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Sun M, Chen WM, Wu SY, Zhang J. Improved postoperative outcomes in pediatric major surgery: evidence from hospital volume analysis. Eur J Pediatr 2024; 183:619-628. [PMID: 37943333 DOI: 10.1007/s00431-023-05308-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 10/21/2023] [Accepted: 10/24/2023] [Indexed: 11/10/2023]
Abstract
This study aimed to examine the association between hospital volume and postoperative outcomes in pediatric major surgery using a nationwide database. The study included pediatric patients who underwent first major elective inpatient surgery and hospitalization for more than 1 day. The results showed no significant difference in the risk of 30-day postoperative mortality based on hospital volume. However, patients in the middle- and high-volume groups had significantly lower rates of 30-day major complications, particularly deep wound infection. In terms of 90-day postoperative outcomes, patients in the high-volume group had a significantly lower risk of mortality and lower rates of major complications, particularly deep wound infection, pneumonia, and septicemia. Conclusions: The study suggests that pediatric patients undergoing major surgery in high and middle-volume groups have better outcomes in terms of major complications compared to the low-volume group. What is Known: • Limited evidence exists on the connection between hospital volume and pediatric surgery outcomes. What is New: • A Taiwan-based study, using national data, found that high and middle hospital-volume groups experienced significantly lower rates of major complications within 30 and 90 days after surgery. • High-volume hospitals demonstrated a substantial decrease in the risk of 90-day postoperative mortality. • The study underscores the importance of specialized pediatric surgical centers and advocates for clear guidelines for hospital selection, potentially improving outcomes and informing future health policies.
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Affiliation(s)
- Mingyang Sun
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Wan-Ming Chen
- Graduate Institute of Business Administration, College of Management, Fu Jen Catholic University, Taipei, Taiwan
- Artificial Intelligence Development Center, Fu Jen Catholic University, Taipei, Taiwan
| | - Szu-Yuan Wu
- Graduate Institute of Business Administration, College of Management, Fu Jen Catholic University, Taipei, Taiwan.
- Artificial Intelligence Development Center, Fu Jen Catholic University, Taipei, Taiwan.
- Department of Food Nutrition and Health Biotechnology, College of Medical and Health Science, Asia University, Taichung, Taiwan.
- Big Data Center, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan, Taiwan.
- Division of Radiation Oncology, Department of Medicine, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan, Taiwan.
- Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan.
- Cancer Center, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, No. 83, Nanchang St.Yilan County 265, Luodong Township, Taiwan.
- Centers for Regional Anesthesia and Pain Medicine, Taipei Municipal Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
- Department of Management, College of Management, Fo Guang University, Yilan, Taiwan.
| | - Jiaqiang Zhang
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, Henan, China.
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Agati S, Bellanti E. Global Cardiac Surgery-Accessibility to Cardiac Surgery in Developing Countries: Objectives, Challenges, and Solutions. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1789. [PMID: 38002880 PMCID: PMC10670438 DOI: 10.3390/children10111789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 10/23/2023] [Accepted: 11/02/2023] [Indexed: 11/26/2023]
Abstract
Cardiac surgery is a modern science in the history of medicine. The impact of cardiac disease, in terms of treatment and prognosis, has made this discipline indispensable to global health. In recent decades, the greatest investment has been dispensed to technological and material improvements to increase life expectancy. This surgery must address different epidemiological aspects dictated by the geography and economic-social conditions of the global populations. For this reason, it is progressively important to address the cardiac surgery accessibility disparity. Many scientific papers and international meetings have studied how cardiac surgery can be more accessible in various countries around the world. In this review, we analyze all the challenges, solutions, and suggestions that can make this surgery accessible to the entire global population, with the purpose of reducing its disparity across all seven continents. For a long time, high-income countries have invested in technological capabilities and experimental advancements without caring about unequal access in the rest of the world. We believe that it is time to reverse this growth trajectory, placing the accessibility and distribution of surgical science as a priority, which is significant for the right to health of all people worldwide. This is the real new challenge in cardiosurgery.
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Affiliation(s)
| | - Ermanno Bellanti
- Mediterranean Pediatric Cardiology Center, Bambino Gesù Children’s Hospital, 98035 Taormina, Italy;
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3
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Lasa JJ, Guffey D, Bhalala U, Thiagarajan RR. Critical Care Unit Characteristics and Extracorporeal Cardiopulmonary Resuscitation Survival in the Pediatric Cardiac Population: Retrospective Analysis of the Virtual Pediatric System Database. Pediatr Crit Care Med 2023; 24:910-918. [PMID: 37458512 DOI: 10.1097/pcc.0000000000003321] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
OBJECTIVES Existing literature provides limited data about ICU characteristics and pediatric extracorporeal cardiopulmonary resuscitation (E-CPR) outcomes. We aimed to evaluate the associations between patient and ICU characteristics, and outcomes after E-CPR in the pediatric cardiac population. DESIGN Retrospective analysis of the Virtual Pediatric System database (VPS, LLC, Los Angeles, CA). SETTING PICUs categorized as either cardiac-only versus mixed ICU cohort type. PATIENTS Consecutive cardiac patients less than 18 years old experiencing cardiac arrest in the ICU and resuscitated using E-CPR. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Event and time-stamp filtering identified E-CPR events. Patient, hospital, and event-related variables were aggregated for independent and multivariable mixed effects logistic regression to assess the association between ICU cohort type and survival. Among ICU admissions in the VPS database, 2010-2018, the prevalence of E-CPR was 0.07%. A total of 671 E-CPR events (650 patients) comprised the final cohort; congenital heart disease (84%) was the most common diagnosis versus acquired heart diseases. The majority of E-CPR events occurred in mixed ICUs (67%, n = 449) and in ICUs with greater than 20 licensed bed capacity (65%, n = 436). Survival to hospital discharge was 51% for the overall cohort. Independent logistic regression failed to reveal any association between survival to hospital discharge and ICU type (ICU type: cardiac ICU, odds ratio [OR], 1.01; 95% CI, 0.71-1.44; p = 0.95). However, multivariable logistic regression revealed an association between cardiac surgical patients and greater odds for survival (OR, 2.03; 95% CI, 1.40-2.95; p < 0.001). Also, there was an association between ICUs with capacity greater than 20 (vs not) and lower survival odds (OR, 0.65; 95% CI, 0.43-0.96). CONCLUSIONS The overall prevalence of E-CPR among critically ill children with cardiac disease observed in the VPS database is low. We failed to identify an association between ICU cohort type and survival. Further investigation into organizational factors is warranted.
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Affiliation(s)
- Javier J Lasa
- Division of Cardiology, Children's Medical Center, UT Southwestern Medical Center, Dallas, TX
- Division of Critical Care, Children's Medical Center, UT Southwestern Medical Center, Dallas, TX
| | - Danielle Guffey
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX
| | - Utpal Bhalala
- Division of Critical Care Medicine, Driscoll Children's Hospital, Corpus Christi, TX
| | - Ravi R Thiagarajan
- Division of Cardiovascular Critical Care, Boston Children's Hospital, Boston, MA
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Prabhu NK, Nellis JR, Moya-Mendez M, Hoover A, Medina C, Meza JM, Allareddy V, Andersen ND, Turek JW. Textbook outcome for the Norwood operation-an informative quality metric in congenital heart surgery. JTCVS OPEN 2023; 15:394-405. [PMID: 37808016 PMCID: PMC10556845 DOI: 10.1016/j.xjon.2023.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/05/2023] [Accepted: 05/09/2023] [Indexed: 10/10/2023]
Abstract
Objectives To develop a more holistic measure of center performance than operative mortality, we created a composite "textbook outcome" for the Norwood operation using several postoperative end points. We hypothesized that achieving the textbook outcome would have a positive prognostic and financial impact. Methods This was a single-center retrospective study of primary Norwood operations from 2005 to 2021. Through interdisciplinary clinician consensus, textbook outcome was defined as freedom from operative mortality, open or catheter-based reintervention, 30-day readmission, extracorporeal membrane oxygenation, cardiac arrest, reintubation, length of stay >75%ile from Society of Thoracic Surgeons data report (66 days), and mechanical ventilation duration >75%ile (10 days). Multivariable logistic regression and Cox proportional hazards modeling were used to determine predictive factors for textbook outcome achievement and association of the outcome with long-term survival, respectively. Results Overall, 30% (58/196) of patients met the textbook outcome. Common reasons for failure to attain textbook outcome were prolonged ventilation (68/138, 49%) and reintubation (63/138, 46%). In multivariable analysis, greater weight (odds ratio [OR], 2.11; 95% confidence interval [CI], 1.17-3.95; P = .02) was associated with achieving the textbook outcome whereas preoperative shock (OR, 0.36; 95% CI, 0.13-0.87; P = .03) and longer bypass time (OR, 0.99; 95% CI, 0.98-1.00; P = .002) were negatively associated. Patients who met the outcome incurred fewer hospital costs ($152,430 [141,798-177,983] vs $269,070 [212,451-372,693], P < .001), and after adjusting for patient factors, achieving textbook outcome was independently associated with decreased risk of all-cause mortality (hazard ratio, 0.45; 95% CI, 0.22-0.89; P = .02). Conclusions Outcomes continue to improve within congenital heart surgery, making operative mortality a less-sensitive metric. The Norwood textbook outcome may represent a balanced measure of a successful episode of care.
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Affiliation(s)
- Neel K. Prabhu
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, NC
| | - Joseph R. Nellis
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, NC
| | - Mary Moya-Mendez
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, NC
| | - Anna Hoover
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, NC
| | - Cathlyn Medina
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, NC
| | - James M. Meza
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, NC
| | - Veerajalandhar Allareddy
- Duke Children's Pediatric and Congenital Heart Center, Durham, NC
- Division of Critical Care Medicine, Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Nicholas D. Andersen
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, NC
- Duke Children's Pediatric and Congenital Heart Center, Durham, NC
| | - Joseph W. Turek
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, NC
- Duke Children's Pediatric and Congenital Heart Center, Durham, NC
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Variation in hospital costs and resource utilisation after congenital heart surgery. Cardiol Young 2023; 33:420-431. [PMID: 35373722 DOI: 10.1017/s1047951122001019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Children undergoing cardiac surgery have overall improving survival, though they consume substantial resources. Nationwide inpatient cost estimates and costs at longitudinal follow-up are lacking. METHODS Retrospective cohort study of children <19 years of age admitted to Pediatric Health Information System administrative database with an International Classification of Diseases diagnosis code undergoing cardiac surgery. Patients were grouped into neonates (≤30 days of age), infants (31-365 days of age), and children (>1 year) at index procedure. Primary and secondary outcomes included hospital stay and hospital costs at index surgical admission and 1- and 5-year follow-up. RESULTS Of the 99,670 cohort patients, neonates comprised 27% and had the highest total hospital costs, though daily hospital costs were lower. Mortality declined (5.6% in 2004 versus 2.5% in 2015, p < 0.0001) while inpatient costs rose (5% increase/year, p < 0.0001). Neonates had greater index diagnosis complexity, greater inpatient costs, required the greatest ICU resources, pharmacotherapy, and respiratory therapy. We found no relationship between hospital surgical volume, mortality, and hospital costs. Neonates had higher cumulative hospital costs at 1- and 5-year follow-up compared to infants and children. CONCLUSIONS Inpatient hospital costs rose during the study period, driven primarily by longer stay. Neonates had greater complexity index diagnosis, required greater hospital resources, and have higher hospital costs at 1 and 5 years compared to older children. Surgical volume and in-hospital mortality were not associated with costs. Further analyses comprising merged clinical and administrative data are necessary to identify longer stay and cost drivers after paediatric cardiac surgery.
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Higher Surgeon Volume is Associated With a Lower Rate of Subsequent Revision Procedures After Total Shoulder Arthroplasty: A National Analysis. Clin Orthop Relat Res 2023:00003086-990000000-01103. [PMID: 36853863 PMCID: PMC10344546 DOI: 10.1097/corr.0000000000002605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 01/25/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND Studies assessing the relationship between surgeon volume and outcomes have shown mixed results, depending on the specific procedure analyzed. This volume relationship has not been well studied in patients undergoing total shoulder arthroplasty (TSA), but it should be, because this procedure is common, expensive, and potentially morbid. QUESTIONS/PURPOSES We performed this study to assess the association between increasing surgeon volume and decreasing rate of revision at 2 years for (1) anatomic TSA (aTSA) and (2) reverse TSA (rTSA) in the United States. METHODS In this retrospective study, we used Centers for Medicare and Medicaid Services (CMS) fee-for-service inpatient and outpatient data from 2015 to 2021 to study the association between annual surgeon aTSA and rTSA volume and 2-year revision shoulder procedures after the initial surgery. The CMS database was chosen for this study because it is a national sample and can be used to follow patients over time. We included patients with Diagnosis-related Group code 483 and Current Procedural Terminology code 23472 for TSA (these codes include both aTSA and rTSA). We used International Classification of Diseases, Tenth Revision, procedural codes. Patients who underwent shoulder arthroplasty for fracture (10% [17,524 of 173,242]) were excluded. We studied the variables associated with the subsequent procedure rate through a generalized linear model, controlling for confounders such as patient age, comorbidity risk score, surgeon and hospital volume, surgeon graduation year, hospital size and teaching status, assuming a binomial distribution with the dependent variable being whether an episode had at least one subsequent procedure within 2 years. The regression was fitted with standard errors clustered at the hospital level, combining all TSAs and within the aTSA and rTSA groups, respectively. Hospital and surgeon yearly volumes were calculated by including all TSAs, primary procedure and subsequent, during the study period. Other hospital-level and surgeon-level characteristics were obtained through public files from the CMS. The CMS Hierarchical Condition Category risk score was controlled because it is a measure reflecting the expected future health costs for each patient based on the patient's demographics and chronic illnesses. We then converted regression coefficients to the percentage change in the odds of having a subsequent procedure. RESULTS After controlling for confounding variables including patient age, comorbidity risk score, surgeon and hospital volume, surgeon graduation year, and hospital size and teaching status, we found that an annual surgeon volume of ≥ 10 aTSAs was associated with a 27% decreased odds of revision within 2 years (95% confidence interval 13% to 39%; p < 0.001), while surgeon volume of ≥ 29 aTSAs was associated with a 33% decreased odds of revision within 2 years (95% CI 18% to 45%; p < 0.001) compared with a volume of fewer than four aTSAs per year. Annual surgeon volume of ≥ 29 rTSAs was associated with a 26% decreased odds of revision within 2 years (95% CI 9% to 39%; p < 0.001). CONCLUSION Surgeons should consider modalities such as virtual planning software, templating, or enhanced surgeon training to aid lower-volume surgeons who perform aTSA and rTSA. More research is needed to assess the value of these modalities and their relationship with the rates of subsequent revision. LEVEL OF EVIDENCE Level III, therapeutic study.
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Abstract
There is extensive research demonstrating significant variation in the utilization of surgery and outcomes from surgery, including differences in mortality, complications, readmission, and failure to rescue. Literature suggests that these variations exist across as well as within small area geographies in the United States. There is also significant evidence of variation in access and outcomes from surgery that is attributable to race. Emerging research is demonstrating that there may be some variation attributable to a patient's social determinants of health and their lived averment. Those affected must work together to determine rate of utilization and how much variation is acceptable.
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Affiliation(s)
- Adrian Diaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 West 12th Avenue, Suite 670, Columbus, OH 43210, USA; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 West 12th Avenue, Suite 670, Columbus, OH 43210, USA.
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Anbarasu CR, Mehl SC, Sun RC, Portuondo JI, Espinoza AF, Whitlock RS, Shah SR, Rodriguez JR, Nuchtern JG, Minifee PK, Le LD, Stafford SJ, Milewicz AL, Mazziotti MV. Variations in Nuss Procedure Operative Techniques and Complications: A Retrospective Review. Eur J Pediatr Surg 2022; 32:357-362. [PMID: 34560787 DOI: 10.1055/s-0041-1735164] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The Nuss procedure is the most common and preferred operative correction of pectus excavatum. Surgeon preference and patient factors can result in variations in Nuss procedure technique. We hypothesize that certain techniques are associated with increased risk of complications. MATERIALS AND METHODS We performed a single-center retrospective review of Nuss operations from 2016 to 2020. Variations in intraoperative techniques included sternal elevator (SE) use, number of bars placed, and usage of bilateral stabilizing sutures. Patient demographics, intraoperative data, and postoperative outcomes were reported as median with interquartile ranges or percentages. Statistical significance (p < 0.05) was determined with Wilcoxon's rank-sum and chi-square tests. Multivariate analysis was performed to control for introduction of intercostal nerve cryoablation and surgeon volume, and reported as odds ratio with 95% confidence interval. RESULTS Two hundred and sixty-five patients were identified. Patients repaired with two bars were older with a larger Haller index (HI). Patient demographics were not significantly different for SE or stabilizing suture use. Placement of two bars was associated with significantly increased risk of readmission. Similarly, SE use was associated with increased risk of pleural effusion and readmission. Finally, the use of bilateral stabilizing sutures resulted in less frequent slipped bars without statistical significance. CONCLUSION Older patients with a larger HI were more likely to need two bars placed to repair pectus excavatum. Placement of multiple bars and SE use are associated with significantly higher odds of certain complications.
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Affiliation(s)
- Centura R Anbarasu
- Department of Surgery, Baylor College of Medicine, Houston, Texas, United States
| | - Steven C Mehl
- Department of Surgery, Baylor College of Medicine, Houston, Texas, United States.,Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - Raphael C Sun
- Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - Jorge I Portuondo
- Department of Surgery, Baylor College of Medicine, Houston, Texas, United States.,Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - Andres F Espinoza
- Department of Surgery, Baylor College of Medicine, Houston, Texas, United States.,Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - Richard S Whitlock
- Department of Surgery, Baylor College of Medicine, Houston, Texas, United States.,Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - Sohail R Shah
- Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - J Ruben Rodriguez
- Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - Jed G Nuchtern
- Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - Paul K Minifee
- Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - Louis D Le
- Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - Shawn J Stafford
- Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - Allen L Milewicz
- Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - Mark V Mazziotti
- Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States
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9
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Center Volume Impacts Readmissions and Mortality after Congenital Cardiac Surgery. J Pediatr 2022; 240:129-135.e2. [PMID: 34547337 DOI: 10.1016/j.jpeds.2021.09.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/10/2021] [Accepted: 09/13/2021] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To characterize the relationship between surgical volume and postoperative outcomes in congenital heart surgery, we used a national cohort to assess the costs, readmissions, and complications in children undergoing cardiac operations. STUDY DESIGN The Nationwide Readmissions Database was used to identify pediatric patients (≤18 years) undergoing congenital cardiac surgery from 2010 to 2017. Hospitals were categorized based on deciles and tertiles of annual caseload with high-volume categorized as the highest tertile of volume. Multivariable regression models adjusting for patient and hospital characteristics were used to study the impact of volume on 30-day nonelective readmission, mortality, home discharge, and resource use. RESULTS Of an estimated 69 448 hospitalizations included for analysis, 56 672 (82%) occurred at high-volume centers. After adjustment for key clinical factors, each decile increase in volume was associated with a 25% relative decrease in the odds of mortality, a 14% decrease in the odds of nonhome discharge, and a 4% relative decrease in the likelihood of 30-day nonelective readmission. After risk adjustment, each incremental increase in volume decile was associated with a one-half-day decrease in the hospital length of stay, but did not alter costs of the index hospitalization. However, after including all readmissions within 30 days of the index discharge, high-volume centers were associated with significantly lower costs compared with low-volume hospitals. CONCLUSIONS Increased congenital cardiac surgery volume is associated with improved mortality, reduced duration of hospitalization, 30-day readmissions, and resource use. These findings demonstrate the inverse relationship between hospital volume and resource use and may have implications for the centralization of care for congenital cardiac surgery.
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Berry JG, Rodean J, Leahy I, Rangel S, Johnson C, Crofton C, Staffa SJ, Hall M, Methot C, Desmarais A, Ferrari L. Hospital Volumes of Inpatient Pediatric Surgery in the United States. Anesth Analg 2021; 133:1280-1287. [PMID: 34673726 DOI: 10.1213/ane.0000000000005748] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Perioperative outcomes of children depend on the skill and expertise in managing pediatric patients, as well as integration of surgical, anesthesiology, and medical teams. We compared the types of pediatric patients and inpatient surgical procedures performed in low- versus higher-volume hospitals throughout the United States. METHODS Retrospective analysis of 323,258 hospitalizations with an operation for children age 0 to 17 years in 2857 hospitals included in the Agency for Healthcare Research and Quality (AHRQ) Kids' Inpatient Database (KID) 2016. Hospitals were categorized by their volume of annual inpatient surgical procedures. Specific surgeries were distinguished with the AHRQ Clinical Classification System. We assessed complex chronic conditions (CCCs) using Feudtner and Colleagues' system. RESULTS The median annual volume of pediatric inpatient surgeries across US hospitals was 8 (interquartile range [IQR], 3-29). The median volume of inpatient surgeries for children with a CCC was 4 (IQR, 1-13). Low-volume hospitals performed significantly fewer types of surgeries (median 2 vs 131 types of surgeries in hospitals with 1-24 vs ≥2000 volumes). Appendectomy and fixation of bone fracture were among the most common surgeries in low-volume hospitals. As the volume of surgical procedures increased from 1 to 24 to ≥2000, the percentage of older children ages 11 to 17 years decreased (70.9%-32.0% [P < .001]) and the percentage of children with a CCC increased (11.2%-60.0% [P < .001]). CONCLUSIONS Thousands of US hospitals performed inpatient surgeries on few pediatric patients, including those with CCCs who have the highest risk of perioperative morbidity and mortality. Evaluation of perioperative decision making, workflows, and pediatric clinicians in low- and higher-volume hospitals is warranted.
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Affiliation(s)
- Jay G Berry
- From the Complex Care Service, Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Jonathan Rodean
- Department of Informatics and Statistics, Children's Hospital Association, Overland Park, Kansas
| | - Izabela Leahy
- Department of Anesthesiology, Perioperative, and Pain Medicine
| | - Shawn Rangel
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.,Department of Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Connor Johnson
- Department of Anesthesiology, Perioperative, and Pain Medicine
| | - Charis Crofton
- From the Complex Care Service, Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Steven J Staffa
- Department of Anesthesiology, Perioperative, and Pain Medicine
| | - Matt Hall
- Department of Informatics and Statistics, Children's Hospital Association, Overland Park, Kansas
| | - Craig Methot
- Department of Anesthesiology, Perioperative, and Pain Medicine
| | - Anna Desmarais
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Lynne Ferrari
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.,Department of Anesthesiology, Perioperative, and Pain Medicine
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Amabile A, Mori M, Brooks C, Weininger G, Shang M, Fereydooni S, Komlo CM, Mullan CW, Hameed I, Geirsson A. The impact of trainees' working hour regulations on outcome in CABG and valve surgery in the State of New York. J Card Surg 2021; 36:4582-4590. [PMID: 34617327 DOI: 10.1111/jocs.16058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 09/26/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIM In 2011, the Accreditation Council for Graduate Medical Education (ACGME) restricted the first-year residents' duty-hour to less than 16-hour shifts, decreased the maximum shift duration for senior residents, and increased minimum time off after on-call duties. Whether these changes may have impacted the outcomes in cardiac surgery remains unclear. METHODS We performed a difference-in-difference analysis of the New York State Cardiac Surgery Reporting System data in 2004-2006 (before the duty-hour policies change) and 2014-2016 (after the change). We evaluated differences in 30-day risk-adjusted mortality rates (RAMR) in coronary artery bypass grafting (CABG) and valve surgeries, stratifying data by hospital type: teaching hospitals (TH) versus nonteaching hospitals (NTH). NTH served as the control not affected by the duty-hour policies. RESULTS (1) The overall surgical volume for CABG surgery has decreased over time (37,645-24,991), while the volume for valve surgery remained similar (20,969-21,532); (2) TH had better short-term outcomes for CABG procedures during 2014-2016 (median RAMR: 1.01% vs. 1.55% in TH vs. NTH, respectively; p = .025) as well as for valve procedures during both 2004-2006 (5.16% vs. 7.49%, p = .020) and 2014-2016 (2.59% vs. 4.09%, p = .033); (3) at difference-in-difference analysis, trainees' duty-hour regulations were not associated with worsening short-term outcomes in both CABG (p = .296) and valve (p = .651) procedures performed in TH. CONCLUSION The introduction of the 2011 trainees' duty-hour regulations was not associated with worse short-term outcomes for CABG and valve surgery performed in the State of NY by TH.
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Affiliation(s)
- Andrea Amabile
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Makoto Mori
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Cornell Brooks
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Gabe Weininger
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael Shang
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Soraya Fereydooni
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Caroline M Komlo
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Clancy W Mullan
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Irbaz Hameed
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Arnar Geirsson
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
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Metzger GA, Cooper J, Lutz C, Jatana KR, Nishimura L, Deans KJ, Minneci PC, Halaweish I. The value of telemedicine for the pediatric surgery patient in the time of COVID-19 and beyond. J Pediatr Surg 2021; 56:1305-1311. [PMID: 33648729 PMCID: PMC7894074 DOI: 10.1016/j.jpedsurg.2021.02.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/19/2021] [Accepted: 02/08/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Prior to COVID-19, the use of telemedicine within pediatric surgery was uncommon. To curb the spread of the virus many institutions restricted non-emergent clinic appointments, resulting in an increase in telemedicine use. We examined the value of telemedicine for patients presenting to a pediatric surgery clinic before and after COVID-19 METHODS: Perspectives and the potential value of telemedicine were assessed by surveying patients or caregivers of patients being evaluated by a general pediatric surgeon in-person prior to COVID-19 and by patients or caregivers of patients who completed a telemedicine appointment with a pediatric surgical provider during the COVID-19 period. RESULTS The pre-COVID survey was completed by 57 respondents and the post-COVID survey by 123. Most respondents were white and were caregivers 31-40 years of age. Prior to COVID-19, only 26% were familiar with telemedicine, 25% reported traveling more than 100 miles and >50% traveled more than 40 miles for their appointment. More than 25% estimated additional travel costs of at least $30 and in 43% of households, at least one adult had to miss time from work. Following a telemedicine appointment during the COVID-19 period, 76% reported the care received as excellent, 86% were very satisfied with their care, 87% reported the appointment was less stressful for their child than an in-person appointment, and 57% would choose a telemedicine appointment in the future. CONCLUSION For families seeking an alternative to the in-person encounter, telemedicine can provide added value over the traditional in-person encounter by reducing the burden of travel without compromising the quality of care. Telemedicine should be viewed as a viable option for pediatric surgery patients and future research directed toward optimizing the experience for patients and providers. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Gregory A. Metzger
- The Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jennifer Cooper
- The Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, OH, USA
| | - Carley Lutz
- The Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kris R. Jatana
- Department of Pediatric Otolaryngology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Leah Nishimura
- The Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, OH, USA
| | - Katherine J. Deans
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA,The Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, OH, USA
| | - Peter C. Minneci
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA,The Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ihab Halaweish
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA.
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13
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Metzger G, Jatana K, Apfeld J, Deans KJ, Minneci PC, Halaweish I. State of telemedicine use in pediatric surgery in the USA—where we stand and what we can gain from the COVID-19 pandemic: a scoping review. WORLD JOURNAL OF PEDIATRIC SURGERY 2021; 4:e000257. [DOI: 10.1136/wjps-2020-000257] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/02/2021] [Accepted: 02/21/2021] [Indexed: 12/26/2022] Open
Abstract
BackgroundWithin the last decade, the use of telemedicine within in primary care in the USA has greatly expanded; however, use remains uncommon in surgical specialties. The spread of Coronavirus disease 2019 (COVID-19) prompted healthcare institutions to limit in-person contact, resulting in an increase in telemedicine across all specialties, including pediatric surgery. The aims of this review were to evaluate potential barriers that limited the use of telemedicine in pediatric surgery prior to the COVID-19 period and to define how best to incorporate its use into a pediatric surgical practice going forward.MethodsA scoping review was performed to identify gaps in the literature pertaining to the use of telemedicine within general pediatric surgery in the USA prior to the outbreak of COVID-19. Next, a focused evaluation of the legislative and organizational policies on telemedicine was performed. Lastly, findings were summarized and recommendations for future research developed in the context of understanding and overcoming barriers that have plagued widespread adoption in the past.ResultsDespite evidence of telemedicine being safe and well received by adult surgical patients, a total of only three studies representing original research on the use of telemedicine within pediatric surgery were identified. Legislative and organizational policies regarding telemedicine have been altered in response to COVID-19, likely resulting in an increase in the use of telemedicine among pediatric surgeons.ConclusionsTelemedicine offers a safe and effective option for patients seeking an alternative to the in-person clinic appointment. The increased utilization of telemedicine during the COVID-19 pandemic will provide an opportunity to learn how best to leverage the technology to decrease disparities and to overcome previous barriers.
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14
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Brown JS, Gordon RJ, Peng Y, Hatton A, Page RS, Macgroarty KA. Lower operating volume in shoulder arthroplasty is associated with increased revision rates in the early postoperative period: long-term analysis from the Australian Orthopaedic Association National Joint Replacement Registry. J Shoulder Elbow Surg 2020; 29:1104-1114. [PMID: 32044253 DOI: 10.1016/j.jse.2019.10.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 10/23/2019] [Accepted: 10/27/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Improved short-term outcomes have been demonstrated with higher surgical volume in shoulder arthroplasty. There is however, little data regarding long-term outcomes. METHOD Revision data from the Australian Orthopaedic Association National Joint Replacement Registry from 2004-2017 was analyzed according to 3 selected surgeon volume thresholds: <10, 10-20, and >20 shoulder arthroplasty cases per surgeon, per year. RESULTS There was a significantly higher rate of revision for stemmed total shoulder arthroplasty (TSA) for osteoarthritis (OA) for the <10/yr compared with the >20/yr group for the first 1.5 years only (hazard ratio [HR] 1.36, 95% confidence interval [CI] 1.08-1.71, P = .009). For reverse total shoulder arthroplasty (rTSA) performed for OA, there was a higher revision rate for the <10/yr compared with the >20/yr group for the first 3 months only (HR 2.58, 95% CI 1.67-3.97, P < .001). In rTSA for cuff arthropathy, there was a significantly higher rate of revision for the <10/yr compared with the >20/yr group throughout the follow-up period (HR 1.66, 95% CI 1.21-2.28, P = .001). There was no significant difference for the primary diagnosis of fracture. CONCLUSION Lower surgical volume was associated with higher all-cause revision rates in the early postoperative period in TSA and rTSA for OA and throughout the follow-up period in rTSA for cuff arthropathy. Despite increases in the volume of shoulder arthroplasties performed in recent years, more than 78% of surgeons undertake fewer than 10 procedures per year.
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Affiliation(s)
- Jamie S Brown
- Brisbane Knee and Shoulder Clinic, Brisbane, QLD, Australia; Queensland University of Technology, Brisbane, QLD, Australia; Lund University Clinical Sciences, Helsingborg, Sweden.
| | | | - Yi Peng
- South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Alesha Hatton
- South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Richard S Page
- Barwon Centre for Orthopaedic Research and Education (B-CORE), Barwon Health and St John of God Hospital, Geelong, VIC, Australia; School of Medicine, Deakin University, Waurn Ponds, VIC, Australia; Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), Adelaide, SA, Australia
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15
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Lushaj EB, Bartlett HL, Lamers LJ, Arndt S, Hermsen J, Ralphe JC, Anagnostopoulos PV. Technical Performance Score Predicts Perioperative Outcomes in Complex Congenital Heart Surgery Performed in a Small-to-Medium-Volume Program. Pediatr Cardiol 2020; 41:88-93. [PMID: 31676956 DOI: 10.1007/s00246-019-02226-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/15/2019] [Indexed: 11/29/2022]
Abstract
As the quality of surgical outcomes depend on many factors, the development of validated tools to assess the different aspects of complex multidisciplinary teams' performance is crucial. The Technical Performance Score (TPS) has only been validated to correlate with outcomes in large-volume surgical programs. Here we assess the utility of TPS in correlation to perioperative outcomes for complex congenital heart surgeries (CHS) performed in a small-to-medium-volume program. 673 patients underwent CHS from 4/2012 to 12/2017 at our institution. Of those, 122 were STAT 4 and STAT 5. TPS was determined for each STAT 4 and STAT 5 operation using discharge echocardiogram: 1 = optimal, 2 = adequate, 3 = inadequate. Patient outcomes were compared including mortality, length of stay, ventilation times, and adverse events. 69 patients (57%) were neonates, 32 (26%) were infants, 17 (14%) were children, 4 (3%) were adults. TPS class 1 was assigned to 85 (70%) operations, TPS class 2 was assigned to 25 (20%) operations, and TPS class 3 was assigned to 12 (10%) operations. TPS was associated with re-intubation, ICU length of stay, postoperative length of stay, and mortality. TPS did not correlate with unplanned 30-day readmissions, need for reoperation, and inotropic score. Technical performance score was associated with perioperative outcomes and is a useful tool to assess the adequacy of repair for high complexity CHS in a small-to-medium-volume surgical program. TPS should be a part of program review in congenital heart programs of all sizes to identify strategies that may reduce postoperative morbidity and potentially improve long-term outcomes.
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Affiliation(s)
- Entela B Lushaj
- Department of Surgery-Cardiothoracic, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Heather L Bartlett
- Department of Pediatrics-Cardiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Luke J Lamers
- Department of Pediatrics-Cardiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Shannon Arndt
- University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Joshua Hermsen
- Department of Surgery-Cardiothoracic, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - J Carter Ralphe
- Department of Pediatrics-Cardiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Petros V Anagnostopoulos
- Department of Pediatrics-Cardiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA. .,Division of Cardiothoracic Surgery, School of Medicine and Public Health, University of Wisconsin, 600 Highland Avenue, Madison, WI, 53792, USA.
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Salciccioli KB, Oluyomi A, Lupo PJ, Ermis PR, Lopez KN. A model for geographic and sociodemographic access to care disparities for adults with congenital heart disease. CONGENIT HEART DIS 2019; 14:752-759. [PMID: 31361081 DOI: 10.1111/chd.12819] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 06/16/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Follow-up at a regional adult congenital heart disease (ACHD) center is recommended for all ACHD patients at least once per the 2018 ACC/AHA guidelines. Other specialties have demonstrated poorer follow-up and outcomes correlating with increased distance from health care providers, but driving time to regional ACHD centers has not been examined in the US population. OBJECTIVE To identify and characterize potential disparities in access to ACHD care in the US based on drive time to ACHD centers and compounding sociodemographic factors. METHODS Mid- to high-volume ACHD centers with ≥500 outpatient ACHD visits and ≥20 ACHD surgeries annually were included based on self-reported, public data. Geographic Information System mapping was used to delineate drive times to ACHD centers. Sociodemographic data from the 2012-2016 American Community Survey (US Census) and the Environmental Systems Research Institute were analyzed based on drive time to nearest ACHD center. Previously established CHD prevalence estimates were used to estimate the similarly located US ACHD population. RESULTS Nearly half of the continental US population (45.1%) lives >1 hour drive to an ACHD center. Overall, 39.7% live 1-4 hours away, 3.4% live 4-6 hours away, and 2.0% live >6 hours away. Hispanics were disproportionately likely to live a >6 hour drive to a center (p < .001). Compared to people with <1 hour drive, those living >6 hours away have higher proportions of uninsured adults (29% vs. 18%; p < .001), households below the federal poverty level (19% vs. 13%; p < .001), and adults with less than college education (18% vs. 12%; p < .001). CONCLUSIONS We estimate that ~45% of the continental US population lives >1 hour to an ACHD center, with 5.4% living >4 hours away. Compounding barriers exist for Hispanic, uninsured, lower socioeconomic status, and less-educated patients. These results may help drive future policy changes to improve access to ACHD care.
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Affiliation(s)
- Katherine B Salciccioli
- Section of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Abiodun Oluyomi
- Environmental Health Service, Section of General Internal Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Philip J Lupo
- Section of Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Peter R Ermis
- Section of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Keila N Lopez
- Section of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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Sakai-Bizmark R, Mena LA, Kumamaru H, Kawachi I, Marr EH, Webber EJ, Seo HH, Friedlander SIM, Chang RKR. Impact of pediatric cardiac surgery regionalization on health care utilization and mortality. Health Serv Res 2019; 54:890-901. [PMID: 30916392 DOI: 10.1111/1475-6773.13137] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Regionalization directs patients to high-volume hospitals for specialized care. We investigated regionalization trends and outcomes in pediatric cardiac surgery. DATA SOURCES/STUDY SETTING Statewide inpatient data from eleven states between 2000 and 2012. STUDY DESIGN Mortality, length of stay (LOS), and cost were assessed using multivariable hierarchical regression with state and year fixed effects. Primary predictor was hospital case-volume, categorized into low-, medium-, and high-volume tertiles. DATA COLLECTION/EXTRACTION METHODS We used Risk Adjustment for Congenital Heart Surgery-1 (RACHS-1) to select pediatric cardiac surgery discharges. PRINCIPAL FINDINGS In total, 2841 (8.5 percent), 8348 (25.1 percent), and 22 099 (66.4 percent) patients underwent heart surgeries in low-, medium-, and high-volume hospitals. Mortality decreased over time, but remained higher in low- and medium-volume hospitals. High-volume hospitals had lower odds of mortality and cost than low-volume hospitals (odds ratio [OR] 0.59, P < 0.01, and relative risk [RR] 0.91, P < 0.01, respectively). LOS was longer for high- and medium-volume hospitals, compared to low-volume hospitals (high-volume: RR 1.18, P < 0.01; medium-volume: RR 1.05, P < 0.01). CONCLUSIONS Regionalization reduced mortality and cost, indicating fewer complications, but paradoxically increased LOS. Further research is needed to explore the full impact on health care utilization.
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Affiliation(s)
- Rie Sakai-Bizmark
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California.,Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, California.,The David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Laurie A Mena
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Hiraku Kumamaru
- Department of Healthcare Quality Assessment, The University of Tokyo School of Medicine, Tokyo, Japan
| | - Ichiro Kawachi
- Department of Social and Behavioral Sciences, Harvard T.H. Chang School of Public Health, Boston, Massachusetts
| | - Emily H Marr
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Eliza J Webber
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Hyun H Seo
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California.,Anderson School of Management, University of California at Los Angeles, Los Angeles, California
| | - Scott I M Friedlander
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Ruey-Kang R Chang
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California.,Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, California.,The David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
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18
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Amagasa S, Kashiura M, Moriya T, Uematsu S, Shimizu N, Sakurai A, Kitamura N, Tagami T, Takeda M, Miyake Y. Relationship between institutional case volume and one-month survival among cases of paediatric out-of-hospital cardiac arrest. Resuscitation 2019; 137:161-167. [PMID: 30802557 DOI: 10.1016/j.resuscitation.2019.02.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 02/11/2019] [Accepted: 02/12/2019] [Indexed: 10/27/2022]
Abstract
AIM To evaluate volume-outcome relationship in paediatric out-of-hospital cardiac arrest (OHCA). METHODS This post hoc analysis of the SOS-KANTO 2012 study included data of paediatric OHCA patients <18 years old who were transported to the 53 emergency hospitals in the Kanto region of Japan between January 2012 and March 2013. Based on the paediatric OHCA case volume, the higher one-third of institutions (more than 10 paediatric OHCA cases during the study period) were defined as high-volume centres, the middle one-third institutions (6-10 cases) were defined as middle-volume centres and the lower one-third of institutions (less than 6 cases) were defined as low-volume centres. The primary outcome measurement was survival at 1 month after cardiac arrest. Multivariate logistic regression analysis for 1-month survival and paediatric OHCA case volume were performed after adjusting for multiple propensity scores. To estimate the multiple propensity score, we fitted a multinomial logistic regression model, which fell into one of the three groups as patient demographics and prehospital factors. RESULTS Among the eligible 282 children, 112, 82 and 88 patients were transported to the low-volume (36 institutions), middle-volume (11 institutions) and high-volume (6 institutions) centres, respectively. Transport to a high-volume centre was significantly associated with a better 1-month survival after adjusting for multiple propensity score (adjusted odds ratio, 2.55; 95% confidence interval, 1.05-6.17). CONCLUSION There may be a relationship between institutional case volume and survival outcomes in paediatric OHCA.
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Affiliation(s)
- Shunsuke Amagasa
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama City, Saitama, 330-8503, Japan; Division of Emergency and Transport Services, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan.
| | - Masahiro Kashiura
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Takashi Moriya
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Satoko Uematsu
- Division of Emergency and Transport Services, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Naoki Shimizu
- Department of Critical Care and Emergency Medicine, Tokyo Metropolitan Children's Medical Center, 2-8-29, Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Atsushi Sakurai
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1, Oyagutikamichou, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Nobuya Kitamura
- Department of Emergency and Critical Care Medicine, Kimitsu Chuo Hospital, 1010, Sakurai, Kisarazushi, Chiba, 292-8535, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, 1-7-1, Nagayama, Tama-shi, Tokyo, 206-8512, Japan
| | - Munekazu Takeda
- Department of Critical Care and Emergency Medicine, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Yasufumi Miyake
- Department of Emergency Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-Ku, Tokyo, 173-8606, Japan
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Coulson TG, Mullany DV, Reid CM, Bailey M, Pilcher D. Measuring the quality of perioperative care in cardiac surgery. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2018; 3:11-19. [PMID: 28927188 DOI: 10.1093/ehjqcco/qcw027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Indexed: 11/13/2022]
Abstract
Quality of care is of increasing importance in health and surgical care. In order to maintain and improve quality, we must be able to measure it and identify variation. In this narrative review, we aim to identify measures used in the assessment of quality of care in cardiac surgery and to evaluate their utility. The electronic databases Pubmed/MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, and CINAHL were searched for original published studies using the terms 'cardiac surgery' and 'quality or outcome or process or structure' as either keywords in the title or text or MeSH terms. Secondary searches and identification of references from original articles were carried out. We found a total of 54 original articles evaluating measurements of quality. While structure, process, and outcome indicators remain the mainstay of quality measurement, new and innovative methods of risk assessment have improved reliability and discrimination. Continuous assessment provides a promising method of both maintaining and improving quality of care. Future studies should focus on long-term and patient-centred outcomes, such as quality-of-life measures.
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Affiliation(s)
- Tim G Coulson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Daniel V Mullany
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Brisbane, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Michael Bailey
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Pilcher
- Department of Intensive Care, The Alfred Hospital, 55 Commercial Rd, Melbourne, Victoria 3004, Australia.,ANZICS Centre for Outcome and Resource Evaluation, Ievers Terrace, Carlton, Melbourne, Victoria, Australia
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Understanding the relationship between hospital volume and patient outcomes for infants with gastroschisis. J Pediatr Surg 2017; 52:1977-1980. [PMID: 28947327 DOI: 10.1016/j.jpedsurg.2017.08.065] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 08/28/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND For many surgical operations, there is a well-established relationship between surgical volume and outcome. We investigated whether this relationship exists for infants with gastroschisis. METHODS Using the Kids' Inpatient Database for years 2003, 2006, 2009, and 2012, we identified all patients undergoing gastroschisis repair. Controlling for patient characteristics and complexity of disease (comorbid intestinal atresia/perforation, necrotizing enterocolitis, and respiratory distress syndrome), we compared surgical outcomes (mortality, length of stay, and incidence of TPN cholestasis) by hospital volume based on quartile for gastroschisis cases treated per year. RESULTS We identified 7769 patients treated at 743 hospitals. The majority of hospitals were low-volume (n=445), while only 49 were high-volume. The overall mortality rate was 4.3%, and the median length of stay was 34days. Adjusting for clinical and demographic characteristics, patients treated at high-volume hospitals had similar rates of TPN cholestasis and similar mortality rates, but a higher chance for a prolonged length of stay compared to those treated at low-volume hospitals. CONCLUSIONS Using national data, we found that gastroschisis patients treated at high-volume hospitals did not have improved outcomes. The benefits of high-volume hospitals, which seem to be important for complex pediatric surgery, may not apply to treatment of gastroschisis. LEVEL OF EVIDENCE Level III Retrospective Study.
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Paediatric cardiac surgery in a peripheral European region: is a joint programme a safe alternative to regionalisation? Cardiol Young 2017; 27:273-283. [PMID: 27086665 DOI: 10.1017/s1047951116000469] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND In 2007, a partnership was initiated between a small-volume paediatric cardiac surgery unit located in Las Palmas de Gran Canaria, Spain, and a large-volume cardiac surgery unit located in Milan, Italy. The main goal of this partnership was to provide surgical treatment to children with CHD in the Canary Islands. METHODS An operative algorithm for performing surgery in elective, urgent, and emergency cases was adopted by the this joint programme. Demographic and in-hospital variables were collected from the medical records of all the patients who had undergone surgical intervention for CHD from January, 2009 to March, 2013. Data were introduced into the congenital database of the European Congenital Heart Surgeons Association Congenital Database and the database was interrogated. RESULTS In total, 65 surgical mission trips were performed during the period of this study. The European Congenital Heart Surgeons Association Congenital Database documented 214 total patients with a mean age at operation of 36.45 months, 316 procedures in total with 198 cardiopulmonary bypass cases, 46 non-cardiopulmonary bypass cases, 26 cardiovascular cases without cardiopulmonary bypass, 22 miscellaneous other types of cases, 16 interventional cardiology cases, six thoracic cases, one non-cardiac, non-thoracic procedure on a cardiac patient with cardiac anaesthesia, and one extracorporeal membrane oxygenation case. The 30-day mortality was 6.07% (13 patients). CONCLUSIONS A joint programme between a small-volume centre and a large-volume centre may represent a valid and reproducible model for safe paediatric cardiac surgery in the context of a peripheral region.
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22
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Lobdell KW, Fann JI, Sanchez JA. “What’s the Risk?” Assessing and Mitigating Risk in Cardiothoracic Surgery. Ann Thorac Surg 2016; 102:1052-8. [DOI: 10.1016/j.athoracsur.2016.08.051] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 08/20/2016] [Indexed: 01/24/2023]
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Preston L, Turner J, Booth A, O'Keeffe C, Campbell F, Jesurasa A, Cooper K, Goyder E. Is there a relationship between surgical case volume and mortality in congenital heart disease services? A rapid evidence review. BMJ Open 2015; 5:e009252. [PMID: 26685029 PMCID: PMC4691785 DOI: 10.1136/bmjopen-2015-009252] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To identify and synthesise the evidence on the relationship between surgical volume and patient outcomes for adults and children with congenital heart disease. DESIGN Evidence synthesis of interventional and observational studies. DATA SOURCES MEDLINE, EMBASE, CINAHL, Cochrane Library and Web of Science (2009-2014) and citation searching, reference lists and recommendations from stakeholders (2003-2014) were used to identify evidence. STUDY SELECTION Quantitative observational and interventional studies with information on volume of surgical procedures and patient outcomes were included. RESULTS 31 of the 34 papers identified (91.2%) included only paediatric patients. 25 (73.5%) investigated the relationship between volume and mortality, 7 (20.6%) mortality and other outcomes and 2 (5.9%) non-mortality outcomes only. 88.2% were from the US, 97% were multicentre studies and all were retrospective observational studies. 20 studies (58.8%) included all congenital heart disease conditions and 14 (41.2%) single conditions or procedures. No UK studies were identified. Most studies showed a relationship between volume and outcome but this relationship was not consistent. The relationship was stronger for single complex conditions or procedures. We found limited evidence about the impact of volume on non-mortality outcomes. A mixed picture emerged revealing a range of factors, in addition to volume, that influence outcome including condition severity, individual centre and surgeon effects and clinical advances over time. CONCLUSIONS The heterogeneity of findings from observational studies suggests that, while a relationship between volume and outcome exists, this is unlikely to be a simple, independent and directly causal relationship. The effect of volume on outcome relative to the effect of other, as yet undetermined, health system factors remains a complex and unresolved research question.
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Affiliation(s)
- L Preston
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - J Turner
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - A Booth
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - C O'Keeffe
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - F Campbell
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - A Jesurasa
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - K Cooper
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - E Goyder
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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24
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Kreutzer J. Catastrophic Adverse Events During Cardiac Catheterization in Pediatric Pulmonary Hypertension May Not Be So Rare. J Am Coll Cardiol 2015; 66:1270-1272. [PMID: 26361159 DOI: 10.1016/j.jacc.2015.07.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 07/14/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Jacqueline Kreutzer
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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25
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Lui C, Grimm JC, Magruder JT, Dungan SP, Spinner JA, Do N, Nelson KL, Cameron DE, Vricella LA, Jacobs ML. The Effect of Institutional Volume on Complications and Their Impact on Mortality After Pediatric Heart Transplantation. Ann Thorac Surg 2015; 100:1423-31. [PMID: 26298167 DOI: 10.1016/j.athoracsur.2015.06.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 04/06/2015] [Accepted: 06/01/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study evaluated the potential association of institutional volume with survival and mortality subsequent to major complications in a modern cohort of pediatric patients after orthotopic heart transplantation (OHT). METHODS The United Network of Organ Sharing database was queried for pediatric patients (aged ≤18 years) undergoing OHT between 2000 and 2010. Institutional volume was defined as the average number of transplants completed annually during each institution's active period and was evaluated as categoric and as a continuous variable. Logistic regression models were used to determine the effect of institutional volumes on postoperative outcomes, which included renal failure, stroke, rejection, reoperation, infection, and a composite complication outcome. Cox modeling was used to analyze the risk-adjusted effect of institutional volume on 30-day, 1-year, and 5-year mortality. Kaplan-Meier estimates were used to compare differences in unconditional survival. RESULTS A total of 3,562 patients (111 institutions) were included and stratified into low-volume (<6.5 transplants/year, 91 institutions), intermediate-volume (6.5 to 12.5 transplants/year, 12 institutions), and high-volume (>12.5 transplants/year, 8 institutions) tertiles. Unadjusted survival was significantly different at 30 days (p = 0.0087) in the low-volume tertile (94.2%; 95% confidence interval, 92.7% to 95.4%) compared with the high-volume tertile (96.8%; 95% confidence interval, 95.7% to 97.7%). No difference was observed at 1 or 5 years. Risk-adjusted Cox modeling demonstrated that low-volume institutions had an increased rate of mortality at 30 days (hazard ratio, 1.91; 95% confidence interval, 1.02 to 3.59; p = 0.044), but not at 1 or 5 years. High-volume institutions had lower incidences of postoperative complications than low-volume institutions (30.3% vs 38.4%, p < 0.001). Despite this difference in the rate of complications, survival in patients with a postoperative complication was similar across the volume tertiles. CONCLUSIONS No association was observed between institutional volume and adjusted or unadjusted long-term survival. High-volume institutions have a significantly lower rate of postoperative complications after pediatric OHT. This association does not correlate with increased subsequent mortality in low-volume institutions. Given these findings, strategies integral to the allocation of allografts in adult transplantation, such as regionalization of care, may not be as relevant to pediatric OHT.
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Affiliation(s)
- Cecillia Lui
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Joshua C Grimm
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - J Trent Magruder
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Samuel P Dungan
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Joseph A Spinner
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Nhue Do
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Kristin L Nelson
- Division of Pediatric Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Duke E Cameron
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Luca A Vricella
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Marshall L Jacobs
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland.
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26
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Abdulla RI. Pediatric cardiology and social engineering. Pediatr Cardiol 2014; 35:1085-7. [PMID: 25204563 DOI: 10.1007/s00246-014-1023-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Ra-id Abdulla
- Department of Pediatric Cardiology, Rush University Medical Center, Chicago, IL, 60612, USA,
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