The role of databases in improving the quality of care for congenital heart disease

Cost Variation Across Centers for the Norwood Operation

BACKGROUND

The Norwood operation is associated with high health care utilization, and prior studies reported substantial variability in Norwood costs across centers. However, specific factors driving this cost variation are unclear. We assessed center variability in Norwood costs and underlying mechanisms in a multicenter cohort.

METHODS

Clinical data from the Pediatric Heart Network Single Ventricle Reconstruction trial were linked with cost data from the Children's Hospital Association Inpatient Essentials database. Center variation was assessed by modeling Norwood costs adjusted for baseline patient characteristics, and the relationship with complications, length of stay (LOS), and specific cost categories was examined. Patients undergoing transplantation or stage 2 palliation during the Norwood admission were excluded.

RESULTS

Nine centers (332 patients) were included. Adjusted mean cost/case varied 4.6-fold across centers (range: $50,559 to $230,851, p < 0.001). In addition, variation was found across centers in the adjusted mean number of complications/case (2.6-fold variation) and adjusted mean LOS/case (1.9-fold variation). Differences in complications explained 63% of the cost variation across centers. After accounting for complications, differences in LOS explained 66% of the remaining cost variation. Seven specific complications were found to occur more frequently at high-cost centers: pleural effusion, seizures, wound infection, thrombus, liver dysfunction, sepsis, necrotizing enterocolitis (all p < 0.001). With regard to types of cost, room and board/supplies and laboratory costs were the primary drivers of cost variation across centers.

CONCLUSIONS

This study identified several factors associated with center variation in Norwood costs, which may be targeted in subsequent initiatives aimed at both improving quality of care and reducing costs.

Indigenous Ethnicity and Low Maternal Education Are Associated with Delayed Diagnosis and Mortality in Infants with Congenital Heart Defects in Panama

Background

This is the first study in Panama and Central America that has included indigenous populations in an assessment of the association between socioeconomic variables with delayed diagnosis and mortality due to congenital heart defects (CHD).

Methods

A retrospective observational study was conducted. A sample calculation was performed and 954 infants born from 2010 to 2014 were randomly selected from clinical records of all Panamanian public health institutions with paediatric cardiologists. Critical CHD was defined according to the defects listed as targets of newborn pulse oximetry screening. Diagnoses were considered delayed when made after the third day of life for the critical CHD and after the twentieth day of life for the non-critical. A logistic regression model was performed to examine the association between socioeconomic variables and delayed diagnosis. A Cox proportional hazards model was used to assess the relationship between socioeconomic features and mortality.

Results

An increased risk of delayed diagnosis was observed in infants with indigenous ethnicity (AOR, 1.56; 95% CI, 1.03–2.37), low maternal education (AOR, 1.57; 95% CI, 1.09–2.25) and homebirth (AOR, 4.32; 95% CI, 1.63–11.48). Indigenous infants had a higher risk of dying due to CHD (HR, 1.43; 95% CI, 1.03–1.99), as did those with low maternal education (HR, 1.95; 95% CI, 1.45–2.62).

Conclusion

Inequalities in access to health care, conditioned by unfavourable socioeconomic features, may play a key role in delayed diagnosis and mortality of CHD patients. Further studies are required to study the relationship between indigenous ethnicity and these adverse health outcomes.

Data integrity of the Pediatric Cardiac Critical Care Consortium (PC4) clinical registry

BACKGROUND

Clinical databases in congenital and paediatric cardiac care provide a foundation for quality improvement, research, policy evaluations and public reporting. Structured audits verifying data integrity allow database users to be confident in these endeavours. We report on the initial audit of the Pediatric Cardiac Critical Care Consortium (PC4) clinical registry. Materials and methods Participants reviewed the entire registry to determine key fields for audit, and defined major and minor discrepancies for the audited variables. In-person audits at the eight initial participating centres were conducted during a 12-month period. The data coordinating centre randomly selected intensive care encounters for review at each site. The audit consisted of source data verification and blinded chart abstraction, comparing findings by the auditors with those entered in the database. We also assessed completeness and timeliness of case submission. Quantitative evaluation of completeness, accuracy, and timeliness of case submission is reported.

RESULTS

We audited 434 encounters and 29,476 data fields. The aggregate overall accuracy was 99.1%, and the major discrepancy rate was 0.62%. Across hospitals, the overall accuracy ranged from 96.3 to 99.5%, and the major discrepancy rate ranged from 0.3 to 0.9%; seven of the eight hospitals submitted >90% of cases within 1 month of hospital discharge. There was no evidence for selective case omission.

CONCLUSIONS

Based on a rigorous audit process, data submitted to the PC4 clinical registry appear complete, accurate, and timely. The collaborative will maintain ongoing efforts to verify the integrity of the data to promote science that advances quality improvement efforts.

The science of assessing the outcomes and improving the quality of the congenital and paediatric cardiac care

PURPOSE OF REVIEW

Although significant progress has been made in the care of patients with paediatric and congenital cardiac disease, optimization of outcomes remains a constant goal. This review article will discuss the latest advances in the science of assessing the outcomes and improving the quality of the congenital and paediatric cardiac care, and will also review some of the latest associated research.

RECENT FINDINGS

Important advances continue to be made in each of the following domains: standardized nomenclature; established uniform core dataset; evaluation of case complexity; verification of the completeness and accuracy of the data; collaboration between subspecialties; strategies for longitudinal follow-up; and incorporating quality improvement. In January 2015, the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) will begin voluntary public reporting of programmatic congenital cardiac surgical outcomes using a new risk model that includes both procedural risk (as defined by the procedure itself and STAT Categories) and a number of patient-specific characteristics including age, weight, prior cardiothoracic operation, prematurity, chromosomal abnormalities, syndromes, noncardiac congenital anatomic abnormalities and preoperative factors. Clinical databases have been linked with administrative database to answer questions neither dataset can answer independently, providing new information about long-term mortality, rates of rehospitalization, long-term morbidity, comparative effectiveness of various treatments, and the cost of healthcare. Multiple research initiatives have recently been published using STS-CHSD.

SUMMARY

The science of assessing the outcomes and improving the quality of congenital and paediatric cardiac care continues to evolve. Recent advances will facilitate the continued evolution of a meaningful method of multiinstitutional outcomes analysis for congenital and paediatric cardiac surgery.