepted: 09/17/2014] [Indexed: 10/24/2022]
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121
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Gupta P, Jacobs JP, Pasquali SK, Hill KD, Gaynor JW, O'Brien SM, He M, Sheng S, Schexnayder SM, Berg RA, Nadkarni VM, Imamura M, Jacobs ML. Epidemiology and outcomes after in-hospital cardiac arrest after pediatric cardiac surgery. Ann Thorac Surg 2014; 98:2138-43; discussion 2144. [PMID: 25443018 DOI: 10.1016/j.athoracsur.2014.06.103] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 06/23/2014] [Accepted: 06/27/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Multicenter data regarding cardiac arrest in children undergoing heart operations are limited. We describe epidemiology and outcomes associated with postoperative cardiac arrest in a large multiinstitutional cohort. METHODS Patients younger than 18 years in the Society of Thoracic Surgeons Congenital Heart Surgery Database (2007 through 2012) were included. Patient factors, operative characteristics, and outcomes were described for patients with and without postoperative cardiac arrest. Multivariable models were used to evaluate the association of center volume with cardiac arrest rate and mortality after cardiac arrest, adjusting for patient and procedural factors. RESULTS Of 70,270 patients (97 centers), 1,843 (2.6%) had postoperative cardiac arrest. Younger age, lower weight, and presence of preoperative morbidities (all p < 0.0001) were associated with cardiac arrest. Arrest rate increased with procedural complexity across common benchmark operations, ranging from 0.7% (ventricular septal defect repair) to 12.7% (Norwood operation). Cardiac arrest was associated with significant mortality risk across procedures, ranging from 15.4% to 62.3% (all p < 0.0001). In multivariable analysis, arrest rate was not associated with center volume (odds ratio, 1.06; 95% confidence interval, 0.71 to 1.57 in low- versus high-volume centers). However, mortality after cardiac arrest was higher in low-volume centers (odds ratio, 2.00; 95% confidence interval, 1.52 to 2.63). This association was present for both high- and low-complexity operations. CONCLUSIONS Cardiac arrest carries a significant mortality risk across the stratum of procedural complexity. Although arrest rates are not associated with center volume, lower-volume centers have increased mortality after cardiac arrest. Further study of mechanisms to prevent cardiac arrest and to reduce mortality in those with an arrest is warranted.
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Affiliation(s)
- Punkaj Gupta
- Division of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
| | - Jeffrey P Jacobs
- Johns Hopkins Children's Heart Surgery, All Children's Hospital, St. Petersburg, Florida; Division of Cardiac Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sara K Pasquali
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Kevin D Hill
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - J William Gaynor
- Department of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sean M O'Brien
- Duke Clinical Research Institute, Durham, North Carolina
| | - Max He
- Duke Clinical Research Institute, Durham, North Carolina
| | - Shubin Sheng
- Duke Clinical Research Institute, Durham, North Carolina
| | - Stephen M Schexnayder
- Division of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Robert A Berg
- Department of Anesthesia and Critical Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Vinay M Nadkarni
- Department of Anesthesia and Critical Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michiaki Imamura
- Division of Cardiothoracic Surgery, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Marshall L Jacobs
- Division of Cardiac Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
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Austin EH. Congenital Heart Surgeons' Society presidential address: delivering medical excellence. World J Pediatr Congenit Heart Surg 2014; 5:571-9. [PMID: 25324256 DOI: 10.1177/2150135114545092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Erle H Austin
- Department of Surgery, University of Louisville, Kosair Children's Hospital, Louisville, KY, USA
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Tomotaki A, Miyata H, Hashimoto H, Murakami A, Ono M. Results of data verification of the Japan congenital cardiovascular database, 2008 to 2009. World J Pediatr Congenit Heart Surg 2014; 5:47-53. [PMID: 24403354 DOI: 10.1177/2150135113508794] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Since 2008, data concerning pediatric cardiovascular surgeries performed in Japan have been collected in the Japan Congenital Cardiovascular Surgery Database (JCCVSD). We assessed the quality of the JCCVSD data through data verification activities conducted in 2010. METHODS During 2008 to 2009, 3345 patients with 4327 procedures at 25 hospitals were registered in the JCCVSD. Among them, six sites were selected for data verification. The completeness of case registration was assessed by comparison with original operational logs. Also, data accuracy of patient demographics, surgical outcomes, and processes were assessed with 10% of the registered cases by comparison with medical records. RESULTS Verification of case registration completeness involved 968 (28.9%) patients and 1279 (29.1%) procedures. As to completeness, we confirmed 1266 (99.0%) of the 1279 procedures. Data accuracy was verified for 129 (3.9%) patients. Accuracy of status of discharge and 30 and 90 days after surgery were very high (99.2%, 100%, and 100%, respectively). Data items with numeric information exhibited lower exact accuracy due to typing error and inconsistent use of rounding; however, the differences between the submitted and the original data were not statistically significant. CONCLUSIONS High completeness and acceptable range of data accuracy were verified for the data submitted to the JCCVSD in 2008 to 2009. The high accuracy regarding follow-up outcomes was especially noteworthy. The initial success of the JCCVSD should be strengthened through further sophistication of registration protocol, continual training of data managers and auditors, and rigorous expansion of verification activities.
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Affiliation(s)
- Ai Tomotaki
- Department of Healthcare Quality Assessment, Graduate School of Medicine, the University of Tokyo, Bunkyo-ku, Tokyo, Japan
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124
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Affiliation(s)
- Michael Gaies
- Department of Pediatrics and Communicable Diseases, Division of Cardiology, University of Michigan, Ann Arbor, MI, USA
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125
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Albanese SB, Zannini LV, Perri G, Crupi G, Turinetto B, Pongiglione G. "Baby Heart Project": the Italian project for accreditation and quality management in pediatric cardiology and cardiac surgery. Pediatr Cardiol 2014; 35:1162-73. [PMID: 24880465 DOI: 10.1007/s00246-014-0910-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 03/26/2014] [Indexed: 11/29/2022]
Abstract
Optimization of the relationship between the supply and the demand for medical services should ideally be taken into consideration for the planning within each national Health System. Although government national health organizations embrace this policy specifically, the contribution of expert committees (under the scientific societies' guarantee in any specific medical field) should be advocated for their capability to collect and analyze the data reported by the various national institutions. In addition, these committees have the competence to analyze the need for the resources necessary to the operation of these centers. The field of pediatric cardiology and cardiac surgery may represent a model of clinical governance of particular interest with regard to programming and to a definition of the quality standards that may be extended to highly specialized institutions and ideally to the entire Health System. The "Baby Heart Project," which represents a model of governance and clinical quality in the field of pediatric cardiology and cardiac surgery, was born from the spontaneous aggregation of a committee of experts, supported by duly appointed Italian Scientific Societies and guided by a national agency for accreditation. The ultimate aim is to standardize both procedures and results for future planning within the national Health System.
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Affiliation(s)
- Sonia B Albanese
- Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital IRCCS, P.zza S. Onofrio, 4-00165, Rome, Italy,
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O'Byrne ML, Yang W, Mercer-Rosa L, Parnell AS, Oster ME, Levenbrown Y, Tanel RE, Goldmuntz E. 22q11.2 Deletion syndrome is associated with increased perioperative events and more complicated postoperative course in infants undergoing infant operative correction of truncus arteriosus communis or interrupted aortic arch. J Thorac Cardiovasc Surg 2014; 148:1597-605. [PMID: 24629220 PMCID: PMC4127373 DOI: 10.1016/j.jtcvs.2014.02.011] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 01/13/2014] [Accepted: 02/03/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The effect of genotype on the outcomes of infant cardiac operations has not been well established. The purpose of the present study was to investigate the effect of 22q11.2 deletion (22q11del) on infants with truncus arteriosus communis (TA) and interrupted aortic arch (IAA) undergoing operative correction during infancy. METHODS We conducted a retrospective cohort study of all infants who had undergone operative correction of TA or IAA at the Children's Hospital of Philadelphia from 1995 to 2007, comparing the perioperative outcomes (hospital length of stay, intensive care, mechanical ventilation, risk of cardiac and noncardiac events, number of consultations, and number of discharge medications) by 22q11del status. RESULTS A total of 104 patients were studied (55 with TA and 49 with IAA), of whom 40 (38%) were 22q11del positive. The 22q11del status was unknown in 9 (7 with TA and 2 with IAA). In patients with known deletion status, those with 22q11del had a longer hospital and intensive care length of stay. Subjects with 22q11del also required more frequent operative reintervention and more consultations and were prescribed more medications at discharge. No significant difference was found in method of feeding between those with and without 22q11del at discharge. CONCLUSIONS In this study, 22q11del is associated with perioperative outcomes in infants undergoing operative correction of TA and IAA, with longer hospital stays and greater resource utilization in the perioperative period. These findings should inform counseling and risk stratification and warrant additional study to identify genotype-specific management strategies to improve outcomes.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa.
| | - Wei Yang
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Laura Mercer-Rosa
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Aimee S Parnell
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Mississippi, University of Mississippi Medical Center, Jackson, Miss
| | - Matthew E Oster
- Children's Healthcare of Atlanta, Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga
| | - Yosef Levenbrown
- Department of Anesthesiology and Critical Care, Alfred I. duPont Hospital for Children, Wilmington, Del, and Jefferson Medical College, Philadelphia, Pa
| | - Ronn E Tanel
- Department of Pediatrics, University of California, San Francisco, School of Medicine, and Division of Pediatric Cardiology, UCSF Benioff Children's Hospital, San Francisco, Calif
| | - Elizabeth Goldmuntz
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
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Jacobs JP, O'Brien SM, Pasquali SK, Kim S, Gaynor JW, Tchervenkov CI, Karamlou T, Welke KF, Lacour-Gayet F, Mavroudis C, Mayer JE, Jonas RA, Edwards FH, Grover FL, Shahian DM, Jacobs ML. The importance of patient-specific preoperative factors: an analysis of the society of thoracic surgeons congenital heart surgery database. Ann Thorac Surg 2014; 98:1653-8; discussion 1658-9. [PMID: 25262395 DOI: 10.1016/j.athoracsur.2014.07.029] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Revised: 07/04/2014] [Accepted: 07/09/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND The most common forms of risk adjustment for pediatric and congenital heart surgery used today are based mainly on the estimated risk of mortality of the primary procedure of the operation. The goals of this analysis were to assess the association of patient-specific preoperative factors with mortality and to determine which of these preoperative factors to include in future pediatric and congenital cardiac surgical risk models. METHODS All index cardiac operations in The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) during 2010 through 2012 were eligible for inclusion. Patients weighing less than 2.5 kg undergoing patent ductus arteriosus closure were excluded. Centers with more than 10% missing data and patients with missing data for discharge mortality or other key variables were excluded. Rates of discharge mortality for patients with or without specific preoperative factors were assessed across age groups and were compared using Fisher's exact test. RESULTS In all, 25,476 operations were included (overall discharge mortality 3.7%, n=943). The prevalence of common preoperative factors and their associations with discharge mortality were determined. Associations of the following preoperative factors with discharge mortality were all highly significant (p<0.0001) for neonates, infants, and children: mechanical circulatory support, renal dysfunction, shock, and mechanical ventilation. CONCLUSIONS Current STS-CHSD risk adjustment is based on estimated risk of mortality of the primary procedure of the operation as well as age, weight, and prematurity. The inclusion of additional patient-specific preoperative factors in risk models for pediatric and congenital cardiac surgery could lead to increased precision in predicting risk of operative mortality and comparison of observed to expected outcomes.
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Affiliation(s)
- Jeffrey Phillip Jacobs
- Johns Hopkins All Children's Heart Institute, Saint Petersburg, Florida; Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Sean M O'Brien
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Sara K Pasquali
- Department of Pediatrics and Communicable Diseases, C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Sunghee Kim
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - Christo Ivanov Tchervenkov
- Division of Pediatric Cardiac Surgery, Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | - Tara Karamlou
- Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Karl F Welke
- Children's Hospital of Illinois, Peoria, Illinois
| | | | - Constantine Mavroudis
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John E Mayer
- Children's Hospital Boston, Harvard University Medical School, Boston, Massachusetts
| | - Richard A Jonas
- Children's National Heart Institute, Children's National Medical Center, Washington, DC
| | - Fred H Edwards
- Shands Jacksonville, University of Florida, College of Medicine-Jacksonville, Jacksonville, Florida
| | | | - David M Shahian
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marshall Lewis Jacobs
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Karamlou T, Jacobs ML, Pasquali S, He X, Hill K, O'Brien S, McMullan DM, Jacobs JP. Surgeon and Center Volume Influence on Outcomes After Arterial Switch Operation: Analysis of the STS Congenital Heart Surgery Database. Ann Thorac Surg 2014; 98:904-11. [DOI: 10.1016/j.athoracsur.2014.04.093] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Revised: 04/05/2014] [Accepted: 04/08/2014] [Indexed: 11/29/2022]
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Smith AH, Doyle TP, Mettler BA, Bichell DP, Gay JC. Identifying predictors of hospital readmission following congenital heart surgery through analysis of a multiinstitutional administrative Database. CONGENIT HEART DIS 2014; 10:142-52. [PMID: 25130487 DOI: 10.1111/chd.12209] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Despite resource burdens associated with hospital readmission, there remains little multiinstitutional data available to identify children at risk for readmission following congenital heart surgery. METHODS AND RESULTS Children undergoing congenital heart surgery and discharged home between January of 2011 and December 2012 were identified within the Pediatric Health Information System database, a multiinstitutional collection of clinical and administrative data. Patient discharges were assigned to derivation and validation cohorts for the purposes of predictive model design, with 17 871 discharges meeting inclusion criteria. Readmission within 30 days was noted following 956 (11%) of discharges within the derivation cohort (n = 9104), with a median time to readmission of 9 days (interquartile range [IQR] 5-18 days). Readmissions resulted in a rehospitalization length of stay of 4 days (IQR 2-8 days) and were associated with an intensive care unit (ICU) admission in 36% of cases. Independent perioperative predictors of readmission included Risk Adjustment in Congenital Heart Surgery score of 6 (odds ratio [OR] 2.6, 95% confidence interval [CI] 1.8-3.7, P < .001) and ICU length of stay of at least 7 days (OR 1.9 95% CI 1.6-2.2, P < .001). Demographic predictors included Hispanic ethnicity (OR 1.2, 95% CI 1.1-1.4, P = .014) and government payor status (OR 1.2, 95% CI 1.1-1.4, P = .007). Predictive model performance was modest among validation cohort (c statistic 0.68, 95% CI 0.66-0.69, P < .001). CONCLUSIONS Readmissions following congenital heart surgery are common and associated with significant resource consumption. While we describe independent predictors that may identify patients at risk for readmission prior to hospital discharge, there likely remains other unreported factors that may contribute to readmission following congenital heart surgery.
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Affiliation(s)
- Andrew H Smith
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tenn, USA; Division of Pediatric Critical Care Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tenn, USA
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Saharan S, Legg AT, Armsby LB, Zubair MM, Reed RD, Langley SM. Causes of readmission after operation for congenital heart disease. Ann Thorac Surg 2014; 98:1667-73. [PMID: 25130076 DOI: 10.1016/j.athoracsur.2014.05.043] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 05/14/2014] [Accepted: 05/22/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Readmission after operations for congenital heart conditions has significant implications for patient care. Readmission rates vary between 8.7% and 15%. The aim of this study was to determine the incidence, causes, and risk factors associated with readmission. METHODS 811 consecutive patients undergoing operations for congenital heart conditions were analyzed. Readmission was defined as admission to any hospital within 30 days of discharge for any cause. Demographic, preoperative, operative, and postoperative variables were evaluated. Univariate comparisons were made between the nonreadmission and readmission groups, and multivariate logistic regression analysis was made to determine independent risk factors for readmission. RESULTS There were a total of 92 readmissions in 79 patients (9.7%). The reasons included cardiac (36, 39%), pulmonary (20, 22%), gastrointestinal (13, 14%), infectious (20, 22%), and other adverse events (2, 2%). Patients with either single-ventricle palliation or nasogastric feeding accounted for 40 (50%) readmissions. On univariate analysis, there were significant differences between readmitted and nonreadmitted patients in relation to patient age, chromosomal abnormality, mortality risk score, duration of mechanical ventilation, postoperative length of stay, single-ventricle physiology, and nasogastric feeding at discharge (p < 0.05). On multivariate analysis, significant risk factors for readmission were single-ventricle physiology (odds ratio [OR] 2.39; 95% confidence interval [CI] 1.28 to 4.47; p=0.005), preoperative arrhythmia (OR 2.59; 95% CI 1.02 to 6.59; p=0.04), longer postoperative length of stay (OR 2.2; 95% CI 1.22 to 3.99; p=0.008), and nasogastric tube feeding at discharge (OR 2.2; 95% CI 1.15 to 4.19; p=0.01). CONCLUSIONS The incidence of readmission after operations for congenital cardiac conditions remains high. Efforts focusing on patients with single-ventricle palliation and those with preoperative arrhythmia, prolonged postoperative length of stay and nasogastric tube feeding at discharge may be particularly beneficial.
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Affiliation(s)
- Sunil Saharan
- Division of Pediatric Cardiology, Department of Pediatrics and Surgery, Doernbecher Children's Hospital, Portland, Oregon.
| | - Arthur T Legg
- Division of Pediatric Cardiology, Department of Pediatrics and Surgery, Doernbecher Children's Hospital, Portland, Oregon
| | - Laurie B Armsby
- Division of Pediatric Cardiology, Department of Pediatrics and Surgery, Doernbecher Children's Hospital, Portland, Oregon
| | - M Mujeeb Zubair
- Division of Pediatric Cardiac Surgery, Department of Pediatrics and Surgery, Doernbecher Children's Hospital, Portland, Oregon
| | - Richard D Reed
- Division of Pediatric Cardiac Surgery, Department of Pediatrics and Surgery, Doernbecher Children's Hospital, Portland, Oregon
| | - Stephen M Langley
- Division of Pediatric Cardiac Surgery, Department of Pediatrics and Surgery, Doernbecher Children's Hospital, Portland, Oregon
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131
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Anderson BR, Ciarleglio AJ, Salavitabar A, Torres A, Bacha EA. Earlier stage 1 palliation is associated with better clinical outcomes and lower costs for neonates with hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 2014; 149:205-10.e1. [PMID: 25227701 DOI: 10.1016/j.jtcvs.2014.07.094] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 07/01/2014] [Accepted: 07/18/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Our aim was to examine the effects of surgical timing on major morbidity, mortality, and total hospital reimbursement for late preterm and term infants with hypoplastic left heart syndrome (HLHS) undergoing stage 1 palliation within the first 2 weeks of life. METHODS We conducted a retrospective cohort study of infants aged ≥35 weeks gestation, with HLHS, admitted to our institution at age ≤5 days, between January 1, 2003, and January 1, 2013. Children with other cardiac abnormalities or other major comorbid conditions were excluded. Univariable and multivariable analyses were performed to determine the association between age at stage 1 palliation and major morbidity, mortality, and hospital reimbursement. RESULTS One hundred thirty-four children met inclusion criteria. Mortality was 7.5% (n = 10). Forty-three percent (n = 58) experienced major morbidity. Median costs were $97,000, in 2013 dollars (interquartile range, $72,000-$151,000). Median age at operation was 5 days (interquartile range, 3-7 days; full range, 1-14 days). All deaths occurred in patients operated on between 4 and 8 days of life. For every day later that surgery was performed, the odds of major morbidity rose by 15.7% (95% confidence interval, 2.5%-30.7%; P = .018) and costs rose by 4.7% (95% confidence interval, 0.9%-8.2%; P < .014). CONCLUSIONS Delay of stage 1 palliation for neonates with HLHS is associated with increased morbidity and health care costs, even within the first 2 weeks of life.
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Affiliation(s)
- Brett R Anderson
- Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY
| | - Adam J Ciarleglio
- Division of Biostatistics, Department of Child and Adolescent Psychiatry, New York University, New York, NY
| | - Arash Salavitabar
- Pediatrics Residency Program, NewYork-Presbyterian/Morgan Stanley Children's Hospital, New York, NY
| | - Alejandro Torres
- Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY
| | - Emile A Bacha
- Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY.
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Pieper D, Mathes T, Asfour B. A systematic review of the impact of volume of surgery and specialization in Norwood procedure. BMC Pediatr 2014; 14:198. [PMID: 25096305 PMCID: PMC4127072 DOI: 10.1186/1471-2431-14-198] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 07/29/2014] [Indexed: 11/16/2022] Open
Abstract
Background The volume-outcome relationship is supposed to be stronger in high risk, low volume procedures. The aim of this systematic review is to examine the available literature on the effects of hospital and surgeon volume, specialization and regionalization on the outcomes of the Norwood procedure. Methods A systematic literature search was performed in Medline, Embase, and the Cochrane Library. On the basis of titles and abstracts, articles of comparative studies were obtained in full-text in case of potential relevance and assessed for eligibility according to predefined inclusion criteria. All relevant data on study design, patient characteristics, hospital volume, surgeon volume and other institutional characteristics, as well as results were extracted in standardized tables. Study selection, data extraction and critical appraisal were carried out independently by two reviewers. Results We included 10 studies. All but one study had an observational design. The number of analyzed patients varied from 75 to 2555. Overall, the study quality was moderate with a huge number of items with an unclear risk of bias. All studies investigating hospital volume indicated a hospital volume-outcome relationship, most of them even having significant results. The results were very heterogeneous for surgeon volume. Conclusions The volume-outcome relationship in the Norwood procedure can be supported. However, the magnitude of the volume effect is difficult to assess.
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Affiliation(s)
- Dawid Pieper
- Institute for Research in Operative Medicine, Witten/Herdecke University, Ostmerheimer Str, 200, Building 38, Cologne D- 51109, Germany.
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Overman DM, Jacobs JP, Prager RL, Wright CD, Clarke DR, Pasquali SK, O'Brien SM, Dokholyan RS, Meehan P, McDonald DE, Jacobs ML, Mavroudis C, Shahian DM. Report from the Society of Thoracic Surgeons National Database Workforce: clarifying the definition of operative mortality. World J Pediatr Congenit Heart Surg 2014; 4:10-2. [PMID: 23799748 DOI: 10.1177/2150135112461924] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Several distinct definitions of postoperative death have been used in various quality reporting programs. Some have defined postoperative mortality as the occurrence of death after a surgical procedure when the patient dies while still in the hospital, while others have considered all deaths occurring within a predetermined, standardized time interval after surgery to be postoperative mortality. While mortality data are still collected and reported using both these individual definitions, the Society of Thoracic Surgeons (STS) believes that either approach alone may be inadequate. Accordingly, the STS prefers a more encompassing metric, Operative Mortality. Operative Mortality is defined in all STS databases as (1) all deaths, regardless of cause, occurring during the hospitalization in which the operation was performed, even if after 30 days (including patients transferred to other acute care facilities); and (2) all deaths, regardless of cause, occurring after discharge from the hospital, but before the end of the 30th postoperative day. This article provides clarification for some uncommon but important scenarios in which the correct application of this definition may be challenging.
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Affiliation(s)
- David M Overman
- The Children's Heart Clinic, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN 55404, USA.
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Watrous RL, Chin AJ. Model-Based Comparison of the Normal and Fontan Circulatory Systems. World J Pediatr Congenit Heart Surg 2014; 5:372-84. [DOI: 10.1177/2150135114529450] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 02/28/2014] [Indexed: 11/16/2022]
Abstract
Background: Every year, approximately 1,000 Fontan operations are performed in the United States. Transplant-free, 30-year survival is only 50%. Although some performance characteristics may be universal among Fontan survivors, others may be patient specific and tunable; in either case, a quantitatively rigorous understanding of the Fontan circulatory arrangement would facilitate improvements in patient surveillance and management. Methods: To create a computational model of a normal two-year-old and a two-year-old patient with hypoplastic left heart syndrome (HLHS) following staged surgical palliations, we extensively modified the lumped parameter model developed by Clark, a multicompartment model of both pulmonary and systemic circulations. Results: With appropriately scaled parameter values, we achieved a maximum relative error (against target values for clinically realistic hemodynamic variables for the normal two-year-old) of 2.8% and an average relative error of 0.9%. Employing the model of a Fontan operation, we achieved a maximum relative error of 2.0% and the average relative error of 0.8%. Conclusions: Even with >200 model parameters, once we identified an acceptable set of values for the normal, only 12 required modification in order to attain clinically plausible hemodynamics in the HLHS after Fontan. When placed within the broad context of our extensive model, the impact on cardiac output of the resistance of the total cavopulmonary connection is found to be significantly affected by ventricular elastance and to be much lower in the two-year-old than in patients with markedly lower end-diastolic elastance (higher end-diastolic compliance).
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Affiliation(s)
- Raymond L. Watrous
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alvin J. Chin
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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135
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Karamlou T, Sexson K, Parrish A, Welke KF, McMullan DM, Permut L, Cohen G. One size does not fit all: the influence of age at surgery on outcomes following Norwood operation. J Cardiothorac Surg 2014; 9:100. [PMID: 24928488 PMCID: PMC4080783 DOI: 10.1186/1749-8090-9-100] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 05/05/2014] [Indexed: 11/22/2022] Open
Abstract
Background Given our large catchment area that often results in later presentation age, we sought to understand our institutional outcomes for the Norwood operation in the context of published data. Specifically, we studied whether operative and late death post-Norwood are dependent on age at operation. Methods Retrospective review of 105 consecutive infants undergoing Norwood (2004–2011) at our institution. Patients were divided into those undergoing Norwood ≤ 7 days of age (N = 43; 41%) and those undergoing Norwood > 7 days of age (N = 63; 59%). Operative mortality (≥30 days), interstage mortality (between Norwood and superior bidirectional Glenn), STS-mortality (operative death + in-hospital death), and late mortality, occurring any time following hospital discharge were compared among groups. Multivariable factors for mortality at each time-point were compared using logistic regression models. Results Underlying diagnosis was HLHS in 67 (64%) with the remainder (N = 38; 36%) being other single ventricle variants. Median age at surgery was 8 days (range 1–63 days) and mean weight at surgery was 3.2 ± 0.6 kg. Pulmonary blood flow was provided by a right ventricle-pulmonary artery conduit in 94% (N = 99). Overall operative survival was 92%, with 73% (N = 66) undergoing bidirectional Glenn. Median age was higher for operative survivors compared to non-survivors (12 days vs. 5 days; P = 0.036), with operative mortality higher for infants ≤7 days at Norwood compared to infants >7 days at Norwood (14% vs. 3%; P = 0.04). After censoring for in-hospital death, age ≤ 7 days was also associated with increased risk for late death (26% vs. 5%; P = 0.005). Conclusions In contrast to other institutional series, infants at our center undergoing Norwood operation at an earlier age have worse outcomes. Adoption of published practice patterns could lead to different local outcomes because of intangible center-specific effects, underscoring the principle that results from one institution may not be generalizable to others. Targeted center-specific internal review, if possible, should precede externally recommended changes in practice.
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Affiliation(s)
- Tara Karamlou
- Division of Pediatric Cardiac Surgery, Benioff Children's Hospital, University of California, San Francisco, 513 Parnassus Avenue, Suite S-549, California, CA 94143, USA.
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136
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Computational modeling of Fontan physiology: at the crossroads of pediatric cardiology and biomedical engineering. Int J Cardiovasc Imaging 2014; 30:1073-84. [DOI: 10.1007/s10554-014-0442-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 04/29/2014] [Indexed: 02/05/2023]
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Pasquali SK, Jacobs ML, He X, Shah SS, Peterson ED, Hall M, Gaynor JW, Hill KD, Mayer JE, Jacobs JP, Li JS. Variation in congenital heart surgery costs across hospitals. Pediatrics 2014; 133:e553-60. [PMID: 24567024 PMCID: PMC3934342 DOI: 10.1542/peds.2013-2870] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND A better understanding of costs associated with common and resource-intense conditions such as congenital heart disease has become increasingly important as children's hospitals face growing pressure to both improve quality and reduce costs. We linked clinical information from a large registry with resource utilization data from an administrative data set to describe costs for common congenital cardiac operations and assess variation across hospitals. METHODS Using linked data from The Society of Thoracic Surgeons and Pediatric Health Information Systems Databases (2006-2010), estimated costs/case for 9 operations of varying complexity were calculated. Between-hospital variation in cost and associated factors were assessed by using Bayesian methods, adjusting for important patient characteristics. RESULTS Of 12,718 operations (27 hospitals) included, median cost/case increased with operation complexity (atrial septal defect repair, [$25,499] to Norwood operation, [$165,168]). Significant between-hospital variation (up to ninefold) in adjusted cost was observed across operations. Differences in length of stay (LOS) and complication rates explained an average of 28% of between-hospital cost variation. For the Norwood operation, high versus low cost hospitals had an average LOS of 50.8 vs. 31.8 days and a major complication rate of 50% vs. 25.3%. High volume hospitals had lower costs for the most complex operations. CONCLUSIONS This study establishes benchmarks for hospital costs for common congenital heart operations and demonstrates wide variability across hospitals related in part to differences in LOS and complication rates. These data may be useful in designing initiatives aimed at both improving quality of care and reducing cost.
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Affiliation(s)
- Sara K. Pasquali
- Department of Pediatrics and Communicable Diseases, University of Michigan C.S. Mott Children’s Hospital, Ann Arbor, Michigan
| | - Marshall L. Jacobs
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Xia He
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Samir S. Shah
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Eric D. Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Matthew Hall
- Children’s Hospital Association, Overland Park, Kansas
| | - J. William Gaynor
- Department of Surgery, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kevin D. Hill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - John E. Mayer
- Department of Cardiovascular Surgery, Children’s Hospital Boston, Boston, Massachusetts; and
| | - Jeffrey P. Jacobs
- Johns Hopkins Children’s Heart Surgery, All Children’s Hospital, St. Petersburg, Florida
| | - Jennifer S. Li
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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138
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Andropoulos DB, Ahmad HB, Haq T, Brady K, Stayer SA, Meador MR, Hunter JV, Rivera C, Voigt RG, Turcich M, He CQ, Shekerdemian LS, Dickerson HA, Fraser CD, McKenzie ED, Heinle JS, Easley RB. The association between brain injury, perioperative anesthetic exposure, and 12-month neurodevelopmental outcomes after neonatal cardiac surgery: a retrospective cohort study. Paediatr Anaesth 2014; 24:266-74. [PMID: 24467569 PMCID: PMC4152825 DOI: 10.1111/pan.12350] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/17/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND Adverse neurodevelopmental outcomes are observed in up to 50% of infants after complex cardiac surgery. We sought to determine the association of perioperative anesthetic exposure with neurodevelopmental outcomes at age 12 months in neonates undergoing complex cardiac surgery and to determine the effect of brain injury determined by magnetic resonance imaging (MRI). METHODS Retrospective cohort study of neonates undergoing complex cardiac surgery who had preoperative and 7-day postoperative brain MRI and 12-month neurodevelopmental testing with Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III). Doses of volatile anesthetics (VAA), benzodiazepines, and opioids were determined during the first 12 months of life. RESULTS From a database of 97 infants, 59 met inclusion criteria. Mean ± sd composite standard scores were as follows: cognitive = 102.1 ± 13.3, language = 87.8 ± 12.5, and motor = 89.6 ± 14.1. After forward stepwise multivariable analysis, new postoperative MRI injury (P = 0.039) and higher VAA exposure (P = 0.028) were associated with lower cognitive scores. ICU length of stay (independent of brain injury) was associated with lower performance on all categories of the Bayley-III (P < 0.02). CONCLUSIONS After adjustment for multiple relevant covariates, we demonstrated an association between VAA exposure, brain injury, ICU length of stay, and lower neurodevelopmental outcome scores at 12 months of age. These findings support the need for further studies to identify potential modifiable factors in the perioperative care of neonates with CHD to improve neurodevelopmental outcomes.
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Affiliation(s)
- Dean B. Andropoulos
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA,Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA,Pediatric Cardiovascular Anesthesiology, Texas Children’s Hospital, Houston, TX, USA
| | - Hasan B. Ahmad
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA,Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA,Edward Via College of Osteopathic Medicine, Blacksburg, VA, USA
| | - Taha Haq
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA,Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Ken Brady
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA,Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA,Pediatric Cardiovascular Anesthesiology, Texas Children’s Hospital, Houston, TX, USA
| | - Stephen A. Stayer
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA,Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA,Pediatric Cardiovascular Anesthesiology, Texas Children’s Hospital, Houston, TX, USA
| | - Marcie R. Meador
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA,Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA,Pediatric Cardiovascular Anesthesiology, Texas Children’s Hospital, Houston, TX, USA
| | - Jill V. Hunter
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA,Pediatric Neuroradiology, Texas Children’s Hospital, Houston, TX, USA
| | - Carlos Rivera
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA,Pediatric Neurology, Texas Children’s Hospital, Houston, TX, USA
| | - Robert G. Voigt
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA,Developmental Pediatrics, Texas Children’s Hospital, Houston, TX, USA
| | - Marie Turcich
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA,Developmental Pediatrics, Texas Children’s Hospital, Houston, TX, USA
| | - Cathy Q. He
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA,Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Lara S. Shekerdemian
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA,Pediatric Critical Care, Texas Children’s Hospital, Houston, TX, USA
| | - Heather A. Dickerson
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA,Pediatric Cardiology, Texas Children’s Hospital, Houston, TX, USA
| | - Charles D. Fraser
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA,Congenital Heart Surgery, Texas Children’s Hospital, Houston, TX, USA
| | - E. Dean McKenzie
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA,Congenital Heart Surgery, Texas Children’s Hospital, Houston, TX, USA
| | - Jeffrey S. Heinle
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA,Congenital Heart Surgery, Texas Children’s Hospital, Houston, TX, USA
| | - R. Blaine Easley
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA,Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA,Pediatric Cardiovascular Anesthesiology, Texas Children’s Hospital, Houston, TX, USA
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Heidari-Bateni G, Norouzi S, Hall M, Brar A, Eghtesady P. Defining the best practice patterns for the neonatal systemic-to-pulmonary artery shunt procedure. J Thorac Cardiovasc Surg 2014; 147:869-873.e3. [DOI: 10.1016/j.jtcvs.2013.10.063] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 10/15/2013] [Accepted: 10/27/2013] [Indexed: 02/06/2023]
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140
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Liu M, Druschel CM, Hannan EL. Risk-adjusted prolonged length of stay as an alternative outcome measure for pediatric congenital cardiac surgery. Ann Thorac Surg 2014; 97:2154-9. [PMID: 24444872 DOI: 10.1016/j.athoracsur.2013.11.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 10/29/2013] [Accepted: 11/11/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Morbid events after pediatric congenital cardiac surgery are increasingly used for better outcome measurement and quality comparisons. This study was undertaken to evaluate the relationship between a hospital's risk-adjusted prevalence of prolonged postoperative length of stay (PLOS) and its risk-adjusted mortality rate to investigate whether PLOS can serve as an appropriate quality measure for pediatric congenital cardiac surgery. METHODS Risk-adjusted prevalence of prolonged PLOS for 12 programs in New York State was estimated using data from 4,776 operations in the New York State pediatric Cardiac Surgery Reporting System (2006-2009). We used logistic regression analysis to adjust for case mix and patient risk factors. The hospital-level correlation between risk-adjusted prolonged PLOS and risk-adjusted mortality rates was examined using Spearman correlation coefficient analysis. RESULTS Risk-adjusted prevalence of prolonged PLOS ranged from 7.48% to 36.52% for pediatric cardiac programs in New York State during the study period. The Spearman correlation test showed a strong positive relationship between a hospital's risk-adjusted prolonged PLOS and mortality rate (r = 0.83; p = 0.0008). CONCLUSIONS Prolonged PLOS can be used in lieu of risk-adjusted mortality rates when it is not practical to use mortality rates owing to low case volume or decreasing mortality rates of some procedures.
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Affiliation(s)
- Ming Liu
- Bureau of Environmental and Occupational Epidemiology, Center for Environmental Health, New York State Department of Health, Albany, New York.
| | - Charlotte M Druschel
- Bureau of Environmental and Occupational Epidemiology, Center for Environmental Health, New York State Department of Health, Albany, New York; School of Public Health, University at Albany, State University of New York, Albany, New York
| | - Edward L Hannan
- School of Public Health, University at Albany, State University of New York, Albany, New York
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Smith AH, Flack EC, Borgman KY, Owen JP, Fish FA, Bichell DP, Kannankeril PJ. A common angiotensin-converting enzyme polymorphism and preoperative angiotensin-converting enzyme inhibition modify risk of tachyarrhythmias after congenital heart surgery. Heart Rhythm 2014; 11:637-43. [PMID: 24389577 DOI: 10.1016/j.hrthm.2014.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND The angiotensin-converting enzyme insertion/deletion (ACE I/D) polymorphism is described in association with numerous phenotypes, including arrhythmias, and may provide predictive value among pediatric patients undergoing congenital heart surgery. OBJECTIVE The purpose of this study was to examine the role of a common polymorphism on postoperative tachyarrhythmias in a large cohort of pediatric patients undergoing congenital heart surgery with cardiopulmonary bypass (CPB). METHODS Subjects undergoing congenital heart surgery with CPB at our institution were consecutively enrolled from September 2007 to December 2012. In addition to DNA, perioperative clinical data were obtained from subjects. RESULTS Postoperative tachyarrhythmias were documented in 45% of 886 enrollees and were associated with prolonged mechanical ventilation (P <.001) and intensive care unit length of stay (P <.001). ACE I/D was in Hardy-Weinberg equilibrium (19% I/I, 49% I/D, 32% D/D). I/D or D/D genotypes were independently associated with a 60% increase in odds of new tachyarrhythmia (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.1-2.3, P = .02). Preoperative ACE inhibitor administration was independently associated with a 47% reduction in odds of postoperative tachyarrhythmia in the entire cohort (OR 0.53, 95% CI 0.32-0.88, P = .01), driven by a 5-fold reduction in tachyarrhythmias among I/I genotype patients (OR 0.19, 95% CI 0.04-0.88, P = .02). CONCLUSION The risk of tachyarrhythmias after congenital heart surgery is independently affected by the ACE I/D polymorphism. Preoperative ACE inhibition is associated with a lower risk of postoperative tachyarrhythmias, an antiarrhythmic effect that appears genotype dependent. An understanding of genotype variation may play an important role in the perioperative management of congenital heart surgery.
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Affiliation(s)
- Andrew H Smith
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee; Division of Pediatric Critical Care Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee.
| | - English C Flack
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Kristie Y Borgman
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jill P Owen
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee; Division of Pediatric Critical Care Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Frank A Fish
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - David P Bichell
- Department of Pediatric Cardiac Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Prince J Kannankeril
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
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142
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Does ICU structure impact patient outcomes after congenital heart surgery? A critical appraisal of "care models and associated outcomes in congenital heart surgery" by Burstein et al (Pediatrics 2011; 127: e1482-e1489). Pediatr Crit Care Med 2014; 15:77-81. [PMID: 24196007 DOI: 10.1097/pcc.0000000000000012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To review the findings and discuss the implications of different ICU care models on morbidity and mortality in pediatric patients after congenital heart surgery. DATA SOURCES The electronic PubMed database was used to perform the clinical query, as well as to search for additional pertinent literature. STUDY SELECTION AND DATA EXTRACTION The article by Burstein DS et al "Care Models and Associated Outcomes in Congenital Heart Surgery. Pediatrics 2011; 15:77-81" was selected for critical appraisal and literature review. DATA SYNTHESIS The authors evaluated in-hospital mortality, postoperative length of stay, and postoperative complications in pediatric patients after congenital heart surgery and compared the odds of these outcomes by model of care received (cardiac ICU or mixed ICU). The data for the study was extracted from the Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery (STS-EACTS) database. Overall, the cardiac ICU group represented hospitals with higher surgical volumes and included more patients with high-risk defects. After multivariate analysis, the adjusted in-hospital mortality was not associated with the care model (cardiac ICU vs. ICU). The only significant finding was a lower morality in the STS-EACTS risk category 3 (odds ratio, 0.47 [95% CI, 0.25-0.86]). There were no significant differences between groups for adjusted postoperative length of stay or postoperative complications. CONCLUSIONS This paper suggests that the composition of the ICU is not a critical factor in determining outcomes after congenital heart surgery. Other factors, such as expertise of the nurses, physicians, and surgeons, as well as technical performance, should be considered.
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143
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Lally KP, Lasky RE, Lally PA, Bagolan P, Davis CF, Frenckner BP, Hirschl RM, Langham MR, Buchmiller TL, Usui N, Tibboel D, Wilson JM. Standardized reporting for congenital diaphragmatic hernia--an international consensus. J Pediatr Surg 2013; 48:2408-15. [PMID: 24314179 DOI: 10.1016/j.jpedsurg.2013.08.014] [Citation(s) in RCA: 116] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 08/26/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND/PURPOSE Congenital diaphragmatic hernia (CDH) remains a significant cause of neonatal death. A wide spectrum of disease severity and treatment strategies makes comparisons challenging. The objective of this study was to create a standardized reporting system for CDH. METHODS Data were prospectively collected on all live born infants with CDH from 51 centers in 9 countries. Patients who underwent surgical correction had the diaphragmatic defect size graded (A-D) using a standardized system. Other data known to affect outcome were combined to create a usable staging system. The primary outcome was death or hospital discharge. RESULTS A total of 1,975 infants were evaluated. A total of 326 infants were not repaired, and all died. Of the remaining 1,649, the defect was scored in 1,638 patients. A small defect (A) had a high survival, while a large defect was much worse. Cardiac defects significantly worsened outcome. We grouped patients into 6 categories based on defect size with an isolated A defect as stage I. A major cardiac anomaly (+) placed the patient in the next higher stage. Applying this, patient survival is 99% for stage I, 96% stage II, 78% stage III, 58% stage IV, 39% stage V, and 0% for non-repair. CONCLUSIONS The size of the diaphragmatic defect and a severe cardiac anomaly are strongly associated with outcome. Standardizing reporting is imperative in determining optimal outcomes and effective therapies for CDH and could serve as a benchmark for prospective trials.
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Affiliation(s)
- Kevin P Lally
- UT Health Medical School and Children's Memorial Hermann Hospital, Houston, TX, USA.
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O'Byrne ML, Mercer-Rosa L, Zhao H, Zhang X, Yang W, Cassedy A, Fogel MA, Rychik J, Tanel RE, Marino BS, Paridon S, Goldmuntz E. Morbidity in children and adolescents after surgical correction of truncus arteriosus communis. Am Heart J 2013; 166:512-8. [PMID: 24016501 DOI: 10.1016/j.ahj.2013.05.023] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 05/25/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Studies of outcome after operative correction of truncus arteriosus communis (TA) have focused on mortality and rates of reintervention. We sought to investigate the clinical status of children and adolescents with surgically corrected TA. METHODS AND RESULTS A cross-sectional study of subjects with TA was performed. Subjects underwent concurrent genetic testing, electrocardiogram, cardiac magnetic resonance imaging, cardiopulmonary exercise testing, and completed questionnaires assessing health status and health-related quality of life. Review of their medical history provided retrospective information on cardiac reintervention and use of medical care. Twenty-five subjects with a median age of 11.8 (8.1-18.99) years were enrolled. The prevalence of 22q11.2 deletion was 32%. Incidence of hospitalization, cardiac reintervention, and noncardiac operations was highest in the first year of life. Combined catheter-based and operative reintervention rates were 52% on the conduit and 56% on the pulmonary arteries. Right ventricular ejection fraction and end-diastolic volume were normal. Moderate or greater truncal valve insufficiency was seen in 11% of subjects, and truncal valve replacement occurred in 8% of subjects. Maximal oxygen consumption (P = .0002), maximal work (P < .0001), and forced vital capacity (P < .0001) were all lower than normal for age and sex. Physical health status and health-related quality of life were both severely diminished. CONCLUSION Patients with TA demonstrate significant comorbid disease throughout childhood, significant burden of operative and catheter-based reintervention, and deficits in exercise performance, functional status, and health-related quality of life.
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Affiliation(s)
- Michael L O'Byrne
- Division of Pediatric Cardiology, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
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145
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Preuss C, Andelfinger G. Genetics of Heart Failure in Congenital Heart Disease. Can J Cardiol 2013; 29:803-10. [DOI: 10.1016/j.cjca.2013.03.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 02/27/2013] [Accepted: 03/06/2013] [Indexed: 01/09/2023] Open
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146
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Zampi JD, Donohue JE, Charpie JR, Yu S, Hanauer DA, Hirsch JC. Retrospective database research in pediatric cardiology and congenital heart surgery: an illustrative example of limitations and possible solutions. World J Pediatr Congenit Heart Surg 2013; 3:283-7. [PMID: 23804858 DOI: 10.1177/2150135112440462] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Secondary use of data, whether from clinical information systems or registries, for carrying out clinical research in rare diseases is a common practice but is fraught with potential errors. We sought to elucidate some of the limitations of database research and describe possible solutions to overcome these limitations. METHODS Using a disease model of a rare postsurgical outcome, we evaluated the ability of four different data sources to correctly identify patients who had that outcome both as individual databases and also when used in conjunction with each other. These results were compared with manual chart review. RESULTS The sensitivity of the various databases to pick up a rare and specific outcome was poor (9.9%-37%), while the specificities were fairly good (91%-96.7%). By combining the databases, the sensitivity was increased to as much as 56.8% without a large decrease in the specificity (85.2%-91.6%). The electronic medical record (EMR) search engine had the highest sensitivity (96.9%) and a high specificity (89.3%) with a very high negative predictive value (99.4%). CONCLUSION For rare and specific diseases or outcomes, a single data source search methodology can miss large numbers of patients and potentially bias study results. Combining overlapping databases can improve the ability to capture these rare diseases or outcomes. While chart review remains the most accurate way to obtain complete case capture, new tools like EMR search engines can facilitate the efficiency of this process without sacrificing search quality.
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Affiliation(s)
- Jeffrey D Zampi
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
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147
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Pasquali SK, He X, Jacobs ML, Hall M, Gaynor JW, Shah SS, Peterson ED, Hill KD, Li JS, Jacobs JP. Hospital variation in postoperative infection and outcome after congenital heart surgery. Ann Thorac Surg 2013; 96:657-63. [PMID: 23816416 DOI: 10.1016/j.athoracsur.2013.04.024] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 03/29/2013] [Accepted: 04/02/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Several initiatives aim to reduce postoperative infection across a variety of surgical patients as a means to improve overall quality of care and reduce variation across centers. However, the association of infection rates with hospital-level outcomes and resource utilization has not been well described. We evaluated this association across a multicenter cohort undergoing congenital heart surgery. METHODS The Society of Thoracic Surgeons Congenital Heart Surgery Database was linked to resource utilization data from the Pediatric Health Information Systems Database for hospitals participating in both (2006 to 2010). Hospital-level infection rates (sepsis, wound infection, mediastinitis, endocarditis, pneumonia) adjusted for patient risk factors and case mix were calculated using Bayesian methodology, and association with hospital mortality rates, postoperative length of stay (LOS), and total costs evaluated. RESULTS The cohort included 32,856 patients (28 centers); 3.7% had a postoperative infection. Across hospitals, the adjusted infection rate varied from 0.9% to 9.8%. Hospitals with the highest infection rates had longer (LOS) (13.2 vs 11.7 days, p < 0.001) and increased hospital costs ($71,100 vs $65,100, p < 0.001), but similar mortality rates (odds ratio 0.99, 95% confidence interval 0.80 to 1.21, p = 0.9). The proportion of variation in costs and LOS explained by infection was 15% and 6%, respectively. CONCLUSIONS Infection after congenital heart surgery contributes to prolonged LOS and increased costs on a hospital level. However, given that infection rates alone explained relatively little of the variation in these outcomes across hospitals, further study is needed to identify additional factors that may be targeted in initiatives to reduce variation and improve outcomes across centers.
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Affiliation(s)
- Sara K Pasquali
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA.
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148
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Development of a diagnosis- and procedure-based risk model for 30-day outcome after pediatric cardiac surgery. J Thorac Cardiovasc Surg 2013; 145:1270-8. [DOI: 10.1016/j.jtcvs.2012.06.023] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Revised: 04/30/2012] [Accepted: 06/12/2012] [Indexed: 11/19/2022]
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149
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Jacobs ML, O'Brien SM, Jacobs JP, Mavroudis C, Lacour-Gayet F, Pasquali SK, Welke K, Pizarro C, Tsai F, Clarke DR. An empirically based tool for analyzing morbidity associated with operations for congenital heart disease. J Thorac Cardiovasc Surg 2013; 145:1046-1057.e1. [PMID: 22835225 PMCID: PMC3824389 DOI: 10.1016/j.jtcvs.2012.06.029] [Citation(s) in RCA: 176] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Revised: 04/26/2012] [Accepted: 06/12/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Congenital heart surgery outcomes analysis requires reliable methods of estimating the risk of adverse outcomes. Contemporary methods focus primarily on mortality or rely on expert opinion to estimate morbidity associated with different procedures. We created an objective, empirically based index that reflects statistically estimated risk of morbidity by procedure. METHODS Morbidity risk was estimated using data from 62,851 operations in the Society of Thoracic Surgeons Congenital Heart Surgery Database (2002-2008). Model-based estimates with 95% Bayesian credible intervals were calculated for each procedure's average risk of major complications and average postoperative length of stay. These 2 measures were combined into a composite morbidity score. A total of 140 procedures were assigned scores ranging from 0.1 to 5.0 and sorted into 5 relatively homogeneous categories. RESULTS Model-estimated risk of major complications ranged from 1.0% for simple procedures to 38.2% for truncus arteriosus with interrupted aortic arch repair. Procedure-specific estimates of average postoperative length of stay ranged from 2.9 days for simple procedures to 42.6 days for a combined atrial switch and Rastelli operation. Spearman rank correlation between raw rates of major complication and average postoperative length of stay was 0.82 in procedures with n greater than 200. Rate of major complications ranged from 3.2% in category 1 to 30.0% in category 5. Aggregate average postoperative length of stay ranged from 6.3 days in category 1 to 34.0 days in category 5. CONCLUSIONS Complication rates and postoperative length of stay provide related but not redundant information about morbidity. The Morbidity Scores and Categories provide an objective assessment of risk associated with operations for congenital heart disease, which should facilitate comparison of outcomes across cohorts with differing case mixes.
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Affiliation(s)
- Marshall L Jacobs
- Department of Pediatric and Congenital Heart Surgery, Cleveland Clinic, Cleveland, Ohio.
| | - Sean M O'Brien
- Department of Biostatistics, Duke University School of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Jeffrey P Jacobs
- The Congenital Heart Institute of Florida, All Children's Hospital and Children's Hospital of Tampa, Cardiac Surgical Associates of Florida, University of South Florida College of Medicine, St Petersburg and Tampa, Fla
| | | | - Francois Lacour-Gayet
- Pediatric Cardiac Surgery Department, Montefiore Children's Hospital, Montefiore Medical Center, New York, NY
| | - Sara K Pasquali
- Department of Pediatrics, Duke University School of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Karl Welke
- Cardiothoracic Surgery, Seattle Children's Hospital, Seattle, Wash
| | | | - Felix Tsai
- Cardiac Surgery, Children's Hospital of the King's Daughters, Norfolk, Va
| | - David R Clarke
- Department of Cardiothoracic Surgery, The Children's Hospital, Aurora, Colo
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150
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Eghtesady P, Brar AK, Hall M. Prioritizing quality improvement in pediatric cardiac surgery. J Thorac Cardiovasc Surg 2013; 145:631-9; discussion 639-40. [DOI: 10.1016/j.jtcvs.2012.12.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Revised: 10/26/2012] [Accepted: 12/05/2012] [Indexed: 11/28/2022]
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