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Impact of Confounding on Cost, Survival, and Length-of-Stay Outcomes for Neonates with Hypoplastic Left Heart Syndrome Undergoing Stage 1 Palliation Surgery

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Abstract

The objective of this analysis was to update trends in LOS and costs by survivorship and ECMO use among neonates with hypoplastic left heart syndrome (HLHS) undergoing stage 1 palliation surgery using 2016 data from the Healthcare Cost and Utilization Project Kids’ Inpatient Database. We identified neonates ≤ 28 days old with HLHS undergoing Stage 1 surgery, defined as a Norwood procedure with modified Blalock–Taussig (BT) shunt, Sano modification, or both. Multivariable regression with year random effects was used to compare LOS and costs by hospital region, case volume, survivorship, and ECMO vs. no ECMO. An E-value analysis, an approach for conducting sensitivity analysis for unmeasured confounding, was performed to determine if unmeasured confounding contributed to the observed effects. Significant differences in total costs, LOS, and mortality were noted by hospital region, ECMO use, and sub-analyses of case volume. However, other than ECMO use and mortality, the maximum E-value confidence interval bound was 1.71, suggesting that these differences would disappear with an unmeasured confounder 1.71 times more associated with both the outcome and exposure (e.g., socioeconomic factors, environment, etc.) Our findings confirm previous literature demonstrating significant resource utilization among Norwood patients, particularly those undergoing ECMO use. Based on our E-value analysis, differences by hospital region and case volume can be explained by moderate unobserved confounding, rather than a reflection of the quality of care provided. Future analyses on surgical quality must account for unobserved factors to provide meaningful information for quality improvement.

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Acknowledgements

CLG conceived the study design and analysis and wrote the manuscript. AYS performed all statistical analyses. RH, AL, PSF, LY, JDP, RKS, and RW each provided input on additional statistical analyses and critical editorial feedback on the manuscript.

Funding

This work is supported by the Teresa and Byron Pollitt Family Chair in Fetal & Neonatal Medicine at Children’s Hospital Los Angeles (Los Angeles/CA/USA). Dr. Lakshmanan is supported by grant KL2TR001854 from the National Center for Advancing Translational Science (NCATS) of the U.S. National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Authors and Affiliations

  1. Division of Neonatology, Department of Pediatrics, Fetal & Neonatal Institute, Children’s Hospital Los Angeles, 4650 Sunset Boulevard, MS #31, Los Angeles, CA, 90027, USA

    Cynthia L. Gong, Ashley Y. Song, Philippe S. Friedlich, Ashwini Lakshmanan & Leah Yieh

  2. Leonard D. Schaeffer Center for Health Policy and Economics, School of Pharmacy, Los Angeles, USA

    Cynthia L. Gong, Ashwini Lakshmanan & Leah Yieh

  3. Keck School of Medicine, University of Southern California, Los Angeles, CA, 90027, USA

    Cynthia L. Gong, Robin Horak, Philippe S. Friedlich, Ashwini Lakshmanan, Jay D. Pruetz, Leah Yieh, S. Ram Kumar & Roberta G. Williams

  4. Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, USA

    Ashley Y. Song & Ashwini Lakshmanan

  5. Department of Anesthesia and Critical Care, Children’s Hospital Los Angeles, Los Angeles, USA

    Robin Horak

  6. Division of Cardiology, Department of Pediatrics, Heart Institute, Children’s Hospital Los Angeles, Los Angeles, USA

    Jay D. Pruetz & Roberta G. Williams

  7. Division of Cardiothoracic Surgery, Department of Surgery, Heart Institute, Children’s Hospital Los Angeles, Los Angeles, USA

    S. Ram Kumar

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  1. Cynthia L. Gong
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Correspondence to Cynthia L. Gong.

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Gong, C.L., Song, A.Y., Horak, R. et al. Impact of Confounding on Cost, Survival, and Length-of-Stay Outcomes for Neonates with Hypoplastic Left Heart Syndrome Undergoing Stage 1 Palliation Surgery. Pediatr Cardiol 41, 996–1011 (2020). https://doi.org/10.1007/s00246-020-02348-5

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