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Backer CL, Dearani JA, Karamlou T, Pasquali SK, Overman DM. Clarifications and Questions on the Volume Issue in Pediatric Cardiac Surgery. Ann Thorac Surg 2024; 117:1071-1073. [PMID: 38608747 DOI: 10.1016/j.athoracsur.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 04/07/2024] [Indexed: 04/14/2024]
Affiliation(s)
- Carl L Backer
- Section of Pediatric Cardiothoracic Surgery, Kentucky Children's Hospital, UK Healthcare, Lexington, Kentucky; Division of Cardiothoracic Surgery, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Joseph A Dearani
- Division of Congenital Cardiac Surgery, Mayo Clinic, Rochester, Minnesota
| | - Tara Karamlou
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Sara K Pasquali
- Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - David M Overman
- Division of Cardiovascular Surgery, The Children's Heart Clinic, Children's Minnesota, Minneapolis, Minnesota; Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, Minnesota
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2
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Pasquali SK. Current Models for Congenital Heart Center Structure and Health System Integration. World J Pediatr Congenit Heart Surg 2024:21501351241235952. [PMID: 38646709 DOI: 10.1177/21501351241235952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Affiliation(s)
- Sara K Pasquali
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
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3
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Cousino MK, Dusing CR, Rea KE, Glenn T, Armstrong B, Les AS, Hansen JE, Pasquali SK, Schumacher KR. Developing the WE BEAT Well-Being Education Programme to foster resilience and build connection in paediatric heart disease. Cardiol Young 2024:1-7. [PMID: 38622972 DOI: 10.1017/s1047951124000556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
BACKGROUND The study of psychological well-being and related resilient outcomes is of increasing focus in cardiovascular research. Despite the critical importance of psychological well-being and related resilient outcomes in promoting optimal cardiac health, there have been very few psychological interventions directed towards children with heart disease. This paper describes the development and theoretical framework of the WE BEAT Wellbeing Education Program, a group-based psychoeducation and coping skills training intervention designed to improve psychological well-being and resilience in adolescents with paediatric heart disease. METHODS Program development was informed by patient and family needs and input gathered via large, international survey methods as well as qualitative investigation, a theoretical framework, and related resilience intervention research. RESULTS An overview of the WE BEAT intervention components and structure of the programme is provided. CONCLUSIONS The WE BEAT Wellbeing Education Program was developed as one of the first resiliency-focused interventions in paediatric heart disease with an overall objective to foster positive psychological well-being and resilient outcomes through a health promotion and prevention lens in an accessible format while providing access to safe, peer-to-peer community building. Feasibility pilot results are forthcoming. Future directions include mobile app-based delivery and larger-scale efficacy and implementation trials.
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Affiliation(s)
- Melissa K Cousino
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
- University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Kelly E Rea
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Thomas Glenn
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
- University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Blake Armstrong
- University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Andrea S Les
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Jesse E Hansen
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
- University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
- University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Kurt R Schumacher
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
- University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
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4
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Pasquali SK, O'Brien SM, Shahian DM, Romano JC, Jacobs JP, Mayer JE. Association Between Past and Present Operative Mortality in Congenital Heart Surgery. Ann Thorac Surg 2024:S0003-4975(24)00122-X. [PMID: 38401767 DOI: 10.1016/j.athoracsur.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 01/18/2024] [Accepted: 02/11/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND Mortality following congenital heart surgery is an important metric across benchmarking, quality, and reporting initiatives. All rely on estimates from prior years, and it is unclear how well these reflect current outcomes. METHODS STS Congenital Database index operations (2014-2019) were included. Adjusted operative mortality in "past" 4- and 1-year intervals vs. the most recent year ("present") was evaluated using Bayesian hierarchical logistic regression with results presented as odds ratios (95% credible interval). RESULTS Among 115,699 operations (106 hospitals), overall present observed mortality was 2.5%. Regression to the mean was evident and individual hospital's present vs. past adjusted mortality were only weakly correlated (-0.11 vs. past 1-year, 0.22 vs. past 4-year data). There was a significant relationship between past and present mortality only for the group of hospitals in the highest mortality quartile, most prominent for past 4-year data [adjusted odds ratio vs. lowest mortality quartile 2.04 (1.44-2.80)]. The proportion of present hospital mortality variation explained by past mortality quartile was 52% (20%-90%) using past 4-year and only 27% (92%-83%) using past 1-year data. Overall 66% of hospitals changed mortality quartiles from past to present (30% by ≥2 quartiles). CONCLUSIONS Past mortality relates to present primarily for groups of hospitals at the extremes, with past 4-year more informative than past 1-year data. For individual hospitals, past may differ from present, regression to the mean is common, and many change quartiles. Past mortality should be used thoughtfully and not as the sole factor informing present decision making.
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Affiliation(s)
- Sara K Pasquali
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI.
| | - Sean M O'Brien
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - David M Shahian
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jennifer C Romano
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI
| | | | - John E Mayer
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA
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5
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Bates KE, Donohue J, Zhang W, Mikesell K, Anderson JB, Bingler M, Brown DW, Gaies MG, Ghanayem N, Lambert LM, Pasquali SK, Schidlow D, Vergales J, Schumacher KR. Assessing enrollment of eligible infants in the national pediatric cardiology quality improvement collaborative (NPC-QIC) through linkage to the pediatric cardiac critical care consortium (PC4) registry. Cardiol Young 2024; 34:373-379. [PMID: 37434511 DOI: 10.1017/s1047951123001671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
BACKGROUND The National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) lacks a rigorous enrollment audit process, unlike other collaborative networks. Most centers require individual families to consent to participate. It is unknown whether there is variation across centers or biases in enrollment. METHODS We used the Pediatric Cardiac Critical Care Consortium (PC4) registry to assess enrollment rates in NPC-QIC for those centers participating in both registries using indirect identifiers (date of birth, date of admission, gender, and center) to match patient records. All infants born 1/1/2018-12/31/2020 and admitted 30 days of life were eligible. In PC4, all infants with a fundamental diagnosis of hypoplastic left heart or variant or who underwent a surgical or hybrid Norwood or variant were eligible. Standard descriptive statistics were used to describe the cohort and center match rates were plotted on a funnel chart. RESULTS Of 898 eligible NPC-QIC patients, 841 were linked to 1,114 eligible PC4 patients (match rate 75.5%) in 32 centers. Match rates were lower in patients of Hispanic/Latino ethnicity (66.1%, p = 0.005), and those with any specified chromosomal abnormality (57.4%, p = 0.002), noncardiac abnormality (67.8%, p = 0.005), or any specified syndrome (66.5%, p = 0.001). Match rates were lower for patients who transferred to another hospital or died prior to discharge. Match rates varied from 0 to 100% across centers. CONCLUSIONS It is feasible to match patients between the NPC-QIC and PC4 registries. Variation in match rates suggests opportunities for improvement in NPC-QIC patient enrollment.
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Affiliation(s)
- Katherine E Bates
- Division of Pediatric Cardiology, Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Janet Donohue
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Wenying Zhang
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Katherine Mikesell
- Division of Pediatric Cardiology, Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jeffrey B Anderson
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Michael Bingler
- Nemours Cardiac Center, Nemours Children's Hospital, Orlando, FL, USA
| | - David W Brown
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Michael G Gaies
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Nancy Ghanayem
- Department of Pediatrics, University of Chicago Comer Children's Hospital and Advocate Children's Hospital, Chicago, IL
| | - Linda M Lambert
- Primary Children's Hospital Heart Center, Salt Lake City, UT, USA
| | - Sara K Pasquali
- Division of Pediatric Cardiology, Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, MI, USA
| | - David Schidlow
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Jeffrey Vergales
- Division of Pediatric Cardiology, University of Virginia, Charlottesville, VA, USA
| | - Kurt R Schumacher
- Division of Pediatric Cardiology, Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, MI, USA
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Backer CL, Overman DM, Dearani JA, Romano JC, Tweddell JS, Kumar SR, Marino BS, Bacha EA, Jaquiss RDB, Zaidi AN, Gurvitz M, Costello JM, Pierick TA, Ravekes WJ, Reagor JA, St Louis JD, Spaeth J, Mahle WT, Shin AY, Lopez KN, Karamlou T, Welke KF, Bryant R, Husain SA, Chen JM, Kaza A, Wells WJ, Glatz AC, Cohen MI, McElhinney DB, Parra DA, Pasquali SK. Recommendations for centers performing pediatric heart surgery in the United States. J Thorac Cardiovasc Surg 2023; 166:1782-1820. [PMID: 37777958 DOI: 10.1016/j.jtcvs.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Abstract
Care and outcomes for the more than 40,000 patients undergoing pediatric and congenital heart surgery in the United States annually are known to vary widely. While consensus recommendations have been published across numerous fields as one mechanism to promote a high level of care delivery across centers, it has been more than two decades since the last pediatric heart surgery recommendations were published in the United States. More recent guidance is lacking, and collaborative efforts involving the many disciplines engaged in caring for these children have not been undertaken to date. The present initiative brings together professional societies spanning numerous care domains and congenital cardiac surgeons, pediatric cardiologists, nursing, and other healthcare professionals from diverse programs around the country to develop consensus recommendations for United States centers. The focus of this initial work is on pediatric heart surgery, and it is recommended that future efforts focus in detail on the adult congenital population. We describe the background, rationale, and methodology related to this collaborative effort, and recommendations put forth for Essential Care Centers (essential services necessary for any program), and Comprehensive Care Centers (services to optimize comprehensive and high-complexity care), encompassing structure, process, and outcome metrics across 14 domains.
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Affiliation(s)
- Carl L Backer
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - David M Overman
- Division of Cardiovascular Surgery, Children's Minnesota, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, Minn
| | | | - Jennifer C Romano
- Department of Cardiac Surgery, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Mich
| | - James S Tweddell
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - S Ram Kumar
- Department of Surgery, Children's Hospital of Los Angeles, Los Angeles, Calif
| | - Bradley S Marino
- Department of Pediatric Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Emile A Bacha
- Department of Surgery, Columbia University/New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | | | - Ali N Zaidi
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michelle Gurvitz
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - John M Costello
- Department of Pediatrics, Medical University of South Carolina, Shawn Jenkins Children's Hospital, Charleston, SC
| | - Trudy A Pierick
- Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa
| | - William J Ravekes
- Department of Pediatrics, Johns Hopkins Children's Center, Baltimore, Md
| | - James A Reagor
- Department of Cardiovascular Perfusion, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - James Spaeth
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - William T Mahle
- Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Andrew Y Shin
- Department of Pediatrics, Stanford Medicine Children's Health, Palo Alto, Calif
| | - Keila N Lopez
- Department of Pediatrics, Texas Children's Hospital, Houston, Tex
| | - Tara Karamlou
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Karl F Welke
- Department of Surgery, Atrium Health Levine Children's Hospital, Charlotte, NC
| | - Roosevelt Bryant
- Department of Surgery, Phoenix Children's Hospital, Phoenix, Ariz
| | - S Adil Husain
- Department of Surgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Jonathan M Chen
- Department of Cardiac Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Aditya Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Winfield J Wells
- Department of Surgery, Children's Hospital of Los Angeles, Los Angeles, Calif
| | - Andrew C Glatz
- Department of Pediatrics, St. Louis Children's Hospital, St. Louis, Mo
| | - Mitchell I Cohen
- Department of Pediatrics, Inova Children's Hospital, Fairfax, Va
| | - Doff B McElhinney
- Department of Pediatrics, Stanford Medicine Children's Health, Palo Alto, Calif
| | - David A Parra
- Department of Pediatrics, Vanderbilt Children's Hospital, Nashville, Tenn
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Mich
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Welke KF, Karamlou T, O'Brien SM, Dearani JA, Tweddell JS, Kumar SR, Romano JC, Backer CL, Pasquali SK. Contemporary Relationship Between Hospital Volume and Outcomes in Congenital Heart Surgery. Ann Thorac Surg 2023; 116:1233-1239. [PMID: 37652353 DOI: 10.1016/j.athoracsur.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 07/19/2023] [Accepted: 08/07/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Studies examining the volume-outcome relationship in congenital heart surgery (CHS) are more than a decade old. Since then, mortality has declined, and case-mix adjustment has evolved. We determined the current relationship between hospital CHS volume and outcomes. METHODS Patients aged ≤18 years undergoing index operations in The Society of Thoracic Surgeons-Congenital Heart Surgery Database (2017-2020) were included. Associations between annual hospital volume and case-mix-adjusted operative mortality, major complications, failure to rescue (FTR), and postoperative length of stay (PLOS) were assessed using Bayesian hierarchical models, overall, by The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category, and for the Norwood procedure. RESULTS Across 101 centers (76,714 index operations), median annual volume was 144 operations/y. Operative mortality was 2.7%. Lower-volume hospitals had higher mortality, with an apparent transition zone at ∼190 operations/y (95% credible interval [CrI], 115-450 operations/y), below which a sustained uptick in the estimated odds of death occurred. Odds of death compared with a 450 operations/y reference were 50 operations/y (odds ratio [OR], 1.84; 95% CrI, 1.41-2.37), 100 operations/y (OR, 1.37; 95% CrI, 1.08-1.71), 200 operations/y (OR, 0.92; 95% CrI, 0.1-1.18), 300 operations/y (OR, 0.89; 95% CrI, 0.76-1.04). The volume-outcome effect was more apparent for STAT 4 to 5 than STAT 1 to 3 operations. In the overall cohort, PLOS and complications were similar across hospital volumes, whereas FTR rates were higher at lower-volume hospitals. Lower-volume hospitals had worse outcomes after the Norwood procedure, most notably mortality and FTR. CONCLUSIONS Hospital volume is associated with mortality and FTR after CHS. The relationship is strongest for high-risk operations. These data can inform ongoing initiatives to improve CHS care.
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Affiliation(s)
- Karl F Welke
- Division of Pediatric Cardiothoracic Surgery, Atrium Health Levine Children's Hospital, Charlotte, North Carolina.
| | - Tara Karamlou
- Department of Pediatric Cardiac Surgery and the Heart, Vascular and Thoracic Institute, Cleveland Clinic Children's Hospital, Cleveland Ohio
| | - Sean M O'Brien
- Duke Clinical Research Institute, Durham, North Carolina
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - James S Tweddell
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - S Ram Kumar
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California; Heart Institute, Children's Hospital Los Angeles, Los Angeles, California
| | - Jennifer C Romano
- Department of Cardiac Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Carl L Backer
- Section of Pediatric Cardiothoracic Surgery, UK HealthCare Kentucky Children's Hospital, Lexington, Kentucky; Cardiothoracic Surgery, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sara K Pasquali
- Division of Cardiology, Department of Pediatrics, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, Michigan
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8
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Backer CL, Overman DM, Dearani JA, Romano JC, Tweddell JS, Kumar SR, Marino BS, Bacha EA, Jaquiss RDB, Zaidi AN, Gurvitz M, Costello JM, Pierick TA, Ravekes WJ, Reagor JA, St Louis JD, Spaeth J, Mahle WT, Shin AY, Lopez KN, Karamlou T, Welke KF, Bryant R, Husain SA, Chen JM, Kaza A, Wells WJ, Glatz AC, Cohen MI, McElhinney DB, Parra DA, Pasquali SK. Recommendations for Centers Performing Pediatric Heart Surgery in the United States. Ann Thorac Surg 2023; 116:871-907. [PMID: 37777933 DOI: 10.1016/j.athoracsur.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Abstract
Care and outcomes for the more than 40,000 patients undergoing pediatric and congenital heart surgery in the United States annually are known to vary widely. While consensus recommendations have been published across numerous fields as one mechanism to promote a high level of care delivery across centers, it has been more than two decades since the last pediatric heart surgery recommendations were published in the United States. More recent guidance is lacking, and collaborative efforts involving the many disciplines engaged in caring for these children have not been undertaken to date. The present initiative brings together professional societies spanning numerous care domains and congenital cardiac surgeons, pediatric cardiologists, nursing, and other healthcare professionals from diverse programs around the country to develop consensus recommendations for United States centers. The focus of this initial work is on pediatric heart surgery, and it is recommended that future efforts focus in detail on the adult congenital population. We describe the background, rationale, and methodology related to this collaborative effort, and recommendations put forth for Essential Care Centers (essential services necessary for any program), and Comprehensive Care Centers (services to optimize comprehensive and high-complexity care), encompassing structure, process, and outcome metrics across 14 domains.
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Affiliation(s)
- Carl L Backer
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - David M Overman
- Division of Cardiovascular Surgery, Children's Minnesota, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, Minnesota
| | | | - Jennifer C Romano
- Department of Cardiac Surgery, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - James S Tweddell
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - S Ram Kumar
- Department of Surgery, Children's Hospital of Los Angeles, Los Angeles, California
| | - Bradley S Marino
- Department of Pediatric Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Emile A Bacha
- Department of Surgery, Columbia University/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Robert D B Jaquiss
- Department of Surgery, UT-Southwestern, Children's Health, Dallas, Texas
| | - Ali N Zaidi
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michelle Gurvitz
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - John M Costello
- Department of Pediatrics, Medical University of South Carolina, Shawn Jenkins Children's Hospital, Charleston, South Carolina
| | - Trudy A Pierick
- Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa
| | - William J Ravekes
- Department of Pediatrics, Johns Hopkins Children's Center, Baltimore, Maryland
| | - James A Reagor
- Department of Cardiovascular Perfusion, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - James D St Louis
- Department of Surgery, Inova Children's Hospital, Fairfax, Virginia
| | - James Spaeth
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - William T Mahle
- Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Geogria
| | - Andrew Y Shin
- Department of Pediatrics, Stanford Medicine Children's Health, Palo Alto, California
| | - Keila N Lopez
- Department of Pediatrics, Texas Children's Hospital, Houston, Texas
| | - Tara Karamlou
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Karl F Welke
- Department of Surgery, Atrium Health Levine Children's Hospital, Charlotte, North Carolina
| | - Roosevelt Bryant
- Department of Surgery, Phoenix Children's Hospital, Phoenix, Arizona
| | - S Adil Husain
- Department of Surgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Jonathan M Chen
- Department of Cardiac Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Aditya Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Winfield J Wells
- Department of Surgery, Children's Hospital of Los Angeles, Los Angeles, California
| | - Andrew C Glatz
- Department of Pediatrics, St. Louis Children's Hospital, St. Louis, Missouri
| | - Mitchell I Cohen
- Department of Pediatrics, Inova Children's Hospital, Fairfax, Virginia
| | - Doff B McElhinney
- Department of Pediatrics, Stanford Medicine Children's Health, Palo Alto, California
| | - David A Parra
- Department of Pediatrics, Vanderbilt Children's Hospital, Nashville, Tennessee
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan
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9
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Backer CL, Overman DM, Dearani JA, Romano JC, Tweddell JS, Ram Kumar S, Marino BS, Bacha EA, Jaquiss RDB, Zaidi AN, Gurvitz M, Costello JM, Pierick TA, Ravekes WJ, Reagor JA, St Louis JD, Spaeth J, Mahle WT, Shin AY, Lopez KN, Karamlou T, Welke KF, Bryant R, Adil Husain S, Chen JM, Kaza A, Wells WJ, Glatz AC, Cohen MI, McElhinney DB, Parra DA, Pasquali SK. Recommendations for Centers Performing Pediatric Heart Surgery in the United States. World J Pediatr Congenit Heart Surg 2023; 14:642-679. [PMID: 37737602 DOI: 10.1177/21501351231190353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
Care and outcomes for the more than 40,000 patients undergoing pediatric and congenital heart surgery in the United States annually are known to vary widely. While consensus recommendations have been published across numerous fields as one mechanism to promote a high level of care delivery across centers, it has been more than two decades since the last pediatric heart surgery recommendations were published in the United States. More recent guidance is lacking, and collaborative efforts involving the many disciplines engaged in caring for these children have not been undertaken to date. The present initiative brings together professional societies spanning numerous care domains and congenital cardiac surgeons, pediatric cardiologists, nursing, and other healthcare professionals from diverse programs around the country to develop consensus recommendations for United States centers. The focus of this initial work is on pediatric heart surgery, and it is recommended that future efforts focus in detail on the adult congenital population. We describe the background, rationale, and methodology related to this collaborative effort, and recommendations put forth for Essential Care Centers (essential services necessary for any program), and Comprehensive Care Centers (services to optimize comprehensive and high-complexity care), encompassing structure, process, and outcome metrics across 14 domains.
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Affiliation(s)
- Carl L Backer
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David M Overman
- Division of Cardiovascular Surgery, Children's Minnesota, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, MN, USA
| | | | - Jennifer C Romano
- Department of Cardiac Surgery, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - James S Tweddell
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - S Ram Kumar
- Department of Surgery, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Bradley S Marino
- Department of Pediatric Cardiology, Cleveland Clinic, Cleveland, OH, USA
| | - Emile A Bacha
- Department of Surgery, Columbia University/New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Robert D B Jaquiss
- Department of Surgery, UT-Southwestern, Children's Health, Dallas, TX, USA
| | - Ali N Zaidi
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michelle Gurvitz
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - John M Costello
- Department of Pediatrics, Medical University of South Carolina, Shawn Jenkins Children's Hospital, Charleston, SC, USA
| | - Trudy A Pierick
- Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - William J Ravekes
- Department of Pediatrics, Johns Hopkins Children's Center, Baltimore, MD, USA
| | - James A Reagor
- Department of Cardiovascular Perfusion, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - James D St Louis
- Department of Surgery, Inova Children's Hospital, Fairfax, VA, USA
| | - James Spaeth
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - William T Mahle
- Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Andrew Y Shin
- Department of Pediatrics, Stanford Medicine Children's Health, Palo Alto, CA, USA
| | - Keila N Lopez
- Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - Tara Karamlou
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Karl F Welke
- Department of Surgery, Atrium Health Levine Children's Hospital, Charlotte, NC, USA
| | - Roosevelt Bryant
- Department of Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - S Adil Husain
- Department of Surgery, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Jonathan M Chen
- Department of Cardiac Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Aditya Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Winfield J Wells
- Department of Surgery, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Andrew C Glatz
- Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Mitchell I Cohen
- Department of Pediatrics, Inova Children's Hospital, Fairfax, VA, USA
| | - Doff B McElhinney
- Department of Pediatrics, Stanford Medicine Children's Health, Palo Alto, CA, USA
| | - David A Parra
- Department of Pediatrics, Vanderbilt Children's Hospital, Vanderbilt, TN, USA
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
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10
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Balasubramanian S, Pasquali SK, Cousino MK, Lowery RE, Les AS, Yu S, McCormick AD, West CL, Fifer CG, Goldberg CS, Romano JC, Owens ST. Representation of Women and Minority Faculty and Fellows in Academic Pediatric Cardiology Training Programs. J Am Coll Cardiol 2023; 81:1181-1188. [PMID: 36948735 DOI: 10.1016/j.jacc.2023.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Studies have shown that diverse care teams optimize patient outcomes. Describing the current representation of women and minorities has been a critical step in improving diversity across several fields. OBJECTIVES To address the lack of data specific to pediatric cardiology, the authors conducted a national survey. METHODS U.S. academic pediatric cardiology programs with fellowship training programs were surveyed. Division directors were invited (July 2021 to September 2021) to complete an e-survey of program composition. Underrepresented minorities in medicine (URMM) were characterized using standard definitions. Descriptive analyses at the hospital, faculty, and fellow level were performed. RESULTS Altogether, 52 of 61 programs (85%) completed the survey, representing 1,570 total faculty and 438 fellows, with a wide range in program size (7-109 faculty, 1-32 fellows). Although women comprise approximately 60% of faculty in pediatrics overall, they made up 55% of fellows and 45% of faculty in pediatric cardiology. Representation of women in leadership roles was notably less, including 39% of clinical subspecialty directors, 25% of endowed chairs, and 16% of division directors. URMM comprise approximately 35% of the U.S. population; however, they made up only 14% of pediatric cardiology fellows and 10% of faculty, with very few in leadership roles. CONCLUSIONS These national data suggest a "leaky pipeline" for women in pediatric cardiology and very limited presence of URRM overall. Our findings can inform efforts to elucidate underlying mechanisms for persistent disparity and reduce barriers to improving diversity in the field.
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Affiliation(s)
- Sowmya Balasubramanian
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA.
| | - Sara K Pasquali
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Melissa K Cousino
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA; Department of Cardiothoracic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Ray E Lowery
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrea S Les
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Sunkyung Yu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Amanda D McCormick
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Caroline L West
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Carlen G Fifer
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Caren S Goldberg
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer C Romano
- Department of Cardiothoracic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Sonal T Owens
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
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11
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Jacobs JP, Kumar SR, St Louis JD, Al-Halees ZY, Habib RH, Parsons N, Hill KD, Pasquali SK, Gaynor JW, Mascio CE, Overman DM, Dearani JA, Mayer JE, Shahian DM, Jacobs ML. Variation in Case-Mix Across Hospitals: Analysis of The Society of Thoracic Surgeons Congenital Heart Surgery Database. Ann Thorac Surg 2023; 115:485-492. [PMID: 35940312 DOI: 10.1016/j.athoracsur.2022.06.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/11/2022] [Accepted: 06/18/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database was queried to document variation of patient characteristics, procedure types, and programmatic case-mix. METHODS All index cardiac operations in patients less than 18 years of age in the STS Congenital Heart Surgery Database (July 2016 to June 2020) were eligible for inclusion except patients weighing ≤2.5 kg undergoing isolated patent ductus arteriosus closure. At the hospital level, we describe variations in patient and procedural characteristics known from previous analyses to be associated with outcomes. We also report variations across hospitals of programmatic case-mix. RESULTS Data were analyzed from 117 sites (90 322 total operations, 87 296 total index cardiac operations eligible for STAT [STS-European Association for Cardio-Thoracic Surgery] 2020 Mortality Score). The median annual total index cardiac operations eligible for STAT 2020 Mortality Score per hospital was 157 (interquartile range [IQR], 94-276). Wide variability was documented in total annual index cardiac operations eligible for STAT 2020 Mortality Score per hospital (ratio 90th/10th percentile = 9.01), operations in neonates weighing <2.5 kg (ratio 90th/10th percentile = 4.09), operations in patients with noncardiac anatomic abnormalities (ratio 90th/10th percentile = 3.46), and operations in patients with preoperative mechanical ventilation (ratio 90th/10th percentile = 3.97). At the hospital level, the median percentage of all index cardiac operations in STAT 2020 Mortality Category 5 was 3.7% (IQR, 1.7%-4.9%), the median percentage of all index cardiac operations in STAT 2020 Mortality Category 4 or 5 was 24.4% (IQR, 19.0%-28.4%), the median hospital-specific mean STAT Mortality Category was 2.39 (IQR, 2.20-2.47), and the median hospital-specific mean STAT Mortality Score was 0.86 (IQR, 0.73-0.91). CONCLUSIONS Substantial variation of patient characteristics, procedure types, and case-mix exists across pediatric and congenital cardiac surgical programs. Knowledge about programmatic case-mix augments data about indirectly standardized programmatic observed-to-expected (O/E) mortality. Indirectly standardized O/E ratios do not provide a complete description of a given pediatric and congenital cardiac surgical program. The indirectly standardized programmatic O/E ratios associated with a given program apply only to its specific case-mix of patients and may represent a quite different case-mix than that of another program.
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Affiliation(s)
- Jeffrey Phillip Jacobs
- Congenital Heart Center, Division of Cardiovascular Surgery, Departments of Surgery and Pediatrics, University of Florida, Gainesville, Florida.
| | - S Ram Kumar
- Department of Surgery, University of Southern California, Los Angeles, California
| | - James D St Louis
- Department of Surgery and Pediatrics, Children's Hospital of Georgia, Augusta University, Augusta, Georgia
| | - Zohair Y Al-Halees
- Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Robert H Habib
- The Society of Thoracic Surgeons Research Center, Chicago, Illinois
| | - Niharika Parsons
- The Society of Thoracic Surgeons Research Center, Chicago, Illinois
| | - Kevin D Hill
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - J William Gaynor
- Cardiac Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christopher E Mascio
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - David M Overman
- Division of Cardiovascular Surgery, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, Minnesota
| | - Joseph A Dearani
- Division of Cardiovascular Surgery, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, Minnesota
| | - John E Mayer
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David M Shahian
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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12
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Gaies M, Olive MK, Owens GE, Charpie JR, Zhang W, Pasquali SK, Klugman D, Costello JM, Schwartz SM, Banerjee M. Methods to Enhance Causal Inference for Assessing Impact of Clinical Informatics Platform Implementation. Circ Cardiovasc Qual Outcomes 2023; 16:e009277. [PMID: 36727516 DOI: 10.1161/circoutcomes.122.009277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Hospitals are increasingly likely to implement clinical informatics tools to improve quality of care, necessitating rigorous approaches to evaluate effectiveness. We leveraged a multi-institutional data repository and applied causal inference methods to assess implementation of a commercial data visualization software in our pediatric cardiac intensive care unit. METHODS Natural experiment in the University of Michigan (UM) Cardiac Intensive Care Unit pre and postimplementation of data visualization software analyzed within the Pediatric Cardiac Critical Care Consortium clinical registry; we identified N=21 control hospitals that contributed contemporaneous registry data during the study period. We used the platform during multiple daily rounds to visualize clinical data trends. We evaluated outcomes-case-mix adjusted postoperative mortality, cardiac arrest and unplanned readmission rates, and postoperative length of stay-most likely impacted by this change. There were no quality improvement initiatives focused specifically on these outcomes nor any organizational changes at UM in either era. We performed a difference-in-differences analysis to compare changes in UM outcomes to those at control hospitals across the pre versus postimplementation eras. RESULTS We compared 1436 pre versus 779 postimplementation admissions at UM to 19 854 (pre) versus 14 160 (post) at controls. Admission characteristics were similar between eras. Postimplementation at UM we observed relative reductions in cardiac arrests among medical admissions, unplanned readmissions, and postoperative length of stay by -14%, -41%, and -18%, respectively. The difference-in-differences estimate for each outcome was statistically significant (P<0.05), suggesting the difference in outcomes at UM pre versus postimplementation is statistically significantly different from control hospitals during the same time. CONCLUSIONS Clinical registries provide opportunities to thoroughly evaluate implementation of new informatics tools at single institutions. Borrowing strength from multi-institutional data and drawing ideas from causal inference, our analysis solidified greater belief in the effectiveness of this software across our institution.
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Affiliation(s)
- Michael Gaies
- Heart Institute, Cincinnati Children's Hospital Medical Center, OH (M.G.)
| | - Mary K Olive
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI (M.K.O., G.E.O., J.R.C., S.K.P.)
| | - Gabe E Owens
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI (M.K.O., G.E.O., J.R.C., S.K.P.)
| | - John R Charpie
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI (M.K.O., G.E.O., J.R.C., S.K.P.)
| | - Wenying Zhang
- Michigan Congenital Heart Outcomes Research and Discovery Unit, PC4 Data Coordinating Center, University of Michigan, Ann Arbor, MI (W.Z.)
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI (M.K.O., G.E.O., J.R.C., S.K.P.)
| | - Darren Klugman
- Department of Anesthesia and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD (D.K.)
| | - John M Costello
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC (J.M.C.)
| | - Steven M Schwartz
- Department of Paediatrics, Temerty Faculty of Medicine, The University of Toronto, ON (S.M.S.)
| | - Mousumi Banerjee
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI (M.B.)
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13
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Opotowsky AR, Allen KY, Bucholz EM, Burns KM, del Nido P, Fenton KN, Gelb BD, Kirkpatrick JN, Kutty S, Lambert LM, Lopez KN, Olivieri LJ, Pajor NM, Pasquali SK, Petit CJ, Sood E, VanBuren JM, Pearson GD, Miyamoto SD. Pediatric and Congenital Cardiovascular Disease Research Challenges and Opportunities. J Am Coll Cardiol 2022; 80:2239-2250. [DOI: 10.1016/j.jacc.2022.09.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 09/27/2022] [Indexed: 11/29/2022]
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14
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Sood V, Pasquali SK. How Good Is Good Enough? Ann Thorac Surg 2022; 114:1737-1738. [PMID: 35439453 DOI: 10.1016/j.athoracsur.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 04/03/2022] [Indexed: 12/31/2022]
Affiliation(s)
- Vikram Sood
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan Medical School, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Sara K Pasquali
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan Medical School, C.S. Mott Children's Hospital, 1540 E Hospital Dr, Ann Arbor, MI 48109.
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15
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Alten J, Cooper DS, Klugman D, Raymond TT, Wooton S, Garza J, Clarke-Myers K, Anderson J, Pasquali SK, Absi M, Affolter JT, Bailly DK, Bertrandt RA, Borasino S, Dewan M, Domnina Y, Lane J, McCammond AN, Mueller DM, Olive MK, Ortmann L, Prodhan P, Sasaki J, Scahill C, Schroeder LW, Werho DK, Zaccagni H, Zhang W, Banerjee M, Gaies M. Preventing Cardiac Arrest in the Pediatric Cardiac Intensive Care Unit Through Multicenter Collaboration. JAMA Pediatr 2022; 176:1027-1036. [PMID: 35788631 PMCID: PMC9257678 DOI: 10.1001/jamapediatrics.2022.2238] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/28/2022] [Indexed: 12/14/2022]
Abstract
Importance Preventing in-hospital cardiac arrest (IHCA) likely represents an effective strategy to improve outcomes for critically ill patients, but feasibility of IHCA prevention remains unclear. Objective To determine whether a low-technology cardiac arrest prevention (CAP) practice bundle decreases IHCA rate. Design, Setting, and Participants Pediatric cardiac intensive care unit (CICU) teams from the Pediatric Cardiac Critical Care Consortium (PC4) formed a collaborative learning network to implement the CAP bundle consistent with the Institute for Healthcare Improvement framework; 15 hospitals implemented the bundle voluntarily. Risk-adjusted IHCA incidence rates were analyzed across 2 time periods, 12 months (baseline) and 18 months after CAP implementation (intervention) using difference-in-differences (DID) regression to compare 15 CAP and 16 control PC4 hospitals that chose not to participate in CAP but had IHCA rates tracked in the PC4 registry. Patients deemed at high risk for IHCA, based on a priori evidence-based criteria and empirical hospital-specific criteria, were selected to receive the CAP bundle. Data were collected from July 2018 to December 2019, and data were analyzed from March to August 2020. Interventions CAP bundle included 5 elements developed to promote increased situational awareness and communication among bedside clinicians to recognize and mitigate deterioration in high-risk patients. Main Outcomes and Measures Risk-adjusted IHCA incidence rate across all CICU admissions (IHCA events divided by all admissions). Results The bundle was activated in 2664 of 10 510 CAP hospital admissions (25.3%); admission characteristics were similar across study periods. There was a 30% relative reduction in risk-adjusted IHCA incidence rate at CAP hospitals (intervention period: 2.6%; 95% CI, 2.2-2.9; baseline: 3.7%; 95% CI, 3.1-4.0), but no change at control hospitals (intervention period: 2.7%; 95% CI, 2.3-2.9; baseline: 2.7%; 95% CI, 2.2-3.0). DID analysis confirmed significantly reduced odds of IHCA among all admissions at CAP hospitals compared with control hospitals during the intervention period vs baseline (odds ratio, 0.72; 95% CI, 0.56-0.91; P = .01). DID odds ratios were 0.72 (95% CI, 0.53-0.98) for the surgical subgroup, 0.74 (95% CI, 0.48-1.14) for the medical subgroup, and 0.72 (95% CI, 0.50-1.03) for the high-risk admission subgroup at CAP hospitals after intervention. All-cause risk-adjusted mortality rate did not change after intervention. Conclusions and Relevance Implementation of this CAP bundle led to significant IHCA reduction across multiple pediatric CICUs. Future studies may determine if this bundle can be effective in other critically ill populations.
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Affiliation(s)
- Jeffrey Alten
- Department of Pediatrics, University of Cincinnati School of Medicine, Heart Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - David S. Cooper
- Department of Pediatrics, University of Cincinnati School of Medicine, Heart Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Darren Klugman
- Division of Cardiac Critical Care Medicine, Children’s National Hospital, Washington, DC
- Division of Anesthesia, Critical Care Medicine, Johns Hopkins Children’s Center, Baltimore, Maryland
| | - Tia Tortoriello Raymond
- Department of Pediatrics, Cardiac Critical Care, Medical City Children’s Hospital, Dallas, Texas
| | - Sharyl Wooton
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Janie Garza
- Department of Pediatrics, Cardiac Critical Care, Medical City Children’s Hospital, Dallas, Texas
| | - Katherine Clarke-Myers
- Department of Pediatrics, Heart Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Jeffrey Anderson
- Department of Pediatrics, University of Cincinnati School of Medicine, Heart Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Sara K. Pasquali
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan Medical School, C.S. Mott Children’s Hospital, Ann Arbor
| | - Mohammed Absi
- Department of Pediatrics, Heart Institute, University of Tennessee, Le Bonheur Children’s Hospital, Memphis
| | - Jeremy T. Affolter
- Department of Pediatrics, Critical Care Medicine, University of Missouri, Children’s Mercy Hospital, Kansas City
- Department of Pediatrics, University of Texas at Austin-Dell Medical School, Dell Children’s Medical Center of Central Texas, Austin
| | - David K. Bailly
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Primary Children’s Hospital, Salt Lake City
| | - Rebecca A. Bertrandt
- Department of Pediatric Critical Care, Medical College of Wisconsin, Children’s Wisconsin, Milwaukee
| | - Santiago Borasino
- Department of Pediatrics, University of Alabama at Birmingham, Cardiac Critical Care, Birmingham
| | - Maya Dewan
- Department of Pediatrics, University of Cincinnati School of Medicine, Division of Critical Care Medicine, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Yuliya Domnina
- Division of Cardiac Critical Care Medicine, Children’s National Hospital, Washington, DC
- Department of Pediatrics and Critical Care Medicine, Cardiac Intensive Care Unit, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John Lane
- Division of Cardiovascular Intensive Care, Phoenix Children’s Hospital, Phoenix Arizona
| | - Amy N. McCammond
- Department of Pediatrics, Pediatric Cardiac Intensive Care, University of California San Francisco, Benioff Children’s Hospital, San Francisco
| | - Dana M. Mueller
- Department of Pediatrics, Division of Critical Care, University of Washington, Seattle Children’s Hospital, Seattle
- Division of Cardiology, Department of Pediatrics, University of California San Diego, Rady Children’s Hospital, San Diego
| | - Mary K. Olive
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan Medical School, C.S. Mott Children’s Hospital, Ann Arbor
| | - Laura Ortmann
- Department of Pediatrics, University of Nebraska Medical Center, Children’s Hospital and Medical Center, Omaha
| | - Parthak Prodhan
- Division of Pediatric Cardiology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock
| | - Jun Sasaki
- Division of Cardiac Critical Care Medicine, Nicklaus Children’s Hospital, Miami, Florida
- Division of Critical Care Medicine, Department of Pediatrics, Weill Cornell Medicine, New York, New York
| | - Carly Scahill
- Department of Pediatrics, Heart Institute, Children’s Hospital Colorado, Aurora
| | - Luke W. Schroeder
- Department of Pediatrics, Medical University of South Carolina, Charleston
| | - David K. Werho
- Division of Cardiology, Department of Pediatrics, University of California San Diego, Rady Children’s Hospital, San Diego
| | - Hayden Zaccagni
- Department of Pediatrics, University of Alabama at Birmingham, Cardiac Critical Care, Birmingham
| | - Wenying Zhang
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Mousumi Banerjee
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Biostatistics, University of Michigan, Ann Arbor
| | - Michael Gaies
- Department of Pediatrics, University of Cincinnati School of Medicine, Heart Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
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16
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Normand SLT, Zelevinsky K, Nathan M, Abing HK, Dearani JA, Galantowicz M, Gaynor JW, Habib RH, Hanley FL, Jacobs JP, Kumar SR, McDonald DE, Pasquali SK, Shahian DM, Tweddell JS, Vener DF, Mayer JE. Mortality Prediction Following Cardiac Surgery in Children - An STS Congenital Heart Surgery Database Analysis. Ann Thorac Surg 2022; 114:785-798. [PMID: 35122722 DOI: 10.1016/j.athoracsur.2021.11.077] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 11/03/2021] [Accepted: 11/12/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND The Society of Thoracic Surgeons' Congenital Heart Surgery Database (STS CHSD) provides risk-adjusted operative mortality rates to approximately 120 North American congenital heart centers. Optimal case-mix adjustment methods for operative mortality risk prediction in this population remain unclear. METHODS A panel created diagnosis-procedure (D-P) combinations of encounters in the CHSD. Models for operative mortality using the new D-P categories, procedure-specific risk factors, and syndromes/abnormalities included in the CHSD were estimated using Bayesian additive regression trees (BART) and lasso models. Performance of the new models was compared to the current STS-CHSD risk model. RESULTS Of 98,825 operative encounters (69,063 training; 29,762 testing), 2,818 (2.85%) STS-defined operative mortalities were observed. Differences in sensitivity, specificity, true and false positive predicted values were negligible across models. Calibration for mortality predictions at the higher end of risk from the lasso and BART models was better than predictions from the STS-CHSD model, likely due to new models' inclusion of diagnosis-palliative procedure variables affecting < 1% of patients overall, but accounting for 27% of mortalities. Model discrimination varied across models for high-risk procedures, hospital volume, and hospitals. CONCLUSIONS Overall performance of the new models did not differ meaningfully from the STS-CHSD risk model. Addition of procedure-specific risk factors and allowing diagnosis to modify predicted risk for palliative operations may augment model performance for very high-risk surgeries. Given the importance of risk adjustment in estimating hospital quality, a comparative assessment of surgical program quality evaluations using the different models is warranted.
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Affiliation(s)
- Sharon-Lise T Normand
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts; Department of Biostatistics, Harvard Chan School of Public Health, Boston, Massachusetts
| | - Katya Zelevinsky
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Haley K Abing
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mark Galantowicz
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | | | - Robert H Habib
- STS Research Center, The Society of Thoracic Surgeons, Chicago, Illinois
| | - Frank L Hanley
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, California
| | - Jeffrey P Jacobs
- Congenital Heart Center, Departments of Surgery and Pediatrics, University of Florida, Gainesville, Florida
| | - S Ram Kumar
- Division of Cardiac Surgery, Department of Surgery, and Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California; Heart Institute, Children's Hospital Los Angeles, Los Angeles, California
| | - Donna E McDonald
- STS Research Center, The Society of Thoracic Surgeons, Chicago, Illinois
| | - Sara K Pasquali
- Division of Cardiology, Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - David M Shahian
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - James S Tweddell
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - David F Vener
- Department of Anesthesiology, Baylor College of Medicine, Houston, Texas; Pediatric and Congenital Cardiac Anesthesia, Texas Children's Hospital, Houston, Texas
| | - John E Mayer
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts.
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17
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Bates KE, Connelly C, Khadr L, Graupe M, Hlavacek AM, Morell E, Pasquali SK, Russell JL, Schachtner SK, Strohacker C, Tanel RE, Ware AL, Wooton S, Madsen NL, Kipps AK. Successful Reduction of Postoperative Chest Tube Duration and Length of Stay After Congenital Heart Surgery: A Multicenter Collaborative Improvement Project. J Am Heart Assoc 2021; 10:e020730. [PMID: 34713712 PMCID: PMC8751825 DOI: 10.1161/jaha.121.020730] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/20/2021] [Indexed: 11/16/2022]
Abstract
Background Congenital heart disease practices and outcomes vary significantly across centers, including postoperative chest tube (CT) management, which may impact postoperative length of stay (LOS). We used collaborative learning methods to determine whether centers could adapt and safely implement best practices for CT management, resulting in reduced postoperative CT duration and LOS. Methods and Results Nine pediatric heart centers partnered together through 2 learning networks. Patients undergoing 1 of 9 benchmark congenital heart operations were included. Baseline data were collected from June 2017 to June 2018, and intervention-phase data were collected from July 2018 to December 2019. Collaborative learning methods included review of best practices from a model center, regular data feedback, and quality improvement coaching. Center teams adapted CT removal practices (eg, timing, volume criteria) from the model center to their local resources, practices, and setting. Postoperative CT duration in hours and LOS in days were analyzed using statistical process control methodology. Overall, 2309 patients were included. Patient characteristics did not differ between the study and intervention phases. Statistical process control analysis showed an aggregate 15.6% decrease in geometric mean CT duration (72.6 hours at baseline to 61.3 hours during intervention) and a 9.8% reduction in geometric mean LOS (9.2 days at baseline to 8.3 days during intervention). Adverse events did not increase when comparing the baseline and intervention phases: CT replacement (1.8% versus 2.0%, P=0.56) and readmission for pleural effusion (0.4% versus 0.5%, P=0.29). Conclusions We successfully lowered postoperative CT duration and observed an associated reduction in LOS across 9 centers using collaborative learning methodology.
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Affiliation(s)
- Katherine E. Bates
- Congenital Heart CenterUniversity of Michigan C.S. Mott Children's HospitalAnn ArborMI
- Department of PediatricsUniversity of Michigan Medical SchoolAnn ArborMI
| | - Chloe Connelly
- Anderson CenterCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Lara Khadr
- Congenital Heart CenterUniversity of Michigan C.S. Mott Children's HospitalAnn ArborMI
- Department of PediatricsUniversity of Michigan Medical SchoolAnn ArborMI
| | - Margaret Graupe
- The Heart InstituteCincinnati Children’s Hospital Medical CenterCincinnatiOH
- Department of PediatricsUniversity of Cincinnati School of MedicineCincinnatiOH
| | - Anthony M. Hlavacek
- Department of PediatricsChildren’s Heart CenterMedical University of South Carolina Children’s HealthCharlestonSC
| | - Evonne Morell
- Department of PediatricsHeart InstituteUniversity of Pittsburgh Medical Center Children's Hospital of PittsburghPittsburghPA
| | - Sara K. Pasquali
- Congenital Heart CenterUniversity of Michigan C.S. Mott Children's HospitalAnn ArborMI
- Department of PediatricsUniversity of Michigan Medical SchoolAnn ArborMI
| | - Jennifer L. Russell
- Department of PediatricsLabatt Family Heart CentreThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Susan K. Schachtner
- Cardiac CenterThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
- Department of PediatricsPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Courtney Strohacker
- Congenital Heart CenterUniversity of Michigan C.S. Mott Children's HospitalAnn ArborMI
- Department of PediatricsUniversity of Michigan Medical SchoolAnn ArborMI
| | - Ronn E. Tanel
- Pediatric Heart CenterUCSF Benioff Children’s HospitalSan FranciscoCA
- Department of PediatricsUCSF School of MedicineSan FranciscoCA
| | - Adam L. Ware
- Department of PediatricsThe Heart CenterPrimary Children’s HospitalSalt Lake CityUT
| | - Sharyl Wooton
- Anderson CenterCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Nicolas L. Madsen
- The Heart InstituteCincinnati Children’s Hospital Medical CenterCincinnatiOH
- Department of PediatricsUniversity of Cincinnati School of MedicineCincinnatiOH
| | - Alaina K. Kipps
- Department of PediatricsBetty Irene Moore Children's Heart CenterLucile Packard Children’s Hospital at StanfordStanford School of MedicinePalo AltoCA
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18
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Karamlou T, Javorski MJ, Weiss A, Pasquali SK, Welke KF. Utility of administrative and clinical data for cardiac surgery research: A case-based approach to guide choice. J Thorac Cardiovasc Surg 2021; 162:1157-1165. [DOI: 10.1016/j.jtcvs.2020.09.135] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/06/2020] [Accepted: 09/08/2020] [Indexed: 11/24/2022]
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19
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Affiliation(s)
- Sara K Pasquali
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, 1540 E. Hospital Drive, Ann Arbor, MI 48109.
| | - J William Gaynor
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
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20
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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21
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Jacobs ML, Jacobs JP, Thibault D, Hill KD, Anderson BR, Eghtesady P, Karamlou T, Kumar SR, Mayer JE, Mery CM, Nathan M, Overman DM, Pasquali SK, St Louis JD, Shahian D, O'Brien SM. Updating an Empirically Based Tool for Analyzing Congenital Heart Surgery Mortality. World J Pediatr Congenit Heart Surg 2021; 12:246-281. [PMID: 33683997 DOI: 10.1177/2150135121991528] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES STAT Mortality Categories (developed 2009) stratify congenital heart surgery procedures into groups of increasing mortality risk to characterize case mix of congenital heart surgery providers. This update of the STAT Mortality Score and Categories is empirically based for all procedures and reflects contemporary outcomes. METHODS Cardiovascular surgical operations in the Society of Thoracic Surgeons Congenital Heart Surgery Database (January 1, 2010 - June 30, 2017) were analyzed. In this STAT 2020 Update of the STAT Mortality Score and Categories, the risk associated with a specific combination of procedures was estimated under the assumption that risk is determined by the highest risk individual component procedure. Operations composed of multiple component procedures were eligible for unique STAT Scores when the statistically estimated mortality risk differed from that of the highest risk component procedure. Bayesian modeling accounted for small denominators. Risk estimates were rescaled to STAT 2020 Scores between 0.1 and 5.0. STAT 2020 Category assignment was designed to minimize within-category variation and maximize between-category variation. RESULTS Among 161,351 operations at 110 centers (19,090 distinct procedure combinations), 235 types of single or multiple component operations received unique STAT 2020 Scores. Assignment to Categories resulted in the following distribution: STAT 2020 Category 1 includes 59 procedure codes with model-based estimated mortality 0.2% to 1.3%; Category 2 includes 73 procedure codes with mortality estimates 1.4% to 2.9%; Category 3 includes 46 procedure codes with mortality estimates 3.0% to 6.8%; Category 4 includes 37 procedure codes with mortality estimates 6.9% to 13.0%; and Category 5 includes 17 procedure codes with mortality estimates 13.5% to 38.7%. The number of procedure codes with empirically derived Scores has grown by 58% (235 in STAT 2020 vs 148 in STAT 2009). Of the 148 procedure codes with empirically derived Scores in 2009, approximately one-half have changed STAT Category relative to 2009 metrics. The New STAT 2020 Scores and Categories demonstrated good discrimination for predicting mortality in an independent validation sample (July 1, 2017-June 30, 2019; sample size 46,933 operations at 108 centers) with C-statistic = 0.791 for STAT 2020 Score and 0.779 for STAT 2020 Category. CONCLUSIONS The updated STAT metrics reflect contemporary practice and outcomes. New empirically based STAT 2020 Scores and Category designations are assigned to a larger set of procedure codes, while accounting for risk associated with multiple component operations. Updating STAT metrics based on contemporary outcomes facilitates accurate assessment of case mix.
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Affiliation(s)
- Marshall L Jacobs
- Department of Surgery, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jeffrey P Jacobs
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Dylan Thibault
- Duke Clinical Research Institute, 12277Duke University School of Medicine, Durham, NC, USA
| | - Kevin D Hill
- Department of Pediatrics, 22957Duke University School of Medicine, Durham, NC, USA
| | - Brett R Anderson
- Division of Pediatric Cardiology, 21611Columbia University Irving Medical Center, New York, NY, USA
| | - Pirooz Eghtesady
- Cardiothoracic Surgery, 12275Washington University in Saint Louis School of Medicine, St Louis, MO, USA
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - S Ram Kumar
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - John E Mayer
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Carlos M Mery
- Texas Center for Pediatric and Congenital Heart Disease, University of Texas Dell Medical School/Dell Children's Medical Center, Austin, TX, USA
| | - Meena Nathan
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA, USA
| | - David M Overman
- Division of Cardiac Surgery, The Children's Heart Clinic, Children's Minnesota, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, MN, USA
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan 21634C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - James D St Louis
- Department of Surgery and Pediatrics, Children's Hospital of Georgia, 1421Augusta University, Augusta, GA, USA
| | - David Shahian
- Division of Cardiac Surgery, Department of Surgery, Center for Quality and Safety, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sean M O'Brien
- Duke Clinical Research Institute, 12277Duke University School of Medicine, Durham, NC, USA
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22
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Witte MK, Mahle WT, Pasquali SK, Nicolson SC, Shekerdemian LS, Wolf MJ, Zhang W, Donohue JE, Gaies M. Spillover of Early Extubation Practices From the Pediatric Heart Network Collaborative Learning Study. Pediatr Crit Care Med 2021; 22:204-212. [PMID: 33273409 PMCID: PMC7855235 DOI: 10.1097/pcc.0000000000002620] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The Pediatric Heart Network Collaborative Learning Study used collaborative learning strategies to implement a clinical practice guideline that increased rates of early extubation after infant repair of tetralogy of Fallot and coarctation of the aorta. We assessed early extubation rates for infants undergoing cardiac surgeries not targeted by the clinical practice guideline to determine whether changes in extubation practices spilled over to care of other infants. DESIGN Observational analyses of site's local Society of Thoracic Surgeons Congenital Heart Surgery Database and Pediatric Cardiac Critical Care Consortium Registry. SETTING Four Pediatric Heart Network Collaborative Learning Study active-site hospitals. PATIENTS Infants undergoing ventricular septal defect repair, atrioventricular septal defect repair, or superior cavopulmonary anastomosis (lower complexity), and arterial switch operation or isolated aortopulmonary shunt (higher complexity). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Aggregate outcomes were compared between the 12 month pre-clinical practice guideline and 12 months after study completion (Follow Up). In infants undergoing lower complexity surgeries, early extubation increased during Follow Up compared with Pre-Clinical Practice Guideline (30.2% vs 18.8%, p = 0.006), and hours to initial postoperative extubation decreased. We observed variation in these outcomes by surgery type, with only ventricular septal defect repair associated with a significant increase in early extubation during Follow Up compared with Pre-Clinical Practice Guideline (47% vs 26%, p = 0.006). Variation by study site was also seen, with only one hospital showing an increase in early extubation. In patients undergoing higher complexity surgeries, there was no difference in early extubation or hours to initial extubation between the study eras. CONCLUSIONS We observed spillover of extubation practices promoted by the Collaborative Learning Study clinical practice guideline to lower complexity operations not included in the original study that was sustainable 1 year after study completion, though this effect differed across sites and operation subtypes. No changes in postoperative extubation outcomes following higher complexity surgeries were seen. The significant variation in outcomes by site suggests that center-specific factors may have influenced spillover of clinical practice guideline practices.
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Affiliation(s)
- Madolin K Witte
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | | | - Sara K Pasquali
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI
| | - Susan C Nicolson
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | | | - Wenying Zhang
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI
| | - Janet E Donohue
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI
| | - Michael Gaies
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI
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23
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Bucholz EM, Sleeper LA, Sananes R, Brosig CL, Goldberg CS, Pasquali SK, Newburger JW. Trajectories in Neurodevelopmental, Health-Related Quality of Life, and Functional Status Outcomes by Socioeconomic Status and Maternal Education in Children with Single Ventricle Heart Disease. J Pediatr 2021; 229:289-293.e3. [PMID: 33031800 PMCID: PMC7855010 DOI: 10.1016/j.jpeds.2020.09.066] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 09/22/2020] [Accepted: 09/24/2020] [Indexed: 11/18/2022]
Abstract
Trajectories of neurodevelopment and quality of life were analyzed in children with hypoplastic left heart syndrome according to socioeconomic status (SES) and maternal education. Lower SES and less maternal education were associated with greater early delays in communication and problem-solving and progressive delays in problem-solving and fine motor skills over time.
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Affiliation(s)
- Emily M Bucholz
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Renee Sananes
- Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cheryl L Brosig
- Department of Pediatrics, Medical College of Wisconsin and Herma Heart Institute, Children's Wisconsin, Milwaukee, WI
| | - Caren S Goldberg
- Department of Pediatrics, University of Michigan CS Mott Children's Hospital, Ann Arbor, MI
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan CS Mott Children's Hospital, Ann Arbor, MI
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
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24
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Steurer MA, Peyvandi S, Costello JM, Moon-Grady AJ, Habib RH, Hill KD, Jacobs ML, Jelliffe-Pawlowski LL, Keller RL, Pasquali SK, Reddy VM, Tabbutt S, Rajagopal S. Association between Z-score for birth weight and postoperative outcomes in neonates and infants with congenital heart disease. J Thorac Cardiovasc Surg 2021; 162:1838-1847.e4. [DOI: 10.1016/j.jtcvs.2021.01.065] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 01/12/2021] [Accepted: 01/15/2021] [Indexed: 12/17/2022]
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Pasquali SK, Thibault D, O'Brien SM, Jacobs JP, Gaynor JW, Romano JC, Gaies M, Hill KD, Jacobs ML, Shahian DM, Backer CL, Mayer JE. National Variation in Congenital Heart Surgery Outcomes. Circulation 2020; 142:1351-1360. [PMID: 33017214 DOI: 10.1161/circulationaha.120.046962] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Optimal strategies to improve national congenital heart surgery outcomes and reduce variability across hospitals remain unclear. Many policy and quality improvement efforts have focused primarily on higher-risk patients and mortality alone. Improving our understanding of both morbidity and mortality and current variation across the spectrum of complexity would better inform future efforts. METHODS Hospitals participating in the Society of Thoracic Surgeons Congenital Heart Surgery Database (2014-2017) were included. Case mix-adjusted operative mortality, major complications, and postoperative length of stay were evaluated using Bayesian models. Hospital variation was quantified by the interdecile ratio (IDR, upper versus lower 10%) and 95% credible intervals (CrIs). Stratified analyses were performed by risk group (Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery [STAT] category) and simulations evaluated the potential impact of reductions in variation. RESULTS A total of 102 hospitals (n=84 407) were included, representing ≈85% of US congenital heart programs. STAT category 1 to 3 (lower risk) operations comprised 74% of cases. All outcomes varied significantly across hospitals: adjusted mortality by 3-fold (upper versus lower decile 5.0% versus 1.6%, IDR 3.1 [95% CrI 2.5-3.7]), mean length of stay by 1.8-fold (19.2 versus 10.5 days, IDR 1.8 [95% CrI 1.8-1.9]), and major complications by >3-fold (23.5% versus 7.0%, IDR 3.4 [95% CrI 3.0-3.8]). The degree of variation was similar or greater for low- versus high-risk cases across outcomes, eg, ≈3-fold mortality variation across hospitals for STAT 1 to 3 (IDR 3.0 [95% CrI 2.1-4.2]) and STAT 4 or 5 (IDR 3.1 [95% CrI 2.4-3.9]) cases. High-volume hospitals had less variability across outcomes and risk categories. Simulations suggested potential reductions in deaths (n=282), major complications (n=1539), and length of stay (101 183 days) over the 4-year study period if all hospitals were to perform at the current median or better, with 37% to 60% of the improvement related to the STAT 1 to 3 (lower risk) group across outcomes. CONCLUSIONS We demonstrate significant hospital variation in morbidity and mortality after congenital heart surgery. Contrary to traditional thinking, a substantial portion of potential improvements that could be realized on a national scale were related to variability among lower-risk cases. These findings suggest modifications to our current approaches to optimize care and outcomes in this population are needed.
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Affiliation(s)
- Sara K Pasquali
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor (S.K.P., M.G.)
| | - Dylan Thibault
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (D.T., S.M.O., K.D.H.)
| | - Sean M O'Brien
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (D.T., S.M.O., K.D.H.)
| | | | - J William Gaynor
- Department of Surgery, Children's Hospital of Philadelphia, PA (J.W.G.)
| | - Jennifer C Romano
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor (J.C.R.)
| | - Michael Gaies
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor (S.K.P., M.G.)
| | - Kevin D Hill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (D.T., S.M.O., K.D.H.)
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (M.L.J.)
| | - David M Shahian
- Department of Surgery, Division of Cardiac Surgery, and Center for Quality and Safety, Massachusetts General Hospital, Harvard Medical School, Boston (D.M.S.)
| | - Carl L Backer
- Department of Surgery, University of Cincinnati, Cincinnati Children's Hospital, OH (C.L.B.)
| | - John E Mayer
- Department of Cardiovascular Surgery, Boston Children's Hospital, MA (J.E.M.)
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26
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Bucholz EM, Sleeper LA, Goldberg CS, Pasquali SK, Anderson BR, Gaynor JW, Cnota JF, Newburger JW. Socioeconomic Status and Long-term Outcomes in Single Ventricle Heart Disease. Pediatrics 2020; 146:peds.2020-1240. [PMID: 32973120 PMCID: PMC7546087 DOI: 10.1542/peds.2020-1240] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Low socioeconomic status (SES) has emerged as an important risk factor for higher short-term mortality and neurodevelopmental outcomes in children with hypoplastic left heart syndrome and related anomalies; yet little is known about how SES affects these outcomes over the long-term. METHODS We linked data from the Single Ventricle Reconstruction trial to US Census Bureau data to analyze the relationship of neighborhood SES tertiles with mortality and transplantation, neurodevelopment, quality of life, and functional status at 5 and 6 years post-Norwood procedure (N = 525). Cox proportional hazards regression and linear regression were used to assess the association of SES with mortality and neurodevelopmental outcomes, respectively. RESULTS Patients in the lowest SES tertile were more likely to be racial minorities, older at stage 2 and Fontan procedures, and to have more complications and fewer cardiac catheterizations over follow-up (all P < .05) compared with patients in higher SES tertiles. Unadjusted mortality was highest for patients in the lowest SES tertile and lowest in the highest tertile (41% vs 29%, respectively; log-rank P = .027). Adjustment for patient birth and Norwood factors attenuated these differences slightly (P = .055). Patients in the lowest SES tertile reported lower functional status and lower fine motor, problem-solving, adaptive behavior, and communication skills at 6 years (all P < .05). These differences persisted after adjustment for baseline and post-Norwood factors. Quality of life did not differ by SES. CONCLUSIONS Among patients with hypoplastic left heart syndrome, those with low SES have worse neurodevelopmental and functional status outcomes at 6 years. These differences were not explained by other patient or clinical characteristics.
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Affiliation(s)
- Emily M. Bucholz
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Lynn A. Sleeper
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Caren S. Goldberg
- Department of Pediatrics, University of Michigan and C.S. Mott Children’s Hospital, Ann Arbor, Michigan
| | - Sara K. Pasquali
- Department of Pediatrics, University of Michigan and C.S. Mott Children’s Hospital, Ann Arbor, Michigan
| | - Brett R. Anderson
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University Irving Medical Center and NewYork-Presbyterian Morgan Stanley Children’s Hospital, New York City, New York
| | - J. William Gaynor
- Division of Pediatric Cardiac Surgery, Cardiac Center, Children’s Hospital of Pennsylvania, Philadelphia, Pennsylvania; and
| | - James F. Cnota
- Department of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
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27
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Welke KF, Pasquali SK, Lin P, Backer CL, Overman DM, Romano JC, Karamlou T. Theoretical Model for Delivery of Congenital Heart Surgery in the United States. Ann Thorac Surg 2020; 111:1628-1635. [PMID: 32860751 DOI: 10.1016/j.athoracsur.2020.06.057] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/27/2020] [Accepted: 06/15/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Over 150 hospitals perform congenital heart surgery (CHS) in the United States. Many hospitals are close together, with a median patient travel distance of 38.5 miles. We began with a theoretical blank slate and used objective methodology guided by population density and volume thresholds to estimate the optimal number and locations of hospitals to provide CHS in the United States. METHODS Guided by published data, we estimated the number of CHS operations in the United States in to be 32,500 per year. We distributed patients geographically based on population density. Metropolitan Statistical Areas (population centers and surrounding areas with close economic/social ties) were used as potential hospital locations. Patients were assigned to the closest hospital location such that all hospitals had a CHS volume of ≥300 operations. RESULTS We estimated 57 hospitals could serve the contiguous United States. Median theoretical hospital volume after regionalization was 451 operations (interquartile range, 366-648). Median patient travel distance was 35.1 miles. Some patients (6396/31,895, 20%) traveled more than 100 miles. CONCLUSIONS Our model suggests the United States could be served by approximately 100 fewer CHS hospitals than currently exist. With hospitals optimally placed, patient travel burden would decrease. This model serves as a platform to improve care delivery by regionalization of CHS.
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Affiliation(s)
- Karl F Welke
- Division of Congenital Cardiac Surgery, Levine Children's Hospital/Atrium Health, Charlotte, North Carolina.
| | - Sara K Pasquali
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan C. S. Mott Children's Hospital, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, Michigan
| | - Paul Lin
- Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, Michigan
| | - Carl L Backer
- Division of Cardiovascular-Thoracic Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - David M Overman
- Division of Cardiovascular Surgery, The Children's Heart Clinic, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Jennifer C Romano
- Department of Cardiac Surgery, University of Michigan C. S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery and the Heart and Vascular Institute, The Cleveland Clinic, Cleveland, Ohio
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Gaies M, Pasquali SK, Banerjee M, Dimick JB, Birkmeyer JD, Zhang W, Alten JA, Chanani N, Cooper DS, Costello JM, Gaynor JW, Ghanayem N, Jacobs JP, Mayer JE, Ohye RG, Scheurer MA, Schwartz SM, Tabbutt S, Charpie JR. Improvement in Pediatric Cardiac Surgical Outcomes Through Interhospital Collaboration. J Am Coll Cardiol 2020; 74:2786-2795. [PMID: 31779793 DOI: 10.1016/j.jacc.2019.09.046] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/01/2019] [Accepted: 09/05/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND Patients undergoing complex pediatric cardiac surgery remain at considerable risk of mortality and morbidity, and variation in outcomes exists across hospitals. The Pediatric Cardiac Critical Care Consortium (PC4) was formed to improve the quality of care for these patients through transparent data sharing and collaborative learning between participants. OBJECTIVES The purpose of this study was to determine whether outcomes improved over time within PC4. METHODS The study analyzed 19,600 hospitalizations (18 hospitals) in the PC4 clinical registry that included cardiovascular surgery from August 2014 to June 2018. The primary exposure was 2 years of PC4 participation; this provided adequate time for hospitals to accrue data and engage in collaborative learning. Aggregate case mix-adjusted outcomes were compared between the first 2 years of participation (baseline) and all months post-exposure. We also evaluated outcomes from the same era in a cohort of similar, non-PC4 hospitals. RESULTS During the baseline period, there was no evidence of improvement. We observed significant improvement in the post-exposure period versus baseline for post-operative intensive care unit mortality (2.1% vs. 2.7%; 22% relative reduction [RR]; p = 0.001), in-hospital mortality (2.5% vs. 3.3%; 24% RR; p = 0.001), major complications (10.1% vs. 11.5%; 12% RR; p < 0.001), intensive care unit length of stay (7.3 days vs. 7.7 days; 5% RR; p < 0.001), and duration of ventilation (61.3 h vs. 70.6 h; 13% RR; p = 0.01). Non-PC4 hospitals showed no significant improvement in mortality, complications, or hospital length of stay. CONCLUSIONS This analysis demonstrates improving cardiac surgical outcomes at children's hospitals participating in PC4. This change appears unrelated to secular improvement trends, and likely reflects PC4's commitment to transparency and collaboration.
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Affiliation(s)
- Michael Gaies
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
| | - Mousumi Banerjee
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Justin B Dimick
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Wenying Zhang
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Jeffrey A Alten
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Nikhil Chanani
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - David S Cooper
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - John M Costello
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - J William Gaynor
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nancy Ghanayem
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | | | - John E Mayer
- Department of Cardiac Surgery, Harvard Medical School, Boston, Massachusetts
| | - Richard G Ohye
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Mark A Scheurer
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Steven M Schwartz
- Departments of Pediatrics and Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Tabbutt
- Department of Pediatrics, University of California, San Francisco School of Medicine, San Francisco, California
| | - John R Charpie
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Pasquali SK, Chiswell K, Hall M, Thibault D, Romano JC, Gaynor JW, Shahian DM, Jacobs ML, Gaies MG, O'Brien SM, Norton EC, Hill KD, Cowper PA, Pinto NM, Shah SS, Mayer JE, Jacobs JP. Estimating Resource Utilization in Congenital Heart Surgery. Ann Thorac Surg 2020; 110:962-968. [PMID: 32105714 DOI: 10.1016/j.athoracsur.2020.01.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 12/20/2019] [Accepted: 01/02/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Optimal methods to assess resource utilization in congenital heart surgery remain unclear. We compared traditional cost-to-charge ratio methods with newer standardized cost methods that aim to more directly assess resources consumed. METHODS Clinical data from The Society of Thoracic Surgeons Database were linked with resource use data from the Pediatric Health Information Systems Database (2010 to 2015). Standardized cost methods specific to the congenital heart surgery population were developed and compared with cost-to-charge ratio methods. Resource use in the overall population and variability across hospitals were described using hierarchical mixed effect models adjusting for case-mix. RESULTS Overall, 43 hospitals (65,331 patients) were included. There were minimal population-level differences in the distribution of resource use as estimated by the two methods. At the hospital level, there was less apparent variability in resource use across centers with the standardized cost vs cost-to-charge ratio method, overall (coefficient of variation 20% vs 25%) and across complexity (The Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery [STAT]) categories. When hospitals were categorized into tertiles by resource use, 33% changed classification depending on which resource use method was used (26% by one tertile and 7% by two tertiles). CONCLUSIONS In this first evaluation of standardized cost methodology in the congenital heart population, we found minimal differences vs traditional methods at the population level. At the hospital level, the magnitude of variation in resource use was less with standardized cost methods, and approximately one third of centers changed resource use categories depending on the methodology used. Because of these differences, care should be taken in future studies and in benchmarking and reporting efforts in selecting optimal methodology.
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Affiliation(s)
- Sara K Pasquali
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan.
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Dylan Thibault
- 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, Division of Cardiac Surgery and 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
| | - Nelangi M Pinto
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - 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
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Affiliation(s)
- Carl L Backer
- Division of Cardiovascular-Thoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, IL (C.L.B.)
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL (C.L.B.)
| | - Sara K Pasquali
- Division of Cardiology, C.S. Mott Children's Hospital, Department of Pediatrics, University of Michigan, Ann Arbor (S.K.P.)
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Mayo College of Medicine, Rochester, MN (J.A.D.)
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Pasquali SK, Banerjee M, Romano JC, Normand SLT. Hospital Performance Assessment in Congenital Heart Surgery: Where Do We Go From Here? Ann Thorac Surg 2020; 109:621-626. [PMID: 31962112 DOI: 10.1016/j.athoracsur.2020.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 01/01/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Sara K Pasquali
- Department of Pediatrics, C.S. Mott Children's Hospital, and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.
| | - Mousumi Banerjee
- Department of Biostatistics, School of Public Health, and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Jennifer C Romano
- Department of Cardiac Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Sharon-Lise T Normand
- Department of Health Care Policy, Harvard Medical School, and Department of Biostatistics, Harvard Chan School of Public Health, Boston, Massachusetts
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Welke KF, Pasquali SK, Lin P, Backer CL, Overman DM, Romano JC, Karamlou T. Regionalization of Congenital Heart Surgery in the United States. Semin Thorac Cardiovasc Surg 2020; 32:128-137. [DOI: 10.1053/j.semtcvs.2019.09.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 09/04/2019] [Indexed: 12/30/2022]
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Jacobs ML, Jacobs JP, Hill KD, O'Brien SM, Pasquali SK, Vener D, Kumar SR, Chiswell K, St Louis JD, Mayer JE, Habib RH, Shahian DM, Fernandez FG. The Society of Thoracic Surgeons Congenital Heart Surgery Database: 2019 Update on Research. Ann Thorac Surg 2019; 108:671-679. [PMID: 31336062 PMCID: PMC8104073 DOI: 10.1016/j.athoracsur.2019.07.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 07/14/2019] [Indexed: 11/17/2022]
Abstract
As the largest congenital and pediatric cardiac surgical clinical data registry in the world, The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS CHSD) serves as a platform for reporting of outcomes and for quality improvement. In addition, it is an important source of data for clinical research and for innovations related to quality measurement. Each year, several teams of investigators undertake analyses of data in the STS CHSD pertaining to the surgical management of specific diagnostic and procedural groups, or to specific processes of care, and their associations with patient characteristics and outcomes across centers participating in the STS CHSD. Additional ongoing projects involve the development of new or refined metrics for quality measurement and reporting of outcomes and center-level performance. The STS, through its Workforce for National Databases and the STS Research Center and Workforce on Research Development provides multiple pathways through which investigators may propose and perform outcomes research projects based on STS CHSD data. This report reviews research published within the past year.
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Affiliation(s)
- Marshall L Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Jeffrey P Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Johns Hopkins All Children's Heart Institute, Johns Hopkins All Children's Hospital, Saint Petersburg, Florida
| | - Kevin D Hill
- Department of Pediatrics and Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Sean M O'Brien
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Sara K Pasquali
- Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - David Vener
- Department of Anesthesia, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - S Ram Kumar
- Department of Surgery, Children's Hospital of Los Angeles, Keck University of Southern California School of Medicine, Los Angeles, California
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - James D St Louis
- Department of Surgery, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - John E Mayer
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert H Habib
- The Society of Thoracic Surgeons Research Center, Chicago, Illinois
| | - David M Shahian
- Department of Surgery, Division of Cardiac Surgery, and Center for Quality and Safety, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Felix G Fernandez
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
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35
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Pasquali SK, Gaies M, Banerjee M, Zhang W, Donohue J, Russell M, Gaynor JW. The Quest for Precision Medicine: Unmeasured Patient Factors and Mortality After Congenital Heart Surgery. Ann Thorac Surg 2019; 108:1889-1894. [PMID: 31398358 DOI: 10.1016/j.athoracsur.2019.06.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 05/16/2019] [Accepted: 06/03/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Emerging data across many fields suggest that unique patient characteristics can impact disease manifestation and response to therapy, supporting "precision medicine" approaches and more individualized and targeted therapeutic strategies. In children undergoing congenital heart surgery, current risk models primarily focus on the population level, and their utility in understanding precise characteristics that place individual patients at risk for poor outcome remains unclear. METHODS We analyzed index surgeries in the Pediatric Cardiac Critical Care Consortium (PC4) registry (August 2014 to May 2016) and utilized a previously constructed model containing patient factors typically included in in-hospital mortality risk models (age, weight, prematurity, chromosomal anomalies/syndromes, preoperative factors, The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score). Partitioned variances based on a hierarchical generalized linear model were used to estimate the proportion of variation in mortality explained by these factors. RESULTS A total of 8406 operations (22 hospitals) were included. We found that only 30% of the total between-patient variation in mortality in our cohort was explained by the patient factors included in our model. Age, The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score, and preoperative mechanical ventilation explained the greatest proportion of variation. Of the variation that remained unexplained, 95% was attributable to unmeasured patient factors. In stratified analyses, these results were consistent across patient subgroups. CONCLUSIONS Patient factors typically included in congenital heart surgery risk models explain only a small portion of total variation in mortality. A better understanding of other underrecognized factors is critical in further defining risk profiles and in developing more individualized and tailored therapeutic strategies.
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Affiliation(s)
- Sara K Pasquali
- Division of Cardiology, Department of Pediatrics and Communicable Diseases, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan.
| | - Michael Gaies
- Division of Cardiology, Department of Pediatrics and Communicable Diseases, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Mousumi Banerjee
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Wenying Zhang
- Division of Cardiology, Department of Pediatrics and Communicable Diseases, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Janet Donohue
- Division of Cardiology, Department of Pediatrics and Communicable Diseases, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Mark Russell
- Division of Cardiology, Department of Pediatrics and Communicable Diseases, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - J William Gaynor
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Nelson JS, Maul TM, Wearden PD, Pasquali SK, Romano JC. National Practice Patterns and Early Outcomes of Aortic Valve Replacement in Children and Teens. Ann Thorac Surg 2019; 108:544-551. [DOI: 10.1016/j.athoracsur.2019.03.098] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/16/2019] [Accepted: 03/25/2019] [Indexed: 10/26/2022]
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Jacobs JP, O’Brien SM, Hill KD, Kumar SR, Austin EH, Gaynor JW, Gruber PJ, Jonas RA, Pasquali SK, Pizarro C, St. Louis JD, Meza J, Thibault D, Shahian DM, Mayer JE, Jacobs ML. Refining The Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Risk Model With Enhanced Risk Adjustment for Chromosomal Abnormalities, Syndromes, and Noncardiac Congenital Anatomic Abnormalities. Ann Thorac Surg 2019; 108:558-566. [DOI: 10.1016/j.athoracsur.2019.01.069] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/26/2019] [Accepted: 01/29/2019] [Indexed: 12/22/2022]
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Prospero CJ, Trachtenberg FL, Pemberton VL, Pasquali SK, Anderson BR, Ash KE, Bainton J, Dunbar-Masterson C, Graham EM, Hamstra MS, Hollenbeck-Pringle D, Jacobs JP, Jacobs ML, John R, Lambert LM, Oster ME, Swan E, Waldron A, Nathan M. Lessons learned in the use of clinical registry data in a multi-centre prospective study: the Pediatric Heart Network Residual Lesion Score Study. Cardiol Young 2019; 29:930-938. [PMID: 31204627 PMCID: PMC6715515 DOI: 10.1017/s1047951119001148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Using existing data from clinical registries to support clinical trials and other prospective studies has the potential to improve research efficiency. However, little has been reported about staff experiences and lessons learned from implementation of this method in pediatric cardiology. OBJECTIVES We describe the process of using existing registry data in the Pediatric Heart Network Residual Lesion Score Study, report stakeholders' perspectives, and provide recommendations to guide future studies using this methodology. METHODS The Residual Lesion Score Study, a 17-site prospective, observational study, piloted the use of existing local surgical registry data (collected for submission to the Society of Thoracic Surgeons-Congenital Heart Surgery Database) to supplement manual data collection. A survey regarding processes and perceptions was administered to study site and data coordinating center staff. RESULTS Survey response rate was 98% (54/55). Overall, 57% perceived that using registry data saved research staff time in the current study, and 74% perceived that it would save time in future studies; 55% noted significant upfront time in developing a methodology for extracting registry data. Survey recommendations included simplifying data extraction processes and tailoring to the needs of the study, understanding registry characteristics to maximise data quality and security, and involving all stakeholders in design and implementation processes. CONCLUSIONS Use of existing registry data was perceived to save time and promote efficiency. Consideration must be given to the upfront investment of time and resources needed. Ongoing efforts focussed on automating and centralising data management may aid in further optimising this methodology for future studies.
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Affiliation(s)
- Carol J. Prospero
- Nemours Cardiac Center, Alfred I. duPont Hospital for
Children, Wilmington, DE USA
| | | | | | - Sara K. Pasquali
- Division of Pediatric Cardiology, Department of Pediatrics,
University of Michigan C.S. Mott Children’s Hospital, Ann Arbor, MI USA
| | - Brett R. Anderson
- Division of Pediatric Cardiology, New York
Presbyterian/Morgan Stanley Children’s Hospital, New York, NY USA
| | - Kathleen E. Ash
- Division of Pediatric Cardiology, Cincinnati
Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Jessica Bainton
- Division of Pediatric Cardiology, The Hospital for Sick
Children, Toronto, ON Canada
| | | | - Eric M. Graham
- Division of Pediatric Cardiology, Medical University of
South Carolina, Charleston, SC USA
| | - Michelle S. Hamstra
- Division of Pediatric Cardiology, Cincinnati
Children’s Hospital Medical Center, Cincinnati, OH USA
| | | | - Jeffrey P. Jacobs
- Department of Surgery, Johns Hopkins All
Children’s Hospital, Saint Petersburg, FL USA
| | - Marshall L. Jacobs
- Division of Cardiac Surgery, Johns Hopkins Heart and
Vascular Institute, Baltimore, MD USA
| | - Rija John
- Division of Congenital Heart Surgery, Texas
Children’s Hospital, Houston, TX USA
| | - Linda M. Lambert
- Division of Pediatric Cardiothoracic Surgery, University
of Utah, Salt Lake City, UT USA
| | - Matthew E. Oster
- Division of Pediatric Cardiology, Emory University School
of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA USA
| | - Elizabeth Swan
- Division of Pediatric Cardiology, Riley Hospital for
Children, Indianapolis, IN USA
| | - Abigail Waldron
- Division of Cardiology,
Children’s Hospital Philadelphia, Philadelphia, PA USA
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children’s
Hospital, Boston, MA USA
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Cooper DS, Riggs KW, Zafar F, Jacobs JP, Hill KD, Pasquali SK, Swanson SK, Gelehrter SK, Wallace A, Jacobs ML, Morales DLS, Bryant R. Cardiac Surgery in Patients With Trisomy 13 and 18: An Analysis of The Society of Thoracic Surgeons Congenital Heart Surgery Database. J Am Heart Assoc 2019; 8:e012349. [PMID: 31237190 PMCID: PMC6662341 DOI: 10.1161/jaha.119.012349] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Congenital heart disease is common in patients with Trisomy 13 (T13) and Trisomy 18 (T18), but offering cardiac surgery to these patients has been controversial. We describe the landscape of surgical management across the United States, perioperative risk factors, and surgical outcomes in patients with T13 and T18. Methods and Results Patients in the Society of Thoracic Surgeons Congenital Heart Surgery Database with T13 and T18 who underwent cardiac surgery (2010-2017) were included. There were 343 operations (T13: n=73 and T18: n=270) performed on 304 patients. Among 125 hospitals, 87 (70%) performed at least 1 operation and 26 centers (30%) performed ≥5 T13/T18 operations. Operations spanned the full spectrum of complexity with 29% (98/343) being in the highest categories of estimated risk. The operative mortality rate was 15%, with a 56% complication rate. Preoperative mechanical ventilation was associated with an odds ratio of mortality >8 for both patients with T13 and T18 (both P<0.012) while presence of a gastrostomy tube (odds ratio, 0.3; P=0.03) or prior cardiac surgery (odds ratio, 0.2; P=0.02) was associated with better survival in patients with T18 but not patients with T13. Conclusions Data from this nationally representative sample indicate that most centers offer surgical intervention for both patients with T13 and T18, even in highly complex patients. However, the overall mortality rate was high in this select patient cohort. The association of preoperative mechanical ventilation with mortality suggests that this subset of patients with T13 and T18 should perhaps not be considered surgical candidates. This information is valuable to clinicians and families for counseling and deciding what interventions to offer.
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Affiliation(s)
- David S Cooper
- 1 Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH.,2 Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
| | - Kyle W Riggs
- 1 Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Farhan Zafar
- 1 Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH.,3 Department of Surgery University of Cincinnati College of Medicine Cincinnati OH
| | - Jeffrey P Jacobs
- 4 Johns Hopkins School of Medicine Baltimore MD.,5 Johns Hopkins All Children's Hospital St. Petersburg FL
| | | | - Sara K Pasquali
- 7 C.S. Mott Children's Hospital University of Michigan Ann Arbor MI
| | - Sara K Swanson
- 8 Brenner Children's Hospital Wake Forest Baptist Medical Center Winston-Salem NC
| | | | | | - Marshall L Jacobs
- 4 Johns Hopkins School of Medicine Baltimore MD.,5 Johns Hopkins All Children's Hospital St. Petersburg FL
| | - David L S Morales
- 1 Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH.,3 Department of Surgery University of Cincinnati College of Medicine Cincinnati OH
| | - Roosevelt Bryant
- 1 Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH.,3 Department of Surgery University of Cincinnati College of Medicine Cincinnati OH
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Quartermain MD, Hill KD, Goldberg DJ, Jacobs JP, Jacobs ML, Pasquali SK, Verghese GR, Wallace AS, Ungerleider RM. Prenatal Diagnosis Influences Preoperative Status in Neonates with Congenital Heart Disease: An Analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database. Pediatr Cardiol 2019; 40:489-496. [PMID: 30341588 DOI: 10.1007/s00246-018-1995-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 09/26/2018] [Indexed: 11/30/2022]
Abstract
The early postnatal course for a newborn with critical congenital heart disease (CHD) can be negatively impacted if diagnosis is delayed. Despite this, there continues to be inconsistent evidence regarding potential benefits associated with prenatal diagnosis (PND) in neonates who undergo cardiac surgery. The objective of this study was to better define the impact of a PND on pre-operative morbidity by utilizing a large clinical database. Neonates (< 30 days) undergoing heart surgery from 2010 to 2014 and entered in the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) were included. Multivariable logistic regression was used to evaluate the association between PND and a composite measure including nine major pre-operative risk factors. Co-variates were included to adjust for important patient characteristics (e.g., weight-for-age z-score, genetic syndromes, prematurity), case complexity, and center effects. Centers and patients with excess missing data for relevant co-variates were excluded. Included were 12,899 neonates undergoing surgery at 112 centers. Major pre-operative risk factors were present in 34% overall. By univariate analysis, PND was associated with a lower overall prevalence of major pre-operative risk factors. After adjusting for potential confounders, major pre-operative risk factors were less prevalent among neonates with PND compared to neonates without PND (adjusted OR 0.62, 95% CI 0.57-0.68, p < 0.001). A sensitivity analysis excluding neonates with genetic syndromes, non-cardiac anatomic abnormalities, and prematurity demonstrated similar findings (adjusted OR 0.55, 95% CI 0.49-0.61, p < 0.0001). Among neonates with CHD, prenatal diagnosis is associated with significantly lower rates of pre-operative risk factors for cardiac surgery. Further studies are needed to define association of these pre-operative benefits of a PND with longer term clinical outcomes.
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Affiliation(s)
- Michael D Quartermain
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA. .,Department of Pediatrics, The Children's Hospital of Philadelphia, 34th Civic Center Blvd. Echo Lab, 3rd Floor Main Bldg, Suite 3NW110, Philadelphia, PA, 19104, USA.
| | - Kevin D Hill
- Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - David J Goldberg
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Jeffrey P Jacobs
- Department of Surgery, All Children's Hospital and Johns Hopkins University, Saint Petersburg, FL, USA
| | - Marshall L Jacobs
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - George R Verghese
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Jacobs JP, Mayer JE, Pasquali SK, Hill KD, Overman DM, St. Louis JD, Kumar SR, Backer CL, Tweddell JS, Dearani JA, Jacobs ML. The Society of Thoracic Surgeons Congenital Heart Surgery Database: 2019 Update on Outcomes and Quality. Ann Thorac Surg 2019; 107:691-704. [DOI: 10.1016/j.athoracsur.2018.12.016] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 12/10/2018] [Indexed: 12/20/2022]
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O'Brien SM, Jacobs JP, Shahian DM, Jacobs ML, Gaynor JW, Romano JC, Gaies MG, Hill KD, Mayer JE, Pasquali SK. Development of a Congenital Heart Surgery Composite Quality Metric: Part 2-Analytic Methods. Ann Thorac Surg 2019; 107:590-596. [PMID: 30227128 PMCID: PMC6559355 DOI: 10.1016/j.athoracsur.2018.07.036] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 06/26/2018] [Accepted: 07/09/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND We describe the statistical methods and results related to development of the first congenital heart surgery composite quality measure. METHODS The composite measure was developed using The Society of Thoracic Surgeons Congenital Heart Surgery Database (2012 to 2015), Bayesian hierarchical modeling, and the current Society of Thoracic Surgeons risk model for case-mix adjustment. It consists of a mortality domain (operative mortality) and morbidity domain (major complications and postoperative length of stay). We evaluated several potential weighting schemes and properties of the final composite measure, including reliability (signal-to-noise ratio) and hospital classification in various performance categories. RESULTS Overall, 100 hospitals (78,425 operations) were included. Each adjusted metric included in the composite varied across hospitals: operative mortality (median, 3.1%; 10th to 90th percentile, 2.1% to 4.4%) major complications (median 11.7%, 10th to 90th percentile, 6.4% to 17.4%), and length of stay (median, 7.0 days; 10th to 90th percentile, 5.9 to 8.2 days). In the final composite weighting scheme selected, mortality had the greatest influence, followed by major complications and length of stay (correlation with overall composite score of 0.87, 0.69, and 0.47, respectively). Reliability of the composite measure was 0.73 compared with 0.59 for mortality alone. The distribution of hospitals across composite measure performance categories (defined by whether the 95% credible interval overlapped The Society of Thoracic Surgeons average) was 75% (same as expected), 9% (worse than expected), and 16% (better than expected). CONCLUSIONS This congenital heart surgery composite measure incorporates aspects of both morbidity and mortality, has clinical face validity, and greater ability to discriminate hospital performance compared with mortality alone. Ongoing efforts will support the use of the composite measure in benchmarking and quality improvement activities.
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Affiliation(s)
- Sean M O'Brien
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Jeffrey P Jacobs
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, St. Petersburg, Florida
| | - David M Shahian
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marshall L Jacobs
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, St. Petersburg, Florida
| | - J William Gaynor
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jennifer C Romano
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Michael G Gaies
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Kevin D Hill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - John E Mayer
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan.
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Welke KF, Pasquali SK, Lin P, Backer CL, Overman DM, Romano JC, Jacobs JP, Karamlou T. Hospital Distribution and Patient Travel Patterns for Congenital Cardiac Surgery in the United States. Ann Thorac Surg 2019; 107:574-581. [DOI: 10.1016/j.athoracsur.2018.07.047] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 07/12/2018] [Accepted: 07/16/2018] [Indexed: 10/28/2022]
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Pasquali SK, Shahian DM, O'Brien SM, Jacobs ML, Gaynor JW, Romano JC, Gaies MG, Hill KD, Mayer JE, Jacobs JP. Development of a Congenital Heart Surgery Composite Quality Metric: Part 1-Conceptual Framework. Ann Thorac Surg 2019; 107:583-589. [PMID: 30227127 PMCID: PMC6441562 DOI: 10.1016/j.athoracsur.2018.07.037] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 06/26/2018] [Accepted: 07/09/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Current pediatric and congenital heart surgery quality measures focus on operative mortality, and numerous stakeholders are interested in more comprehensive measures. This report describes the background, rationale, and conceptual framework related to the development of the first composite quality metric in the field. METHODS A multidisciplinary panel reviewed methodology and framework related to quality measurement and several composite quality measures across adult cardiac surgery and other fields. The panel subsequently developed methodology and selected measures for a congenital heart surgery composite measure and reviewed potential advantages and limitations. Individual measures considered for potential inclusion in the composite were reviewed within the context of Donabedian's triad and the Institute of Medicine quality domains. Decisions were made through group consensus. RESULTS The final composite measure selected is comprised of two domains: (1) a mortality domain (operative mortality) and (2) a morbidity domain (the 6 major complications endorsed by The Society of Thoracic Surgeons and Congenital Heart Surgeons Society plus cardiac arrest, and postoperative length of stay). Potential advantages include the more comprehensive view of quality compared with mortality alone and improvements in discrimination of hospital performance through increasing the number of end points. Potential limitations include the lack of longer term outcomes and challenges related to case-mix adjustment. CONCLUSIONS We have applied and adapted conceptual framework and methodology related to composite quality measures across other fields to congenital heart surgery. The composite quality metric created is inclusive of both morbidity and mortality, and expands our view of quality in this patient 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.
| | - David M Shahian
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sean M O'Brien
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Marshall L Jacobs
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, St. Petersburg, Florida
| | - J William Gaynor
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jennifer C Romano
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Michael G Gaies
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Kevin D Hill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - John E Mayer
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Jeffrey P Jacobs
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, St. Petersburg, Florida
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Bates KE, Mahle WT, Bush L, Donohue J, Gaies MG, Nicolson SC, Shekerdemian L, Witte M, Wolf M, Shea JA, Likosky DS, Pasquali SK. Variation in Implementation and Outcomes of Early Extubation Practices After Infant Cardiac Surgery. Ann Thorac Surg 2018; 107:1434-1440. [PMID: 30557537 DOI: 10.1016/j.athoracsur.2018.11.031] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 10/23/2018] [Accepted: 11/14/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND The Pediatric Heart Network Collaborative Learning Study (PHN CLS) increased early extubation after infant tetralogy of Fallot (TOF) and coarctation repair overall at participating sites through implementing a clinical practice guideline (CPG). We evaluated variability across sites in CPG implementation and outcomes. METHODS Patient characteristics and outcomes (time to extubation, length of stay [LOS]) were compared across sites, including pre-CPB to post-CPG changes. Semistructured interviews were analyzed to assess similarities and differences in implementation strategies across sites. RESULTS A total of 322 patients were included (4 active sites, 1 model site). Patient characteristics were similar across active sites, whereas pre-CPG median time to extubation varied from 15.4 to 35.5 hours. All active sites had a significant post-CPG decline (p < 0.001); however, there was variation in the post-CPG median time to extubation (0.3 to 5.3 hours, p = 0.01) and magnitude of change (-73.3% to -99.2%). Site A achieved the shortest post-CPG time to extubation and had the greatest percentage change. Two sites had significant decreases in medical ICU LOS in TOF patients; no hospital LOS changes were seen. All sites valued the collaborative learning strategy, site visits, CPG flexibility, and had similar core team composition. Site A used several unique strategies: inclusion of other staff and fellows, regular in-person data reviews, additional data collection, and creation of complementary protocols. CONCLUSIONS All PHN CLS sites successfully reduced time to extubation. The magnitude of change varied and may be partly explained by different CPG implementation strategies. These data can guide CPG dissemination and design of future improvement projects.
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Affiliation(s)
- Katherine E Bates
- Department of Pediatrics, Michigan Medicine, 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
| | - Lauren Bush
- Department of Pediatrics, Michigan Medicine, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Janet Donohue
- Department of Pediatrics, Michigan Medicine, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Michael G Gaies
- Department of Pediatrics, Michigan Medicine, C.S. Mott Children's Hospital, 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 Critical Care, Texas Children's Hospital, Houston, Texas
| | - Madolin Witte
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Michael Wolf
- Department of Pediatrics, Children's Healthcare of Atlanta and Emory University, Atlanta, Georgia
| | - Judy A Shea
- Department of Internal Medicine, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Sara K Pasquali
- Department of Pediatrics, Michigan Medicine, C.S. Mott Children's Hospital, Ann Arbor, Michigan
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Kartha VM, Jacobs JP, Vener DF, Hill KD, Goldenberg NA, Pasquali SK, Meza JM, O’Brien SM, Feng L, Chiswell K, Eghtesady P, Badhwar V, Rehman M, Jacobs ML. National Benchmarks for Proportions of Patients Receiving Blood Transfusions During Pediatric and Congenital Heart Surgery: An Analysis of the STS Congenital Heart Surgery Database. Ann Thorac Surg 2018; 106:1197-1203. [DOI: 10.1016/j.athoracsur.2018.04.088] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 03/30/2018] [Accepted: 04/14/2018] [Indexed: 11/30/2022]
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Eckhauser A, Pasquali SK, Ravishankar C, Lambert LM, Newburger JW, Atz AM, Ghanayem N, Schwartz SM, Zhang C, Jacobs JP, Minich LL. Variation in care for infants undergoing the Stage II palliation for hypoplastic left heart syndrome. Cardiol Young 2018; 28:1109-1115. [PMID: 30039776 PMCID: PMC6156925 DOI: 10.1017/s1047951118000999] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The Single Ventricle Reconstruction trial randomised neonates with hypoplastic left heart syndrome to a systemic-to-pulmonary-artery shunt strategy. Patients received care according to usual institutional practice. We analysed practice variation at the Stage II surgery to attempt to identify areas for decreased variation and process control improvement. METHODS Prospectively collected data were available in the Single Ventricle Reconstruction public-use database. Practice variation across 14 centres was described for 397 patients who underwent Stage II surgery. Data are centre-level specific and reported as interquartile ranges across all centres, unless otherwise specified. RESULTS Preoperative Stage II median age and weight across centres were 5.4 months (interquartile range 4.9-5.7) and 5.7 kg (5.5-6.1), with 70% performed electively. Most patients had pre-Stage-II cardiac catheterisation (98.5-100%). Digoxin was used by 11/14 centres in 25% of patients (23-31%), and 81% had some oral feeds (68-84%). The majority of the centres (86%) performed a bidirectional Glenn versus hemi-Fontan. Median cardiopulmonary bypass time was 96 minutes (75-113). In aggregate, 26% of patients had deep hypothermic circulatory arrest >10 minutes. In 13/14 centres using deep hypothermic circulatory arrest, 12.5% of patients exceeded 10 minutes (8-32%). Seven centres extubated 5% of patients (2-40) in the operating room. Postoperatively, ICU length of stay was 4.8 days (4.0-5.3) and total length of stay was 7.5 days (6-10). CONCLUSIONS In the Single Ventricle Reconstruction Trial, practice varied widely among centres for nearly all perioperative factors surrounding Stage II. Further analysis may facilitate establishing best practices by identifying the impact of practice variation.
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Affiliation(s)
- Aaron Eckhauser
- 1Department of Surgery,Division of Cardiothoracic Surgery,Section of Pediatric Cardiothoracic Surgery,University of Utah,Primary Children's Hospital,Salt Lake City,UT,USA
| | - Sara K Pasquali
- 2Department of Pediatrics,Division of Pediatric Cardiology,University of Michigan,C.S. Mott Children's Hospital,Ann Arbor,MI,USA
| | - Chitra Ravishankar
- 3Department of Pediatrics,Division of Pediatric Cardiology,Children's Hospital of Philadelphia,Philadelphia,PA,USA
| | - Linda M Lambert
- 1Department of Surgery,Division of Cardiothoracic Surgery,Section of Pediatric Cardiothoracic Surgery,University of Utah,Primary Children's Hospital,Salt Lake City,UT,USA
| | - Jane W Newburger
- 4Department of Cardiology,Boston Children's Hospital,Boston,MA,USA
| | - Andrew M Atz
- 6Department of Pediatrics,Division of Cardiology,Medical University of South Carolina,Charleston,SC,USA
| | - Nancy Ghanayem
- 7Department of Pediatrics,Division of Pediatric Critical Care,Baylor College of Medicine,Texas Children's Hospital,Houston,TX,USA
| | - Steven M Schwartz
- 8Departments of Critical Care Medicine and Paediatrics,Divisions of Cardiac Critical Care Medicine and Cardiology,University of Toronto,The Hospital for Sick Children,Toronto,CA,USA
| | - Chong Zhang
- 9Division of Epidemiology,University of Utah,Salt Lake City,UT,USA
| | - Jeffery P Jacobs
- 10Department of Surgery,Division of Cardiovascular Surgery,John's Hopkins University,Johns Hopkins All Children's Hospital,St. Petersburg,FL,USA
| | - L LuAnn Minich
- 1Department of Surgery,Division of Cardiothoracic Surgery,Section of Pediatric Cardiothoracic Surgery,University of Utah,Primary Children's Hospital,Salt Lake City,UT,USA
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Holst KA, Dearani JA, Said SM, Davies RR, Pizarro C, Knott-Craig C, Kumar TS, Starnes VA, Kumar SR, Pasquali SK, Thibault DP, Meza JM, Hill KD, Chiswell K, Jacobs JP, Jacobs ML. Surgical Management and Outcomes of Ebstein Anomaly in Neonates and Infants: A Society of Thoracic Surgeons Congenital Heart Surgery Database Analysis. Ann Thorac Surg 2018; 106:785-791. [DOI: 10.1016/j.athoracsur.2018.04.049] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/11/2018] [Accepted: 04/18/2018] [Indexed: 11/27/2022]
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Jacobs ML, Jacobs JP, Hill KD, O’Brien SM, Pasquali SK, Vener D, Kumar SR, Chiswell K, Habib RH, Shahian DM, Fernandez FG. The Society of Thoracic Surgeons Congenital Heart Surgery Database: 2018 Update on Research. Ann Thorac Surg 2018; 106:654-663. [DOI: 10.1016/j.athoracsur.2018.06.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 06/24/2018] [Indexed: 12/27/2022]
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