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Maddali MM, Al-Mamari AH, Raju S, Sathiya PM. Clinical Variables Specific to Timing of Tracheal Extubation Following Pediatric Cardiac Surgery. World J Pediatr Congenit Heart Surg 2024; 15:193-201. [PMID: 37981790 DOI: 10.1177/21501351231204325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
BACKGROUND The primary objective of this study was to identify specific factors in pediatric cardiac surgical patients when tracheal extubation was performed on the operating table after completion of open-heart surgery (Group-1), postoperatively in the intensive care unit within 6 h (Group-II) or after 6 h (Group-III). The causes of failed extubation, the presence of chromosomal disorders in addition to arterial blood gas analysis parameters at the time of tracheal extubation, and the duration of intensive care unit stay were also evaluated in each group. METHODS In addition to the three groups, Groups I and II were combined as a "fast-track" extubation group. The demographic data, Risk Adjustment for Congenital Heart Surgery (RACHS-1) score, the Society of Thoracic Surgeons - European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Category (STAT Mortality Category), cardiopulmonary bypass (CPB) time, aortic cross-clamp (ACC) time, and vasoactive-inotropic score (VIS) at the time of tracheal extubation along with data related to secondary objectives were recorded for each patient. RESULTS A significant association was found by bivariate analysis between clinical variables and for both operating table and fast-track extubation in terms of age, weight, RACHS-1 score, STAT category, CPB and ACC time, and VIS. A multivariate-adjusted analysis showed weight, lower STAT category, CPB time, and VIS were independent predictors for operating table and fast-track extubation. CONCLUSIONS Younger age, lower weight, higher RACHS-1, STAT category, and VIS, along with longer CPB and ACC, are associated with delay in the timing of tracheal extubation in pediatric cardiac surgical patients.
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Affiliation(s)
- Madan Mohan Maddali
- Department of Cardiac Anesthesia, National Heart Center, Royal Hospital, Muscat, Oman
| | | | - Sowmiya Raju
- Department of Cardiac Anesthesia, National Heart Center, Royal Hospital, Muscat, Oman
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Martin SS, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Barone Gibbs B, Beaton AZ, Boehme AK, Commodore-Mensah Y, Currie ME, Elkind MSV, Evenson KR, Generoso G, Heard DG, Hiremath S, Johansen MC, Kalani R, Kazi DS, Ko D, Liu J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Perman SM, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Tsao CW, Urbut SM, Van Spall HGC, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Palaniappan LP. 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association. Circulation 2024; 149:e347-e913. [PMID: 38264914 DOI: 10.1161/cir.0000000000001209] [Citation(s) in RCA: 182] [Impact Index Per Article: 182.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
BACKGROUND The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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3
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Chua ME, Silangcruz JM, Kim JK, Koyle MA, Sriharan A. A Scoping Review on Learning Health Networks Available in Pediatric Surgical Specialties. J Pediatr Surg 2023; 58:2416-2428. [PMID: 37544802 DOI: 10.1016/j.jpedsurg.2023.07.006] [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: 01/03/2023] [Revised: 07/10/2023] [Accepted: 07/10/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Learning health networks (LHN) are consortia of institutions that collaborate and embrace the elements of the learning health system (LHS), including quality improvement, education, research, and stakeholder involvement. Their ultimate goal is rapid information dissemination in clinical care. Pediatric surgical specialties perform unique yet high-impact procedures that could benefit from LHN, thereby improving surgical outcomes and care through LHS approaches. Consequently, health system leaders should be aware of LHN and their importance in enhancing surgical care and improving outcomes. This scoping review aims to map and characterize the existing LHN applied in pediatric surgical specialties. METHODS A systematic literature search was performed on Medline, EMBASE, and Scopus up to June 2022, with an update search conducted in May 2023. Additionally, Google Scholar, ProQuest and inquiry from topic experts were used for cross-referencing relevant review articles to identify grey literature. This scoping review was conducted and reported according to the PRISMA-scoping review extension. RESULTS A total of 56 publications for 19 LHN were identified and included in this scoping review. Out of 19 identified LHN in pediatric surgical specialties, 18 were organized in North America. Eight of the networks are related to pediatric general surgery and another eight were related to pediatric transplantation. The 16 out of 19 LHN were initiated after 2001. To date, only eight of the LHNs generated reports of comparative improved outcomes. CONCLUSION This scoping review provides an overview of the available LHNs in pediatric surgical specialties. Over the past decade, several pediatric surgical specialties have embraced the principles of learning health systems, forming inter-institutional collaborations that utilize information technology to generate big data on patient-level clinical information, engage in quality improvement cycles, adopt evidence-based practices, and actively involve patients and stakeholders. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Michael E Chua
- Global Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, ON, Canada; Institute of Urology, St. Luke's Medical Center, Quezon City, NCR, Philippines.
| | | | - Jin Kyu Kim
- Department of Surgery, Faculty of Medicine and Surgery, University of Toronto, ON, Canada
| | - Martin A Koyle
- System Leadership and Innovation, Institute of Health Policy, Management and Evaluation, University of Toronto, ON, Canada
| | - Abi Sriharan
- System Leadership and Innovation, Institute of Health Policy, Management and Evaluation, University of Toronto, ON, Canada
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4
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Yamamoto T, Schindler E. Regional anesthesia as part of enhanced recovery strategies in pediatric cardiac surgery. Curr Opin Anaesthesiol 2023; 36:324-333. [PMID: 36924271 PMCID: PMC10155682 DOI: 10.1097/aco.0000000000001262] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review article was to highlight the enhanced recovery protocols in pediatric cardiac surgery, including early extubation, rapid mobilization and recovery, reduction of opioid-related side effects, and length of pediatric ICU and hospital stay, resulting in decreased costs and perioperative morbidity, by introducing recent trends in perioperative anesthesia management combined with peripheral nerve blocks. RECENT FINDINGS Efficient postoperative pain relief is essential for realizing enhanced recovery strategies, especially in pediatric patients. It has been reported that approaches to perioperative pain management using additional peripheral nerve blocks ensure early extubation and a shorter duration of ICU and hospital stay. This article provides an overview of several feasible musculofascial plane blocks to achieve fast-track anesthesia management for pediatric cardiac surgery. SUMMARY Recent remarkable advances in combined ultrasound techniques have made it possible to perform various peripheral nerve blocks. The major strategy underlying fast-track anesthesia management is to achieve good analgesia while reducing perioperative opioid use. Furthermore, it is important to consider early extubation not only as a competition for time to extubation but also as the culmination of a qualitative improvement in the outcome of treatment for each patient.
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Affiliation(s)
- Tomohiro Yamamoto
- Division of Anesthesiology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Ehrenfried Schindler
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
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5
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Tsao CW, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Beaton AZ, Boehme AK, Buxton AE, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Fugar S, Generoso G, Heard DG, Hiremath S, Ho JE, Kalani R, Kazi DS, Ko D, Levine DA, Liu J, Ma J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Virani SS, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association. Circulation 2023; 147:e93-e621. [PMID: 36695182 DOI: 10.1161/cir.0000000000001123] [Citation(s) in RCA: 1459] [Impact Index Per Article: 1459.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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6
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Gil D, Aljiffry A, Dryer R, Rao N, Figueroa J, Downey L, Shaw FR, Beshish AG. Extubation delays and the associated prostaglandin and opiate dose following coarctation of the aorta repair. PROGRESS IN PEDIATRIC CARDIOLOGY 2022. [DOI: 10.1016/j.ppedcard.2022.101574] [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: 11/15/2022]
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7
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Katz AJ, Lion RP, Martens T, Newcombe J, Razzouk A, Shih W, Amirnovin R, Gordon BM. Pediatric Surgical Pulmonary Valve Replacement Outcomes After Implementation of a Clinical Pathway. World J Pediatr Congenit Heart Surg 2022; 13:420-425. [PMID: 35757942 DOI: 10.1177/21501351221098127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Standardization of perioperative care can reduce resource utilization while improving patient outcomes. We sought to describe our outcomes after the implementation of a perioperative clinical pathway for pediatric patients undergoing elective surgical pulmonary valve replacement and compare these results to previously published national benchmarks. METHODS A retrospective single-center descriptive study was conducted of all pediatric patients who underwent surgical pulmonary valve replacement from 2017 through 2020, after the implementation of a clinical pathway. Outcomes included hospital length of stay and 30-day reintervention, readmission, and mortality. RESULTS Thirty-three patients (55% female, median age 11 [7, 13] years, 32 [23, 44] kg) were included in the study. Most common diagnosis and indication for surgery was Tetralogy of Fallot (61%) with pulmonary valve insufficiency (88%). All patients had prior cardiac surgery. Median hospital length of stay was 2 [2, 2] days, and longest length of stay was three days. There were no 30-day readmissions, reinterventions, or mortalities. Median follow-up time was 19 [9, 31] months. CONCLUSIONS Formalization of a perioperative surgical pulmonary valve replacement clinical pathway can safely promote short hospital length of stay without any short-term readmissions or reinterventions, especially when compared with previously published benchmarks. Such formalization enables the dissemination of best practices to other institutions to reduce hospital length of stay and limit costs.
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Affiliation(s)
- Alex J Katz
- Department of Pediatrics, 23333Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Richard P Lion
- Department of Pediatrics, Division of Critical Care, 23333Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Timothy Martens
- Department of Cardiovascular and Thoracic Surgery, 23333Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Jennifer Newcombe
- Department of Cardiovascular and Thoracic Surgery, 23333Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Anees Razzouk
- Department of Cardiovascular and Thoracic Surgery, 23333Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Wendy Shih
- School of Public Health, 4608Loma Linda University, Loma Linda, CA, USA
| | - Rambod Amirnovin
- Department of Pediatrics, Division of Critical Care, 23333Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Brent M Gordon
- Department of Pediatrics, Division of Cardiology, 23333Loma Linda University Children's Hospital, Loma Linda, CA, USA
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8
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Tsao CW, Aday AW, Almarzooq ZI, Alonso A, Beaton AZ, Bittencourt MS, Boehme AK, Buxton AE, Carson AP, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Ferguson JF, Generoso G, Ho JE, Kalani R, Khan SS, Kissela BM, Knutson KL, Levine DA, Lewis TT, Liu J, Loop MS, Ma J, Mussolino ME, Navaneethan SD, Perak AM, Poudel R, Rezk-Hanna M, Roth GA, Schroeder EB, Shah SH, Thacker EL, VanWagner LB, Virani SS, Voecks JH, Wang NY, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association. Circulation 2022; 145:e153-e639. [PMID: 35078371 DOI: 10.1161/cir.0000000000001052] [Citation(s) in RCA: 2627] [Impact Index Per Article: 1313.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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Chowdhury D, Johnson JN, Baker-Smith CM, Jaquiss RDB, Mahendran AK, Curren V, Bhat A, Patel A, Marshall AC, Fuller S, Marino BS, Fink CM, Lopez KN, Frank LH, Ather M, Torentinos N, Kranz O, Thorne V, Davies RR, Berger S, Snyder C, Saidi A, Shaffer K. Health Care Policy and Congenital Heart Disease: 2020 Focus on Our 2030 Future. J Am Heart Assoc 2021; 10:e020605. [PMID: 34622676 PMCID: PMC8751886 DOI: 10.1161/jaha.120.020605] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The congenital heart care community faces a myriad of public health issues that act as barriers toward optimum patient outcomes. In this article, we attempt to define advocacy and policy initiatives meant to spotlight and potentially address these challenges. Issues are organized into the following 3 key facets of our community: patient population, health care delivery, and workforce. We discuss the social determinants of health and health care disparities that affect patients in the community that require the attention of policy makers. Furthermore, we highlight the many needs of the growing adults with congenital heart disease and those with comorbidities, highlighting concerns regarding the inequities in access to cardiac care and the need for multidisciplinary care. We also recognize the problems of transparency in outcomes reporting and the promising application of telehealth. Finally, we highlight the training of providers, measures of productivity, diversity in the workforce, and the importance of patient-family centered organizations in advocating for patients. Although all of these issues remain relevant to many subspecialties in medicine, this article attempts to illustrate the unique needs of this population and highlight ways in which to work together to address important opportunities for change in the cardiac care community and beyond. This article provides a framework for policy and advocacy efforts for the next decade.
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Affiliation(s)
| | - Jonathan N Johnson
- Division of Pediatric Cardiology Mayo Clinic Rochester MN.,Division of Cardiovascular Diseases Mayo Clinic Rochester MN
| | - Carissa M Baker-Smith
- Sidney Kimmel Medical College of Thomas Jefferson UniversityNemours'/Alfred I duPont Hospital for Children Cardiac Center Wilmington DE
| | - Robert D B Jaquiss
- Department of Cardiothoracic Surgery and Pediatrics Children's Hospital and University of Texas, Southwestern Medical Center Dallas TX
| | - Arjun K Mahendran
- Department of Pediatrics University of Florida-Congenital Heart Center Gainesville FL
| | - Valerie Curren
- Division of Cardiology Children's National Hospital Washington DC
| | - Aarti Bhat
- Seattle Children's Hospital and University of Washington Seattle WA
| | - Angira Patel
- Division of Cardiology Ann & Robert H. Lurie Children's Hospital of Chicago Chicago IL.,Department of Pediatrics Northwestern University Feinberg School of Medicine Chicago IL
| | - Audrey C Marshall
- Cardiac Diagnostic and Interventional Unit The Hospital for Sick Children Toronto Ontario Canada
| | - Stephanie Fuller
- Division of Cardiothoracic Surgery Children's Hospital of Philadelphia Philadelphia PA
| | - Bradley S Marino
- Division of Cardiology Ann & Robert H. Lurie Children's Hospital of Chicago Chicago IL.,Department of Pediatrics Northwestern University Feinberg School of Medicine Chicago IL
| | - Christina M Fink
- Department of Pediatric Cardiology Cleveland Clinic Cleveland OH
| | - Keila N Lopez
- Lillie Frank Abercrombie Section of Cardiology Department of Pediatrics Texas Children's HospitalBaylor College of Medicine Houston TX
| | - Lowell H Frank
- Division of Cardiology Children's National Hospital Washington DC
| | | | | | | | | | - Ryan R Davies
- Department of Cardiothoracic Surgery and Pediatrics Children's Hospital and University of Texas, Southwestern Medical Center Dallas TX
| | - Stuart Berger
- Division of Cardiology Ann & Robert H. Lurie Children's Hospital of Chicago Chicago IL.,Department of Pediatrics Northwestern University Feinberg School of Medicine Chicago IL
| | - Christopher Snyder
- Division of Pediatric Cardiology The Congenital Heart Collaborative University Hospital Rainbow Babies and Children's Hospital Cleveland OH
| | - Arwa Saidi
- Department of Pediatrics University of Florida-Congenital Heart Center Gainesville FL
| | - Kenneth Shaffer
- Texas Center for Pediatric and Congenital Heart Disease University of Texas Dell Medical School/Dell Children's Medical Center Austin TX
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10
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Murin P, Weixler VH, Romanchenko O, Schulz A, Redlin M, Cho MY, Sinzobahamvya N, Miera O, Kuppe H, Berger F, Photiadis J. Fast-track extubation after cardiac surgery in infants: Tug-of-war between performance and reimbursement? J Thorac Cardiovasc Surg 2021; 162:435-443. [DOI: 10.1016/j.jtcvs.2020.09.123] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 08/28/2020] [Accepted: 09/18/2020] [Indexed: 11/26/2022]
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11
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Pasquali SK, Thibault D, Hall M, Chiswell K, Romano JC, Gaynor JW, Shahian DM, Jacobs ML, Gaies MG, O'Brien SM, Norton EC, Hill KD, Cowper PA, Shah SS, Mayer JE, Jacobs JP. Evolving Cost-Quality Relationship in Pediatric Heart Surgery. Ann Thorac Surg 2021; 113:866-873. [PMID: 34116004 DOI: 10.1016/j.athoracsur.2021.05.050] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/16/2021] [Accepted: 05/14/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND For the >40,000 US children undergoing congenital heart surgery annually, the relationship between hospital quality and costs remains unclear. Prior studies report conflicting results and clinical outcomes have continued to improve over time. We examined a large contemporary cohort, aiming to better inform ongoing initiatives seeking to optimize healthcare value in this population. METHODS Clinical information (Society of Thoracic Surgeons Congenital Database) was merged with standardized cost data (Pediatric Health Information Systems) for children undergoing heart surgery from 2010-2015. In-hospital cost variability was analyzed using Bayesian hierarchical models adjusted for case-mix. Quality metrics examined included in-hospital mortality, post-operative complications, length of stay (PLOS), and a composite. RESULTS Overall 32 hospitals (n=45,315 patients) were included. Median adjusted cost/case varied across hospitals from $67,700 to $51,200 in the high vs. low cost tertile (ratio 1.32, 95% credible interval 1.29-1.35), and all quality metrics also varied across hospitals. Across cost tertiles there were no significant differences in the quality metrics examined, with the exception of PLOS. The PLOS findings were driven by high-risk STAT 4-5 cases [adjusted median LOS 16.8 vs. 14.9 days in high vs. low cost tertile (ratio 1.13, 1.05-1.24)], and ICU PLOS. CONCLUSIONS Contemporary congenital heart surgery costs vary across hospitals but were not associated with most quality metrics examined, highlighting that performance in one area does not necessarily convey to others. Cost variability was associated with PLOS, particularly related to ICU PLOS and high-risk cases. Care processes influencing PLOS may provide targets for value-based initiatives in this population.
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Affiliation(s)
- Sara K Pasquali
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan.
| | - Dylan Thibault
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Jennifer C Romano
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - J William Gaynor
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David M Shahian
- Department of Surgery, Center for Quality and Safety, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael G Gaies
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Sean M O'Brien
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Edward C Norton
- Department of Health Management and Policy, Department of Economics, University of Michigan, Ann Arbor, Michigan
| | - Kevin D Hill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Patricia A Cowper
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Samir S Shah
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - John E Mayer
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Jeffrey P Jacobs
- Department of Surgery, University of Florida, Gainesville, Florida
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Fuller S, Kumar SR, Roy N, Mahle WT, Romano JC, Nelson JS, Hammel JM, Imamura M, Zhang H, Fremes SE, McHugh-Grant S, Nicolson SC. The American Association for Thoracic Surgery Congenital Cardiac Surgery Working Group 2021 consensus document on a comprehensive perioperative approach to enhanced recovery after pediatric cardiac surgery. J Thorac Cardiovasc Surg 2021; 162:931-954. [PMID: 34059337 DOI: 10.1016/j.jtcvs.2021.04.072] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 04/26/2021] [Accepted: 04/26/2021] [Indexed: 12/22/2022]
Affiliation(s)
- Stephanie Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - S Ram Kumar
- Division of Cardiac Surgery, Department of Surgery, and Department of Pediatrics, Keck School of Medicine of the University of Southern California, Heart Institute, Children's Hospital Los Angeles, Los Angeles, Calif.
| | - Nathalie Roy
- Department of Cardiac Surgery, Boston Children's Hospital, Department of Surgery, Harvard Medical School, Boston, Mass
| | - William T Mahle
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jennifer C Romano
- Departments of Cardiac Surgery and Pediatrics, University of Michigan, CS Mott Children's Hospital, Ann Arbor, Mich
| | - Jennifer S Nelson
- Department of Cardiovascular Services, Nemours Children's Hospital, and Department of Surgery, University of Central Florida College of Medicine, Orlando, Fla
| | - James M Hammel
- Department of Cardiothoracic Surgery, Children's Hospital and Medical Center of Omaha, Omaha, Neb
| | - Michiaki Imamura
- Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Haibo Zhang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Stephen E Fremes
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sara McHugh-Grant
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Penn
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Penn
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13
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Hadaya J, Downey P, Tran Z, Sanaiha Y, Verma A, Shemin RJ, Benharash P. Impact of Postoperative Infections on Readmission and Resource Use in Elective Cardiac Surgery. Ann Thorac Surg 2021; 113:774-782. [PMID: 33882295 DOI: 10.1016/j.athoracsur.2021.04.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 03/06/2021] [Accepted: 04/12/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Efforts to reduce postoperative infections have garnered national attention, leading to practice guidelines for cardiac surgical perioperative care. The present study characterized the impact of healthcare-acquired infection (HAI) on index hospitalization costs and post-discharge healthcare utilization. METHODS Adults undergoing elective coronary artery bypass grafting (CABG) and/or valve operations were identified in the 2016-2018 Nationwide Readmissions Database. Infections were categorized into bloodstream, gastrointestinal, pulmonary, surgical site, or urinary tract infections. Generalized linear or flexible hazard models were used to assess associations between infections and outcomes. Observed-to-expected (O/E) ratios were generated to examine inter-hospital variation in HAI. RESULTS Of an estimated 444,165 patients, 8.0% developed HAI. Patients with HAI were older, had a greater burden of chronic diseases, and more commonly underwent CABG/valve or multi-valve operations (all p<0.001). HAI was independently associated with mortality (odds ratio 4.02, 95% CI 3.67-4.40), non-home discharge (3.48, 95% CI 3.21-3.78), and a cost increase of $23,000 (95% CI 20,900-25,200). At 90 days, HAI was associated with greater hazard of readmission (1.29, 95% CI 1.24-1.35). Pulmonary infections had the greatest incremental impact on patient-level ($24,500, 95% CI 23,100-26,00) and annual cohort costs ($121.8 million, 95% CI 102.2-142.9 million). Significant hospital level variation in HAI was evident, with O/E ranging from 0.17 to 4.3 for cases performed in 2018. CONCLUSIONS Infections following cardiac surgery remain common and are associated with inferior outcomes and increased resource use. The presence of inter-hospital variation in this contemporary cohort emphasizes the ongoing need for systematic approaches in their prevention and management.
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Affiliation(s)
- Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California
| | - Peter Downey
- Department of Cardiovascular & Thoracic Surgery, University of Kansas Health System, Kansas City, Kansas
| | - Zachary Tran
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California
| | - Richard J Shemin
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California.
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14
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Checchia PA, Brown KL, Wernovsky G, Penny DJ, Bronicki RA. The Evolution of Pediatric Cardiac Critical Care. Crit Care Med 2021; 49:545-557. [PMID: 33591011 DOI: 10.1097/ccm.0000000000004832] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Paul A Checchia
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Katherine L Brown
- Heart and Lung Division and Biomedical Research Centre, Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Gil Wernovsky
- Cardiac Critical Care and Pediatric Cardiology, Children's National Medical Center and George Washington University School of Medicine and Health Sciences, Washington DC
| | - Daniel J Penny
- Section of Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston TX
| | - Ronald A Bronicki
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
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15
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Quintessenza J. Commentary: It's all about what the patient needs, not what we are used to or comfortable with. J Thorac Cardiovasc Surg 2020; 162:446-447. [PMID: 33610370 DOI: 10.1016/j.jtcvs.2020.10.116] [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: 10/28/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 10/23/2022]
Affiliation(s)
- James Quintessenza
- Pediatric Cardiac Surgery (PAR), Johns Hopkins All Children's Heart Institute, St Petersburg, Fla.
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16
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Abstract
OBJECTIVES Early extubation following pediatric cardiac surgery is common, but debate exists whether location affects outcome, with some centers performing routine early extubations in the operating room (odds ratio) and others in the cardiac ICU. We aimed to define early extubation practice variation across hospitals and assess impact of location on hospital length-of-stay and other outcomes. DESIGN Secondary analysis of the Pediatric Cardiac Critical Care Consortium registry. SETTING Twenty-eight Pediatric Cardiac Critical Care Consortium hospitals. PATIENTS Patients undergoing Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery mortality category 1-3 operations between August 2014 and February 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We defined early extubation as extubation less than 6 hours after postoperative admission. Hospitals were categorized based on the proportion of their early extubation patients who underwent an odds ratio extubation. Categories included low- (< 50% of early extubation, n = 12), medium- (50%-90%, n = 8), or high- (> 90%, n = 8) frequency odds ratio early extubation centers. The primary outcome of interest was postoperative hospital length-of-stay. We analyzed 16,594 operations (9,143 early extubation, 55%). Rates of early extubation ranged from 16% to 100% across hospitals. Odds ratio early extubation rates varied from 16% to 99%. Patient characteristics were similar across hospital odds ratio early extubation categories. Early extubation rates paralleled the hospital odds ratio early extubation rates-77% patients underwent early extubation at high-frequency odds ratio extubation centers compared with 39% at low-frequency odds ratio extubation centers (p < 0.001). High- and low-frequency odds ratio early extubation hospitals had similar length-of-stay, cardiac arrest rates, and low mortality. However, high-frequency odds ratio early extubation hospitals used more noninvasive ventilation than low-frequency hospitals (15% vs. 9%; p < 0.01), but had fewer extubation failures (3.6% vs. 4.5%; p = 0.02). CONCLUSIONS Considerable variability exists in early extubation practices after low- and moderate-complexity pediatric cardiac surgery. In this patient population, hospital length-of-stay did not differ significantly between centers with different early extubation strategies based on location or frequency.
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17
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Woo JL, Anderson BR. Diagnosis-Related Groups, Reimbursement, and the Quality Disconnect. World J Pediatr Congenit Heart Surg 2020; 11:563-564. [PMID: 32853068 DOI: 10.1177/2150135120933150] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Joyce L Woo
- Division of Pediatric Cardiology, 21611Columbia University Irving Medical Center/New York-Presbyterian, Morgan Stanley Children's Hospital, NY, USA
| | - Brett R Anderson
- Division of Pediatric Cardiology, 21611Columbia University Irving Medical Center/New York-Presbyterian, Morgan Stanley Children's Hospital, NY, USA
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18
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Johnson JT, Scholtens DM, Kuang A, Feng XY, Eltayeb OM, Post LA, Marino BS. Does Value Vary by Center Surgical Volume for Neonates With Truncus Arteriosus? A Multicenter Study. Ann Thorac Surg 2020; 112:170-177. [PMID: 32768429 DOI: 10.1016/j.athoracsur.2020.05.178] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 05/18/2020] [Accepted: 05/28/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Truncus arteriosus is a congenital heart defect with high resource use, cost, and mortality. Value assessment (outcome relative to cost) can improve quality of care and decrease cost. This study hypothesized that truncus arteriosus repair at a high-volume center would result in better outcomes at lower cost (higher value) compared with a low-volume center. METHODS This study retrospectively analyzed a multicenter cohort of neonates undergoing truncus arteriosus repair (2004 to 2015) by using the Pediatric Health Information Systems database. Multivariate quantile, logistic, and negative binomial regression models were used to evaluate total hospital cost, in-hospital mortality, ventilation days, intensive care unit length of stay (LOS), hospital LOS, and days of inotropic agent use by center volume (high-volume >3/year) and age at repair while adjusting for sex, ethnicity, race, genetic abnormality, prematurity, low birth weight, concurrent interrupted arch repair, and truncal valve repair. RESULTS Of 1024 neonates with truncus arteriosus, 495 (48%) were treated at high-volume centers. Costs at the 75th percentile were lower at high-volume vs low-volume centers by $28,456 (P = .02) at all ages at repair. Patients at high-volume centers had lower median postoperative ventilation days (5 days vs 6 days; P < .001), intensive care unit LOS (13 days vs 19 days; P < .001), hospital LOS (23 days vs 28 days; P = .02), and inotropic agent use (3 days vs 4 days; P = .004). In-hospital mortality did not differ by center volume. CONCLUSIONS In neonates undergoing truncus arteriosus repair, costs are lower and outcomes are better at high-volume centers, thus resulting in higher value at all ages of repair. Value-based interventions should be considered to improve outcomes and decrease cost in truncus arteriosus care.
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Affiliation(s)
- Joyce T Johnson
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Denise M Scholtens
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Alan Kuang
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Xiang Yu Feng
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Osama M Eltayeb
- Division of Cardiothoracic Surgery, Department of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Lori A Post
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Bradley S Marino
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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19
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Faraoni D, Ng WCK. Pro: Early Extubation After Pediatric Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 34:2539-2541. [PMID: 32561246 DOI: 10.1053/j.jvca.2020.05.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/18/2020] [Indexed: 12/16/2022]
Affiliation(s)
- David Faraoni
- Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada.
| | - William C K Ng
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada; Department of Anesthesia and Pain Management, University Health Network - Toronto General Hospital, Toronto, Canada
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20
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McHugh KE, Pasquali SK, Mahle WT. Reply. Ann Thorac Surg 2020; 109:989. [PMID: 31706876 PMCID: PMC7983305 DOI: 10.1016/j.athoracsur.2019.09.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 09/14/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Kimberly E McHugh
- Department of Pediatrics, Medical University of South Carolina, 165 Ashley Ave, MSC 915, Charleston, SC 29425.
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - William T Mahle
- Department of Pediatrics, Children's Healthcare of Atlanta and Emory University, Atlanta, Georgia
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21
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Peer SM, Jonas RA. Controlling the Cost of Management of Congenital Heart Disease. Ann Thorac Surg 2019; 109:988-989. [PMID: 31521596 DOI: 10.1016/j.athoracsur.2019.07.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 07/11/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Syed Murfad Peer
- Department of Cardiac Surgery, Children's National Health System, 111 Michigan Ave NW, Washington, DC 20010.
| | - Richard A Jonas
- Department of Cardiac Surgery, Children's National Health System, 111 Michigan Ave NW, Washington, DC 20010
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22
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Enhancing efficiency and scientific impact of a clinical trials network: the Pediatric Heart Network Integrated CARdiac Data and Outcomes (iCARD) Collaborative. Cardiol Young 2019; 29:1121-1126. [PMID: 31385565 PMCID: PMC6980390 DOI: 10.1017/s104795111900163x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Recent years have seen an exponential increase in the variety of healthcare data captured across numerous sources. However, mechanisms to leverage these data sources to support scientific investigation have remained limited. In 2013 the Pediatric Heart Network (PHN), funded by the National Heart, Lung, and Blood Institute, developed the Integrated CARdiac Data and Outcomes (iCARD) Collaborative with the goals of leveraging available data sources to aid in efficiently planning and conducting PHN studies; supporting integration of PHN data with other sources to foster novel research otherwise not possible; and mentoring young investigators in these areas. This review describes lessons learned through the development of iCARD, initial efforts and scientific output, challenges, and future directions. This information can aid in the use and optimisation of data integration methodologies across other research networks and organisations.
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23
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Karamlou T, Rao R, Najm H. Collaborative Learning Models in Pediatric Cardiac Care: The Continuum of Learning and Positive Change Through Shared Inquiry. Ann Thorac Surg 2019; 107:1293-1296. [PMID: 30902624 DOI: 10.1016/j.athoracsur.2019.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 02/26/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Tara Karamlou
- Division of Pediatric Cardiac Surgery, Heart Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Rohit Rao
- Division of Cardiology, Department of Pediatrics, Rady Children's Hospital, San Diego, California
| | - Hani Najm
- Division of Pediatric Cardiac Surgery, Heart Vascular Institute, Cleveland Clinic, Cleveland, Ohio
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24
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Gaies M, Pasquali SK, Nicolson SC, Shekerdemian L, Witte M, Wolf M, Zhang W, Donohue JE, Mahle WT. Sustainability of Infant Cardiac Surgery Early Extubation Practices After Implementation and Study. Ann Thorac Surg 2018; 107:1427-1433. [PMID: 30391249 DOI: 10.1016/j.athoracsur.2018.09.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/07/2018] [Accepted: 09/12/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND The Pediatric Heart Network Collaborative Learning Study (PHN CLS) successfully changed practice at four hospitals to increase the rate of early extubation within 6 hours after infant heart surgery. It is unknown whether this practice continued after study completion. METHODS We linked the PHN CLS dataset to the Pediatric Cardiac Critical Care Consortium registry to compare outcomes at four active hospitals between the study period (post-clinical practice guideline [CPG]) and the first year after study completion (follow-up) after a 3-month washout. Inclusion and exclusion criteria were the same across eras. Primary outcome was early extubation rate after tetralogy of Fallot or aortic coarctation repair. Secondary outcomes included time to first extubation and intensive care and hospital lengths of stay. RESULTS There were 121 patients in the post-CPG era and 139 patients in the follow-up era with no difference in patient characteristics or operation subtypes. Post-CPG early extubation rate declined from 67% to 30% in follow-up (p < 0.0001); time to first extubation increased (4.5 versus 13.5 hours, p < 0.0001). One hospital maintained the rate of early extubation (72% versus 67%), whereas the other three hospitals had significantly lower rates in follow-up (p < 0.02 for each). Intensive care (2.8 versus 2.9 days) and postoperative hospital (6 versus 5 days) stays did not differ between eras (p > 0.05 for both). Findings were consistent across operation subtypes. CONCLUSIONS Extubation practice in the first year of follow-up after the PHN CLS reverted toward prestudy levels. One of four hospitals maintained its early extubation strategy, suggesting that specific implementation and maintenance approaches may effectively sustain impact from quality initiatives.
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Affiliation(s)
- Michael Gaies
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Sara K Pasquali
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, Michigan
| | - Susan C Nicolson
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lara Shekerdemian
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Madolin Witte
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Michael Wolf
- Department of Pediatrics, Emory University, Atlanta, Georgia; Sibley Heart Center, Emory University, Atlanta, Georgia
| | - Wenying Zhang
- Michigan Congenital Heart Outcomes Research and Discovery Unit, Pediatric Cardiac Critical Care Consortium Data Coordinating Center, University of Michigan, Ann Arbor, Michigan
| | - Janet E Donohue
- Michigan Congenital Heart Outcomes Research and Discovery Unit, Pediatric Cardiac Critical Care Consortium Data Coordinating Center, University of Michigan, Ann Arbor, Michigan
| | - William T Mahle
- Department of Pediatrics, Emory University, Atlanta, Georgia; Sibley Heart Center, Emory University, Atlanta, Georgia
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