1
|
Shinjo D, Ozawa N, Nakadate N, Kanamori Y, Matsumoto K, Noguchi T, Ohtera S, Kato H. Development of a set of quality indicators in paediatric and perinatal care in Japan with a modified Delphi method. BMJ Paediatr Open 2023; 7:e002209. [PMID: 37940343 PMCID: PMC10632888 DOI: 10.1136/bmjpo-2023-002209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/30/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUNDS Few paediatric and perinatal quality indicators (QIs) have been developed in the Japanese setting, and the quality of care is not assured or validated. The aim of this study was to develop QIs in paediatric and perinatal care in Japan using an administrative database and confirm the feasibility and applicability of the indicators using a single-site practice test. METHODS We used a RAND-modified Delphi method that integrates evidence review with expert consensus development. QI candidates were generated from clinical practice guidelines (CPGs) available in English or Japanese and existing QIs in nine selected paediatric or perinatal conditions. Consensus building was based on independent panel ratings. The performance of QIs was retrospectively assessed using data from an administrative database at the National Children's Hospital. Data between April 2018 and March 2019 were used, while data between April 2019 and March 2021 were also used for selected condition, considering the small number of patients. Each QI was calculated as follows: number of times the indicator was met/number of participants×100. RESULTS From the literature review conducted between 2010 and 2020, 124 CPGs and 193 existing indicators were identified to generate QI candidates. Through the consensus-building process, 133 QI candidates were assessed and 79 QIs were accepted. The practice test revealed wide variations in the process-level performance of QIs in four categories: patient safety: median 43.9% (IQR 16.7%-85.6%), general paediatrics: median 98.8% (IQR 84.2%-100%), advanced paediatrics: median 94.4% (IQR 46.0%-100%) and advanced obstetrics: median 80.3% (IQR 59.6%-100%). CONCLUSIONS We established 79 QIs for paediatric and perinatal care in Japan using an administrative database that can be applied to hospitals nationwide. The practice test confirmed the measurability of the developed QIs. Benchmarking these QIs will be an attractive approach to improving the quality of care.
Collapse
Affiliation(s)
- Daisuke Shinjo
- Department of Health Policy and Informatics, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
- Department of Information Technology and Management, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Nobuaki Ozawa
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Naoya Nakadate
- Division of Medical Security and Patient Safety, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Yutaka Kanamori
- Division of Surgery, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Kimikazu Matsumoto
- Children's Cancer Center, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Takashi Noguchi
- Department of Information Technology and Management, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Shosuke Ohtera
- Department of Health Economics, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan
| | | |
Collapse
|
2
|
Kalfa D, Karamichalis JM, Singh SK, Jiang P, Anderson BR, Vargas D, Choudhury T, Habib A, Bacha E. Operative mortality after Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category 1 to 3 procedures: Deficiencies and opportunities for quality improvement. J Thorac Cardiovasc Surg 2023; 166:325-333.e3. [PMID: 36621456 DOI: 10.1016/j.jtcvs.2022.11.022] [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: 05/15/2022] [Revised: 11/08/2022] [Accepted: 11/12/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVES We examined cases of operative mortality at a single quaternary academic center for patients undergoing relatively lower-risk (Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category 1-3) procedures, as a means of identifying systemic weaknesses and opportunities for quality improvement. METHODS A retrospective review of all operative mortality events for patients who underwent a Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category 1, 2, or 3 index procedure (2009-2020) at our institution was performed. After a detailed chart review was performed by 2 independent faculty for each case, factors and system deficiencies that contributed to mortality were identified. RESULTS A total of 42 mortalities were identified. A total of 37 patients (88%) had at least 1 Society of Thoracic Surgeons-designated risk factor, including prior cardiac operations (48%), extracardiac malformations (43%), and preoperative ventilation (33%). Eight patients (19%) had non-Society of Thoracic Surgeons-designated preoperative patient-level variables considered as at potential risk, including severe ventricular dysfunction, pulmonary hypertension, lung hypoplasia, and undiagnosed severe coronary abnormalities. Four patients (10%) had no identified preoperative risk factors. After detailed chart review, 5 broad categories were identified: patient-related factors (n = 33; 78%), postoperative infection (n = 13; 31%), postoperative residual lesions (n = 7; 17%), Fontan physiology failure (n = 4; 10%), and unexplained left ventricular failure after tetralogy of Fallot repair (n = 3; 7%). A total of 74% of patients had at least 1 preoperative, intraoperative, or postoperative system deficiency. A total of 50% of surgeries were urgent or emergency. CONCLUSIONS Operative mortality after Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category 1 to 3 procedures is related to the presence of multifactorial risk patterns (Society of Thoracic Surgeons and non-Society of Thoracic Surgeons-designated patient-level risk factors and variables, broad risk categories, system deficiencies, emergency surgery). A multidisciplinary approach to care, with early recognition and treatment of modifiable additional burdens, could reduce this risk.
Collapse
Affiliation(s)
- David Kalfa
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY.
| | - John M Karamichalis
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Sameer K Singh
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Pengfei Jiang
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Brett R Anderson
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Diana Vargas
- Division of Pediatrics, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Tarif Choudhury
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Anthony Habib
- Division of Anesthesiology, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Emile Bacha
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| |
Collapse
|
3
|
Cooch PB, Kim MO, Swami N, Tamma PD, Tabbutt S, Steurer MA, Wattier RL. Broad- Versus Narrow-Spectrum Perioperative Antibiotics and Outcomes in Pediatric Congenital Heart Disease Surgery: Analysis of the Vizient Clinical Data Base. J Pediatric Infect Dis Soc 2023; 12:205-213. [PMID: 37018466 PMCID: PMC10146935 DOI: 10.1093/jpids/piad022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 04/04/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND Despite guidelines recommending narrow-spectrum perioperative antibiotics (NSPA) as prophylaxis for most children undergoing congenital heart disease (CHD) surgery, broad-spectrum perioperative antibiotics (BSPA) are variably used, and their impact on postoperative outcomes is poorly understood. METHODS We used administrative data from U.S. hospitals participating in the Vizient Clinical Data Base. Admissions from 2011 to 2018 containing a qualifying CHD surgery in children 0-17 years old were evaluated for exposure to BSPA versus NSPA. Propensity score-adjusted models were used to compare postoperative length of hospital stay (PLOS) by exposure group, while adjusting for confounders. Secondary outcomes included subsequent antimicrobial treatment and in-hospital mortality. RESULTS Among 18 088 eligible encounters from 24 U.S. hospitals, BSPA were given in 21.4% of CHD surgeries, with mean BSPA use varying from 1.7% to 96.1% between centers. PLOS was longer for BSPA-exposed cases (adjusted hazard ratio 0.79; 95% confidence interval [CI]: 0.71-0.89, P < .0001). BSPA was associated with higher adjusted odds of subsequent antimicrobial treatment (odds ratio [OR] 1.24; 95% CI: 1.06-1.48), and there was no significant difference in adjusted mortality between exposure groups (OR 2.06; 95% CI: 1.0-4.31; P = .05). Analyses of subgroups with the most BSPA exposure, including high-complexity procedures and delayed sternal closure, also did not find (but could not exclude) a measurable benefit from BSPA on PLOS. CONCLUSIONS BSPA use was common in high-risk populations, and varied substantially between centers. Standardizing perioperative antibiotic practices between centers may reduce unnecessary broad-spectrum antibiotic exposure and improve clinical outcomes.
Collapse
Affiliation(s)
- Peter B Cooch
- Department of Pediatrics, Division of Infectious Diseases and Global Health, University of California San Francisco, San Francisco, California, USA
- Department of Pediatrics, Kaiser Permanente Northern California, Oakland, California, USA
| | - Mi-Ok Kim
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Naveen Swami
- Department of Surgery, Division of Pediatric Cardiothoracic Surgery, University of California San Francisco, San Francisco, CaliforniaUSA
| | - Pranita D Tamma
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sarah Tabbutt
- Department of Pediatrics, Division of Critical Care, University of California San Francisco, San Francisco, California, USA
| | - Martina A Steurer
- Department of Pediatrics, Division of Critical Care, University of California San Francisco, San Francisco, California, USA
| | - Rachel L Wattier
- Department of Pediatrics, Division of Infectious Diseases and Global Health, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
4
|
Du X, Wang H, Wang S, He Y, Zheng J, Zhang H, Hao Z, Chen Y, Xu Z, Lu Z. Machine Learning Model for Predicting Risk of In-Hospital Mortality after Surgery in Congenital Heart Disease Patients. Rev Cardiovasc Med 2022; 23:376. [PMID: 39076183 PMCID: PMC11269077 DOI: 10.31083/j.rcm2311376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/27/2022] [Accepted: 08/26/2022] [Indexed: 07/31/2024] Open
Abstract
Background A machine learning model was developed to estimate the in-hospital mortality risk after congenital heart disease (CHD) surgery in pediatric patient. Methods Patients with CHD who underwent surgery were included in the study. A Extreme Gradient Boosting (XGBoost) model was constructed based onsurgical risk stratification and preoperative variables to predict the risk of in-hospital mortality. We compared the predictive value of the XGBoost model with Risk Adjustment in Congenital Heart Surgery-1 (RACHS-1) and Society of Thoracic Surgery-European Association for Cardiothoracic Surgery (STS-EACTS) categories. Results A total of 24,685 patients underwent CHD surgery and 595 (2.4%) died in hospital. The area under curve (AUC) of the STS-EACTS and RACHS-1 risk stratification scores were 0.748 [95% Confidence Interval (CI): 0.707-0.789, p < 0.001] and 0.677 (95% CI: 0.627-0.728, p < 0.001), respectively. Our XGBoost model yielded the best AUC (0.887, 95% CI: 0.866-0.907, p < 0.001), and sensitivity and specificity were 0.785 and 0.824, respectively. The top 10 variables that contribute most to the predictive performance of the machine learning model were saturation of pulse oxygen categories, risk categories, age, preoperative mechanical ventilation, atrial shunt, pulmonary insufficiency, ventricular shunt, left atrial dimension, a history of cardiac surgery, numbers of defects. Conclusions The XGBoost model was more accurate than RACHS-1 and STS-EACTS in predicting in-hospital mortality after CHD surgery in China.
Collapse
Affiliation(s)
- Xinwei Du
- Department of Cardiothoracic Surgery, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiaotong University, 200127 Shanghai, China
| | - Hao Wang
- Department of Cardiothoracic Surgery, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiaotong University, 200127 Shanghai, China
| | - Shunmin Wang
- Department of Cardiothoracic Surgery, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiaotong University, 200127 Shanghai, China
| | - Yi He
- Information Center, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiaotong University, 200127 Shanghai, China
| | - Jinghao Zheng
- Department of Cardiothoracic Surgery, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiaotong University, 200127 Shanghai, China
| | - Haibo Zhang
- Department of Cardiothoracic Surgery, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiaotong University, 200127 Shanghai, China
| | - Zedong Hao
- Shanghai Synyi Medical Technology Co., Ltd. 201203 Shanghai, China
| | - Yiwei Chen
- Shanghai Synyi Medical Technology Co., Ltd. 201203 Shanghai, China
| | - Zhiwei Xu
- Department of Cardiothoracic Surgery, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiaotong University, 200127 Shanghai, China
| | - Zhaohui Lu
- Department of Cardiothoracic Surgery, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiaotong University, 200127 Shanghai, China
| |
Collapse
|
5
|
McSharry B, Straney L, Alexander J, Gentles T, Winlaw D, Beca J, Millar J, Shann F, Wilkins B, Numa A, Stocker C, Erickson S, Slater A. RACHS - ANZ : A Modified Risk Adjustment in Congenital Heart Surgery Model for Outcome Surveillance in Australia and New Zealand. J Am Heart Assoc 2020; 8:e011390. [PMID: 31039662 PMCID: PMC6512128 DOI: 10.1161/jaha.118.011390] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Outcomes for pediatric cardiac surgery are commonly reported from international databases compiled from voluntary data submissions. Surgical outcomes for all children in a country or region are less commonly reported. We aimed to describe the bi‐national population‐based outcome for children undergoing cardiac surgery in Australia and New Zealand and determine whether the Risk Adjustment for Congenital Heart Surgery (RACHS) classification could be used to create a model that accurately predicts in‐hospital mortality in this population. Methods and Results The study was conducted in all children's hospitals performing cardiac surgery in Australia and New Zealand between January 2007 and December 2015. The performance of the original RACHS‐1 model was assessed and compared with an alternative RACHS‐ANZ (Australia and New Zealand) model, developed balancing discrimination with parsimonious variable selection. A total of 14 324 hospital admissions were analyzed. The overall hospital mortality was 2.3%, ranging from 0.5% for RACHS category 1 procedures, to 17.0% for RACHS category 5 or 6 procedures. The original RACHS‐1 model was poorly calibrated with death overpredicted (1161 deaths predicted, 289 deaths observed). The RACHS‐ANZ model had better performance in this population with excellent discrimination (Az‐ROC of 0.830) and acceptable Hosmer and Lemeshow goodness‐of‐fit (P=0.216). Conclusions The original RACHS‐1 model overpredicts mortality in children undergoing heart surgery in the current era. The RACHS‐ANZ model requires only 3 risk variables in addition to the RACHS procedure category, can be applied to a wider range of patients than RACHS‐1, and is suitable to use to monitor regional pediatric cardiac surgery outcomes.
Collapse
Affiliation(s)
- Brent McSharry
- 1 Paediatric Intensive Care Unit Starship Children's Hospital Auckland New Zealand
| | - Lahn Straney
- 3 Department of Epidemiology and Preventive Medicine Monash University Melbourne Australia
| | - Janet Alexander
- 4 Australian and New Zealand Intensive Care Society Melbourne Australia
| | - Tom Gentles
- 2 Green Lane Paediatric and Congenital Cardiac Service Starship Children's Hospital Auckland New Zealand
| | - David Winlaw
- 5 Heart Centre for Children The Children's Hospital Westmead Sydney Australia.,7 School of Medicine University of Sydney Australia
| | - John Beca
- 1 Paediatric Intensive Care Unit Starship Children's Hospital Auckland New Zealand
| | - Johnny Millar
- 8 Intensive Care Unit Royal Children's Hospital Melbourne Australia.,9 Department of Paediatrics University of Melbourne Australia
| | - Frank Shann
- 8 Intensive Care Unit Royal Children's Hospital Melbourne Australia.,9 Department of Paediatrics University of Melbourne Australia
| | - Barry Wilkins
- 6 Paediatric Intensive Care Unit The Children's Hospital Westmead Sydney Australia
| | - Andrew Numa
- 10 Paediatric Intensive Care Unit Sydney Children's Hospital Sydney Australia
| | - Christian Stocker
- 11 Paediatric Intensive Care Unit Queensland Children's Hospital Brisbane Australia
| | - Simon Erickson
- 12 Paediatric Intensive Care Unit Perth Children's Hospital Perth Australia
| | - Anthony Slater
- 11 Paediatric Intensive Care Unit Queensland Children's Hospital Brisbane Australia
| | | |
Collapse
|
6
|
El Rassi I, Assy J, Arabi M, Majdalani MN, Yunis K, Sharara R, Maroun-Aouad M, Khaddoum R, Siddik-Sayyid S, Foz C, Bulbul Z, Bitar F. Establishing a High-Quality Congenital Cardiac Surgery Program in a Developing Country: Lessons Learned. Front Pediatr 2020; 8:357. [PMID: 32850519 PMCID: PMC7406661 DOI: 10.3389/fped.2020.00357] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 05/28/2020] [Indexed: 12/14/2022] Open
Abstract
Background: Developing countries are profoundly affected by the burden of congenital heart disease (CHD) because of limited resources, poverty, cost, and inefficient governance. The outcome of pediatric cardiac surgery in developing countries is suboptimal, and the availability of sustainable programs is minimal. Aim: This study describes the establishment of a high quality in-situ pediatric cardiac surgery program in Lebanon, a limited resource country. Methods: We enrolled all patients operated for CHD at the Children's Heart Center at the American University of Beirut between January 2014 and December 2018. Financial information was obtained. We established a partnership between the state, private University hospital, and philanthropic organizations to support the program. Results: In 5 years, 856 consecutive patients underwent 993 surgical procedures. Neonates and infants constituted 22.5 and 22.6% of our cohort, respectively. Most patients (82.6%) underwent one cardiac procedure. Our results were similar to those of the Society of Thoracic Surgeons (STS) harvest and to the expected mortalities in RACHS-1 scores with an overall mortality of 2.8%. The government (Public) covered 43% of the hospital bill, the Philanthropic organizations covered 30%, and the Private hospital provided a 25% discount. The parents' out-of-pocket contribution included another 2%. The average cost per patient, including neonates, was $19,800. Conclusion: High standard pediatric cardiac surgery programs can be achieved in limited-resource countries, with outcome measures comparable to developed countries. We established a viable financial model through a tripartite partnership between Public, Private, and Philanthropy (3P system) to provide high caliber care to children with CHD.
Collapse
Affiliation(s)
- Issam El Rassi
- Department of Surgery, The American University of Beirut-Medical Center, Beirut, Lebanon
| | - Jana Assy
- Department of Pediatrics and Adolescent Medicine, The American University of Beirut-Medical Center, Beirut, Lebanon
| | - Mariam Arabi
- Department of Pediatrics and Adolescent Medicine, The American University of Beirut-Medical Center, Beirut, Lebanon
| | - Marianne Nimah Majdalani
- Department of Pediatrics and Adolescent Medicine, The American University of Beirut-Medical Center, Beirut, Lebanon
| | - Khalid Yunis
- Department of Pediatrics and Adolescent Medicine, The American University of Beirut-Medical Center, Beirut, Lebanon
| | - Rana Sharara
- Department of Pediatrics and Adolescent Medicine, The American University of Beirut-Medical Center, Beirut, Lebanon
| | - Marie Maroun-Aouad
- Department of Anesthesiology at the Children's Heart Center, The American University of Beirut-Medical Center, Beirut, Lebanon
| | - Roland Khaddoum
- Department of Anesthesiology at the Children's Heart Center, The American University of Beirut-Medical Center, Beirut, Lebanon
| | - Sahar Siddik-Sayyid
- Department of Anesthesiology at the Children's Heart Center, The American University of Beirut-Medical Center, Beirut, Lebanon
| | - Carine Foz
- Department of Anesthesiology at the Children's Heart Center, The American University of Beirut-Medical Center, Beirut, Lebanon
| | - Ziad Bulbul
- Department of Pediatrics and Adolescent Medicine, The American University of Beirut-Medical Center, Beirut, Lebanon
| | - Fadi Bitar
- Department of Pediatrics and Adolescent Medicine, The American University of Beirut-Medical Center, Beirut, Lebanon
| |
Collapse
|
7
|
Abstract
OBJECTIVES Surgery of the aortic arch poses risk of recurrent laryngeal nerve injury due to the anatomic proximity and can manifest as vocal cord dysfunction after surgery. We assessed risk factors for vocal cord dysfunction and calculated surgical procedure associated rates in young infants after congenital heart surgery. DESIGN Cross section analysis. SETTING Forty-four children's hospitals reporting administrative data to Pediatric Health Information System. PARTICIPANTS Cardiac surgical patients less than or equal to 90 days old and discharged between January 2004 and June 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Overall, 2,319 of 46,567 subjects (5%) had vocal cord dysfunction, increasing from 4% to 7% over the study period. Of those with vocal cord dysfunction, 75% had unilateral partial paralysis. Vocal cord dysfunction was significantly more common in newborn infants (74%), those with aortic arch procedures (77%) and with greater surgical complexity. Rates of vocal cord dysfunction ranged from 0.7% to 22.4% across surgical procedure groups. Vocal cord dysfunction was significantly associated with greater use of: prolonged mechanical ventilation (53% vs 40%), diaphragmatic plication (3% vs 1%), feeding tube use (32% vs 8%), surgical airways (4% vs 2%), and prolonged length of stay (44 vs 21 d). Vocal cord dysfunction testing increased significantly over the study (6-14 %), and vocal cord dysfunction diagnosis increased almost two-fold (odds ratio, 1.9; 95% CI, 1.7-2.1) comparing the last to first study quarters with the increase in vocal cord dysfunction diagnosis occurring predominately in surgeries to the aortic arch supported by cardiopulmonary bypass. However, aortic procedures without cardiopulmonary bypass and nonaortic arch procedures were common surgeries accounting for 27% and 23% of vocal cord dysfunction cases despite low overall vocal cord dysfunction rates (3.7% and 2.6%). CONCLUSIONS Vocal cord dysfunction complicated all cardiac surgical procedures among infants including those without aortic arch involvement. Increased efforts to determine appropriate indications for prevention, screening and treatment of vocal cord dysfunction among young infants after congenital heart surgery are needed.
Collapse
|
8
|
Hu GH, Duan L, Jiang M, Zhang CL, Duan YY. Wider intraoperative glycemic fluctuation increases risk of acute kidney injury after pediatric cardiac surgery. Ren Fail 2018; 40:611-617. [PMID: 30396300 PMCID: PMC6225368 DOI: 10.1080/0886022x.2018.1532908] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE The association between poor intraoperative glycemic control and postoperative acute kidney injury (AKI) in adult cardiac surgery has been observed, but data in the pediatrics remain unknown. We performed a hypothesis that intraoperative hyperglycemia and/or wider glycemic fluctuation were associated with the incidence of postoperative AKI in pediatric cardiac surgery. METHODS A retrospective study was performed in pediatrics who underwent cardiac surgery from 2013 to 2016. Perioperative glycemic data up to 48 hours after surgery were collected and analyzed. Patients with AKI were matched 1:1 with patients without AKI by a propensity score. Variables of demographic data, preoperative renal function and glycemic level, perioperative cardiac condition were matched. RESULTS The incidence of AKI was 11.5% (118/1026), with 53.4% (63/118), 30.5% (36/118), and 16.1% (19/118) categorized as AKIN stages I, II, and III, respectively. Children who experienced AKI were younger and cyanotic, underwent more complex surgeries, had higher peak intraoperative glucose levels, wider intraoperative glycemic fluctuation, greater inotropic scores and more transfusions, and poor outcomes (all p < .05). After matching, the AKI group had significantly wider intraoperative glycemic fluctuation (p < .05). Logistic regression showed intraoperative glycemic fluctuation was one of the risk factors for AKI (p = .033) and degree of AKI severity stage increased when the glycemic fluctuation increased (p < .01). CONCLUSIONS Wider intraoperative glycemic fluctuation, but not hyperglycemia, was associated with an increased incidence of postoperative AKI after pediatric cardiac surgery.
Collapse
Affiliation(s)
- Guo-Huang Hu
- a Department of Surgery , The Fourth hospital of Changsha, Hunan Normal University , Changsha , China
| | - Lian Duan
- b Department of Cardiovascular Surgery , Xiangya Hospital, Central South University , Changsha , China
| | - Meng Jiang
- b Department of Cardiovascular Surgery , Xiangya Hospital, Central South University , Changsha , China
| | - Cheng-Liang Zhang
- b Department of Cardiovascular Surgery , Xiangya Hospital, Central South University , Changsha , China
| | - Yan-Ying Duan
- c Department of Occupational and Environmental Health , Public Health School, Central South University , Changsha , China
| |
Collapse
|
9
|
Duan L, Hu GH, Jiang M, Zhang CL, Duan YY. [Association of hypoalbuminemia with acute kidney injury in children after cardiac surgery]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2018; 20:475-480. [PMID: 29972122 PMCID: PMC7389947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 05/08/2018] [Indexed: 11/12/2023]
Abstract
OBJECTIVE To study whether hypoalbuminemia after pediatric cardiopulmonary bypass (CPB) for cardiac surgery is a risk factor for postoperative acute kidney injury (AKI). METHODS A retrospective analysis was performed on the clinical data of 1 110 children who underwent CPB surgery between 2012 and 2016. According to the minimum serum albumin within 48 hours postoperatively, these patients were divided into hypoalbuminemia group (≤35 g/L) and normal albumin group (>35 g/L). The two groups were compared in terms of perioperative data and the incidence of AKI. Furthermore, the incidence of AKI was compared again after propensity score matching for the unbalanced factors during the perioperative period. The perioperative risk factors for postoperative AKI were analyzed by logistic regression. RESULTS The overall incidence rate of postoperative AKI was 13.78% (153/1 110), and the mortality rate was 2.52% (28/1 110). The mortality rate of children with AKI was 13.1% (20/153). The patients with hypoalbuminemia after surgery (≤35 g/L) accounted for 44.50% (494/1 110). Before and after propensity score matching, the hypoalbuminemia group had a significantly higher incidence of AKI than the normal albumin group (P<0.05). The children with AKI had a significantly lower serum albumin level after surgery than those without AKI (P<0.05). The multivariate logistic regression analysis showed albumin ≤35 g/L was one of the independent risk factors for postoperative AKI. CONCLUSIONS Albumin ≤35 g/L within 48 hours postoperatively is an independent risk factor for postoperative AKI in children after CPB surgery.
Collapse
Affiliation(s)
- Lian Duan
- Department of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha 410008, China.
| | | | | | | | | |
Collapse
|
10
|
Duan L, Hu GH, Jiang M, Zhang CL, Duan YY. [Association of hypoalbuminemia with acute kidney injury in children after cardiac surgery]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2018; 20:475-480. [PMID: 29972122 PMCID: PMC7389947 DOI: 10.7499/j.issn.1008-8830.2018.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To study whether hypoalbuminemia after pediatric cardiopulmonary bypass (CPB) for cardiac surgery is a risk factor for postoperative acute kidney injury (AKI). METHODS A retrospective analysis was performed on the clinical data of 1 110 children who underwent CPB surgery between 2012 and 2016. According to the minimum serum albumin within 48 hours postoperatively, these patients were divided into hypoalbuminemia group (≤35 g/L) and normal albumin group (>35 g/L). The two groups were compared in terms of perioperative data and the incidence of AKI. Furthermore, the incidence of AKI was compared again after propensity score matching for the unbalanced factors during the perioperative period. The perioperative risk factors for postoperative AKI were analyzed by logistic regression. RESULTS The overall incidence rate of postoperative AKI was 13.78% (153/1 110), and the mortality rate was 2.52% (28/1 110). The mortality rate of children with AKI was 13.1% (20/153). The patients with hypoalbuminemia after surgery (≤35 g/L) accounted for 44.50% (494/1 110). Before and after propensity score matching, the hypoalbuminemia group had a significantly higher incidence of AKI than the normal albumin group (P<0.05). The children with AKI had a significantly lower serum albumin level after surgery than those without AKI (P<0.05). The multivariate logistic regression analysis showed albumin ≤35 g/L was one of the independent risk factors for postoperative AKI. CONCLUSIONS Albumin ≤35 g/L within 48 hours postoperatively is an independent risk factor for postoperative AKI in children after CPB surgery.
Collapse
Affiliation(s)
- Lian Duan
- Department of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha 410008, China.
| | | | | | | | | |
Collapse
|
11
|
Duan L, Hu GH, Jiang M, Zhang CL. [Clinical characteristics and prognostic analysis of children with congenital heart disease complicated by postoperative acute kidney injury]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2017; 19:1196-1201. [PMID: 29132469 PMCID: PMC7389321 DOI: 10.7499/j.issn.1008-8830.2017.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 08/23/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To analyze the perioperative clinical data of children with congenital heart disease complicated by acute kidney injury (AKI) after cardiopulmonary bypass (CPB) surgery, and to explore potential factors influencing the prognosis. METHODS A retrospective analysis was performed among 118 children with congenital heart disease who developed AKI within 48 hours after CPB surgery. RESULTS In the 118 patients, 18 died after 48 hours of surgery. Compared with the survivors, the dead children had significantly higher incidence of cyanotic disease and Risk Adjustment for Congenital Heart Surgery-1 (RACHS-1) scores before surgery; during surgery, the dead children had significantly longer CPB time and aortic cross-clamping time, a significantly higher proportion of patients receiving crystalloid solution for myocardial protection, and a significantly higher mean blood glucose level. Within 48 hours after surgery, the dead children had significantly higher positive inotropic drug scores, significantly higher creatinine values, a significantly higher incidence of stage 3 AKI, a significantly higher proportion of patients receiving renal replacement the, and significantly higher usage of blood products (P<0.05). The mortality rate of the patients increased with increased intraoperative blood glucose levels (P<0.05). Patients with intraoperative blood glucose levels >8.3 mmol/L had a significantly lower postoperative cumulative survival rate and a significantly shorter mean survival time than those with blood glucose levels ≤ 8.3 mmol/L (P<0.05). CONCLUSIONS Intraoperative blood glucose levels are associated with the prognosis in children with congenital heart disease complicated by AKI after CPB surgery. Maintaining good intraoperative blood glucose control can improve the prognosis of the children.
Collapse
Affiliation(s)
- Lian Duan
- Department of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha 410008, China.
| | | | | | | |
Collapse
|
12
|
Metrics to Assess Extracorporeal Membrane Oxygenation Utilization in Pediatric Cardiac Surgery Programs. Pediatr Crit Care Med 2017; 18:779-786. [PMID: 28498231 DOI: 10.1097/pcc.0000000000001205] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Only a small fraction of pediatric cardiac surgical patients are supported with extracorporeal membrane oxygenation following cardiac surgery, but extracorporeal membrane oxygenation use is more common among those undergoing higher complexity surgery. We evaluated extracorporeal membrane oxygenation metrics indexed to annual cardiac surgical volume to better understand extracorporeal membrane oxygenation use among U.S. cardiac surgical programs. DESIGN Retrospective analysis SETTING:: Forty-three U.S. Children's Hospitals in the Pediatric Health Information System that performed cardiac surgery and used extracorporeal membrane oxygenation. PATIENTS All patients (< 19 yr) undergoing cardiac surgery during January 2003 to July 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Both extracorporeal membrane oxygenation use and surgical mortality were risk adjusted using Risk Adjustment for Congenital Heart Surgery 1. Extracorporeal membrane oxygenation metrics indexed to annual cardiac surgery cases were calculated for each hospital and the metric values divided into quintiles for comparison across hospitals. Among 131,786 cardiac surgical patients, 3,782 (2.9%) received extracorporeal membrane oxygenation. Median case mix adjusted rate of extracorporeal membrane oxygenation use was 2.8% (interquartile range, 1.6-3.4%). Median pediatric cardiac case mix adjusted surgical mortality was 3.5%. Extracorporeal membrane oxygenation-associated surgical mortality was 1.3% (interquartile range, 0.7-1.6%); without extracorporeal membrane oxygenation, median case mix adjusted surgical mortality would increase from 3.5% to 5.0%. Among patients who died, 36.7% (median) were supported with extracorporeal membrane oxygenation. The median reduction in case mix adjusted surgical mortality from extracorporeal membrane oxygenation surgical survival was 30.1%. The median extracorporeal membrane oxygenation free surgical survival was 95% (interquartile range, 94-96%). Centers with less than 150 annual surgical cases had significantly lower median extracorporeal membrane oxygenation use (0.78%) than centers with greater than 275 cases (≥ 2.8% extracorporeal membrane oxygenation use). Extracorporeal membrane oxygenation use and mortality varied within quintiles and across quintiles of center annual surgical case volume. CONCLUSIONS Risk adjusted extracorporeal membrane oxygenation metrics indexed to annual surgical volume provide potential for benchmarking as well as a greater understanding of extracorporeal membrane oxygenation utilization, efficacy, and impact on cardiac surgery mortality.
Collapse
|
13
|
Peterson JK, Chen Y, Nguyen DV, Setty SP. Current trends in racial, ethnic, and healthcare disparities associated with pediatric cardiac surgery outcomes. CONGENIT HEART DIS 2017; 12:520-532. [PMID: 28544396 DOI: 10.1111/chd.12475] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 04/10/2017] [Accepted: 04/22/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Despite overall improvements in congenital heart disease outcomes, racial and ethnic disparities have continued. The purpose of this study is to examine the effect of race and ethnicity, as well as other risk factors on congenital heart surgery length of stay and in-hospital mortality. DESIGN From the 2012 Healthcare Cost and Utilization Project Kids Inpatient Database (KID), we identified 13 130 records with Risk Adjustment in Congenital Heart Surgery complexity score-eligible procedures. Multivariate logistic and linear regression modeling with survey weights, stratification and clustering was used to examine the relationships between predictor variables and length of stay as well as in-hospital mortality. RESULTS No significant mortality differences were found among all race and ethnicity groups across each age group. Black neonates and black infants had a longer length of stay (neonatal estimate = 8.73 days, P = .0034; infant estimate 1.10 days, P = .0253), relative to whites. Government-sponsored insurance was associated with increased odds of neonatal mortality (odds ratio = 1.51, P = .0055), increased length of stay in neonates (estimate = 4.26 days, P = .0009) and infants (estimate = 1.52 days, P = .0181), relative to private insurance. Government-sponsored insurance was associated with increased number of chronic conditions, which were also associated with increased LOS (estimate 8.39 days, P < .001 in neonates; estimate 3.60 days, P < .001 in infants; estimate 1.87 days, P < .001 children). CONCLUSIONS Racial/ethnic disparities in congenital heart surgical outcomes may be changing compared with previous studies using the KID database. Increased length of stay in children with government-sponsored insurance may reflect expansion of individual states government-sponsored insurance eligibility criteria for children with complex chronic medical conditions. These findings warrant cautious optimism regarding racial and ethnic disparities in congenital heart surgery outcomes.
Collapse
Affiliation(s)
- Jennifer K Peterson
- Long Beach Memorial Hospital/Miller Children's and Women's Hospital, Long Beach, California, USA
| | - Yanjun Chen
- Biostatistics, Epidemiology, and Research Design Unit, University of California, Irvine, California, USA
| | - Danh V Nguyen
- Department of Medicine, University of California, Irvine School of Medicine, Orange, California, USA
| | - Shaun P Setty
- Long Beach Memorial Hospital/Miller Children's and Women's Hospital, Long Beach, California, USA
| |
Collapse
|