Abstract
Surgical treatment of congenital heart disease represents a major cause of pediatric hospitalization and healthcare resource use. Larger centers may provide more efficient care with resulting shorter length of postoperative hospitalization (LOH). Data from 46 centers over 25 years were used to evaluate whether surgical volume was an important determinant of LOH using a competing risk regression strategy that concurrently accounted for deaths, transfers, and discharges with some time interactions. Earlier discharge was more likely for infants and older children compared to neonates [subhazard ratios at postoperative day 6 of 1.64 (99 % confidence interval (CI) 1.57, 1.72) and 2.67 (99 % CI 2.53, 2.80), respectively], but less likely for patients undergoing operations in Risk Adjustment for Congenital Heart Surgery categories 2, 3, 4, and 5/6 compared to category 1 [subhazard ratios at postoperative day 6 of 0.66 (99 % CI 0.64, 0.68), 0.34 (95 % CI 0.33, 0.35), 0.28 (99 % CI 0.27, 0.30), and 0.10 (99 % CI 0.09, 0.11), respectively]. There was no difference by sex [non-time-dependent subhazard ratio 1.019 (99 % CI 0.995, 1.040)]. For every 100-operation increase in center annual surgical volume, the non-time-dependent subhazard for discharge was 1.035 (99 % CI 1.006, 1.064) times greater, and center-specific exponentiated random effects ranged from 0.70 to 1.42 with a variance of 0.023. The conditional discharge rate increased with increasing age and later era. No sex-specific difference was found. Centers performing more operations discharged patients sooner than lower volume centers, but this difference appears to be too small to be of clinical significance. Interestingly, unmeasured institutional characteristics estimated by the center random effects were variable, suggesting that these played an important role in LOH and merit further investigation.
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References
Alghamdi AA, Singh SK, Hamilton BCS et al (2010) Early extubation after pediatric cardiac surgery: systematic review, meta-analysis, and evidence-based recommendations. J Card Surg 25:586–595. doi:10.1111/j.1540-8191.2010.01088.x
Boulet S, Grosse S, Riehle-Colarusso T, Correa-Villasenor A (2010) Health care costs of congenital heart defects. In: Congenital heart defects: from origin to treatment, New York, pp 493–501
Burstein DS, Jacobs JP, Li JS et al (2011) Care models and associated outcomes in congenital heart surgery. Pediatrics 127:e1482–e1489. doi:10.1542/peds.2010-2796
Centers for Disease Control (2013) Congenital heart defects. http://www.cdc.gov/ncbddd/heartdefects/
Costello JM, Morrow DF, Graham DA et al (2008) Systematic intervention to reduce central line–associated bloodstream infection rates in a pediatric cardiac intensive care unit. Pediatrics 121:915–923. doi:10.1542/peds.2007-1577
DiBardino DJ, Pasquali SK, Hirsch JC et al (2015) Effect of sex and race on outcome in patients undergoing congenital heart surgery: an analysis of the society of thoracic surgeons congenital heart surgery database. Ann Thorac Surg 94:2054–2060. doi:10.1016/j.athoracsur.2012.05.124
Fine JP, Gray RJ (1999) A proportional hazards model for the subdistribution of a competing risk. J Am Stat Assoc 94:496–509. doi:10.2307/2670170
Grambsch PM, Therneau TM (1994) Proportional hazard tests and diagnostics based on weighted residuals. Biometrika 81:515–526
Hoffman JIE, Kaplan S (2002) The incidence of congenital heart disease. J Am Coll Cardiol 39:1890–1900
Hoffman JIE, Kaplan S, Liberthson RR (2004) Prevalence of congenital heart disease. Am Heart J 147:425–439
Howard F, Brown KL, Garside V et al (2010) Fast-track paediatric cardiac surgery: the feasibility and benefits of a protocol for uncomplicated cases. Eur J Cardiothoracic Surg 37:193–196. doi:10.1016/j.ejcts.2009.06.039
Jenkins KJ, Gauvreau K, Newburger JW et al (2002) Consensus-based method for risk adjustment for surgery for congenital heart disease. J Thorac Cardiovasc Surg 123:110–118. doi:10.1067/mtc.2002.119064
Johnson JN, Jaggers J, Li S et al (2010) Center variation and outcomes associated with delayed sternal closure after stage 1 palliation for hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 139:1205–1210. doi:10.1016/j.jtcvs.2009.11.029
Katsahian S, Boudreau C (2011) Estimating and testing for center effects in competing risks. Stat Med 30:1608–1617. doi:10.1002/sim.4132
Kochilas L, Vinocur J, Menk J (2014) Age-dependent sex effects on outcomes after pediatric cardiac surgery. J Am Heart Assoc 3:e000608. doi:10.1161/JAHA.113.000608
Lau B, Cole SR, Gange SJ (2009) Competing risk regression models for epidemiologic data. Am J Epidemiol 170:244–256. doi:10.1093/aje/kwp107
Newburger J, Wypij D, Bellinger D et al (2003) Length of stay after infant heart surgery is related to cognitive outcome at age 8 years. J Pediatr 143:67–73
O’Brien SM, Clarke DR, Jacobs JP et al (2009) An empirically based tool for analyzing mortality associated with congenital heart surgery. J Thorac Cardiovasc Surg 138:1139–1153. doi:10.1016/j.jtcvs.2009.03.071
Pasquali SK, Li JS, Burstein DS et al (2012) Association of center volume with mortality and complications in pediatric heart surgery. Pediatrics 129:e370–e376. doi:10.1542/peds.2011-1188
Pasquali S, He X, Jacobs M et al (2014) Excess costs associated with complications and prolonged length of stay after congenital heart surgery. Ann Thorac Surg 98:1660–1666. doi:10.1016/j.athoracsur.2014.06.032
Reller MD, Strickland MJ, Mahle WT et al (2008) Prevalence of congenital heart defects in metropolitan Atlanta, 1998–2005. J Pediatr 153:807–813
Russo CA, Elixhauser A (2007) Hospitalizations for birth defects, 2004. HCUP Statistical Brief #24. U.S. Agency for Healthcare Research and Quality, Rockville, MD
R Core Team (2013) R: a language and environment for statistical computing. R Foundation for Statistical Computing, Vienna. http://www.R-project.org/
SAS Institute (2011) The SAS system, release 9.3
Thomas J, Guire K, Horvat G (1997) Is patient length of stay related to quality of care? Hosp Health Serv Adm 42:489–507
Vinocur JM, Moller JH, Kochilas LK (2012) Putting the Pediatric Cardiac Care Consortium in context: evaluation of scope and case mix compared with other reported surgical datasets. Circ Cardiovasc Qual Outcomes 5:577–579. doi:10.1161/CIRCOUTCOMES.111.964841
Vinocur J, Menk J, Connett J et al (2013) Surgical volume and center effects on early mortality after pediatric cardiac surgery: 25-year North American experience from a multi-institutional registry. Pediatr Cardiol 34:1226–1236. doi:10.1007/s00246-013-0633-4
Welke KF, O’Brien SM, Peterson ED et al (2009) The complex relationship between pediatric cardiac surgical case volumes and mortality rates in a national clinical database. J Thorac Cardiovasc Surg 137:1133–1140. doi:10.1016/j.jtcvs.2008.12.012
Wilkinson K, Brunskill S, Doree C et al (2014) Red cell transfusion management for patients undergoing cardiac surgery for congenital heart disease. Cochrane Database Syst Rev. doi:10.1002/14651858.CD009752.pub2
Yang Q, Chen H, Correa A et al (2006) Racial differences in infant mortality attributable to birth defects in the United States 1989 to 2002. Birth Defects Res A Clin Mol Teratol 76:706–713. doi:10.1002/bdra.20308
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We thank the program directors and data collection coordinators from the participating PCCC centers; without their effort and dedication, this work could not have been completed.
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None of the authors has any conflict of interest. L. Kochilas is supported by NIH/NHLBI (R01 HL122392-01). B. J. S. al-Haddad was supported by NIH MSTP grant T32 GM008244. J. Menk is supported by the NIH Clinical and Translational Science Award at the University of Minnesota: 8 UL1 TR000114-02. The following statement is required for all projects using resources from the University of Minnesota Clinical and Translational Science Institute (CTSI): This publication was supported by Grant Number 1 UL1 RR033183 from the National Center for Research Resources (NCRR) and by Grant Number 8 UL1 TR000114-02 from the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH) to the University of Minnesota CTSI. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CTSI or the NIH. The University of Minnesota CTSI is part of a national Clinical and Translational Science Award (CTSA) consortium created to accelerate laboratory discoveries into treatments for patients.
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al-Haddad, B.J.S., Menk, J.S., Kochilas, L. et al. Factors Affecting Length of Postoperative Hospitalization for Pediatric Cardiac Operations in a Large North American Registry (1982–2007). Pediatr Cardiol 37, 884–891 (2016). https://doi.org/10.1007/s00246-016-1364-0
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DOI: https://doi.org/10.1007/s00246-016-1364-0