Skip to main content

Advertisement

SpringerLink
Log in

Surgical Volume-to-Outcome Relationship and Monitoring of Technical Performance in Pediatric Cardiac Surgery

  • Review Article
  • Published:
Pediatric Cardiology Aims and scope Submit manuscript

Abstract

A significant inverse relationship of surgical institutional and surgeon volumes to outcome has been demonstrated in many high-stakes surgical specialties. By and large, the same results were found in pediatric cardiac surgery, for which a more thorough analysis has shown that this relationship depends on case complexity and type of surgical procedures. Lower-volume programs tend to underperform larger-volume programs as case complexity increases. High-volume pediatric cardiac surgeons also tend to have better results than low-volume surgeons, especially at the more complex end of the surgery spectrum (e.g., the Norwood procedure). Nevertheless, this trend for lower mortality rates at larger centers is not universal. All larger programs do not perform better than all smaller programs. Moreover, surgical volume seems to account for only a small proportion of the overall between-center variation in outcome. Intraoperative technical performance is one of the most important parts, if not the most important part, of the therapeutic process and a critical component of postoperative outcome. Thus, the use of center-specific, risk-adjusted outcome as a tool for quality assessment together with monitoring of technical performance using a specific score may be more reliable than relying on volume alone. However, the relationship between surgical volume and outcome in pediatric cardiac surgery is strong enough that it ought to support adapted and well-balanced health care strategies that take advantage of the positive influence that higher center and surgeon volumes have on outcome.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. American Academy of Pediatrics (2002) Section on Cardiology and Cardiac Surgery. Guidelines for pediatric cardiovascular centers. Pediatrics 109:544–549

    Article  Google Scholar 

  2. Bacha EA (2007) Patient safety and human factors in pediatric cardiac surgery. Pediatr Cardiol 28:116–121

    Article  PubMed  Google Scholar 

  3. Bacha E (2012) Invited commentary. Ann Thorac Surg 93:1998

    Article  PubMed  Google Scholar 

  4. Bazzani LG, Marcin JP (2007) Case volume and mortality in pediatric cardiac surgery patients in California, 1998–2003. Circulation 115:2652–2659

    Article  PubMed  Google Scholar 

  5. Birkmeyer JD, Stukel TA, Siewers AE et al (2003) Surgeon volume and operative mortality in the United States. N Engl J Med 349:2117–2127

    Article  CAS  PubMed  Google Scholar 

  6. Chang RK, Klitzner TS (2002) Can regionalization decrease the number of deaths for children who undergo cardiac surgery? A theoretical analysis. Pediatrics 109:173–181

    Article  PubMed  Google Scholar 

  7. Checchia PA, McCollegan J, Daher N et al (2005) The effect of surgical case volume on outcome after the Norwood procedure. J Thorac Cardiovasc Surg 129:754–759

    Article  PubMed  Google Scholar 

  8. Dudley RA, Johansen KL, Brand R et al (2000) Selective referral to high-volume hospitals: estimating potentially avoidable deaths. JAMA 283:1159–1166

    Article  CAS  PubMed  Google Scholar 

  9. Gauvreau K (2007) Reevaluation of the volume–outcome relationship for pediatric cardiac surgery. Circulation 115:2599–2601

    Article  PubMed  Google Scholar 

  10. Halm EA, Lee C, Chassin MR (2002) Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann Intern Med 137:511–520

    Article  PubMed  Google Scholar 

  11. Hannan EL, Siu AL, Kumar D et al (1995) The decline in coronary artery bypass graft surgery mortality in New York State: the role of surgeon volume. JAMA 273:209–213

    Article  CAS  PubMed  Google Scholar 

  12. Hannan EL, Racz M, Kavey RE et al (1998) Pediatric cardiac surgery: the effect of hospital and surgeon volume on in-hospital mortality. Pediatrics 101:963–969

    Article  CAS  PubMed  Google Scholar 

  13. Hirsch JC, Gurney JG, Donohue JE et al (2008) Hospital mortality for Norwood and arterial switch operations as a function of institutional volume. Pediatr Cardiol 29:713–717

    Article  PubMed  Google Scholar 

  14. Ho V (2000) Evolution of the volume–outcome relation for hospitals performing coronary angioplasty. Circulation 101:1806–1811

    Article  CAS  PubMed  Google Scholar 

  15. Hornik CP, He X, Jacobs JP et al (2012) Relative impact of surgeon and center volume on early mortality after the Norwood operation. Ann Thorac Surg 93:1992–1997

    Article  PubMed Central  PubMed  Google Scholar 

  16. Jenkins KJ, Newburger JW, Lock JE et al (1995) In-hospital mortality for surgical repair of congenital heart defects: preliminary observations of variation by hospital caseload. Pediatrics 95:323–330

    CAS  PubMed  Google Scholar 

  17. Kang N, Tsang VT, Gallivan S et al (2006) Quality assurance in congenital heart surgery. Eur J Cardiothorac Surg 29:693–697

    Article  PubMed  Google Scholar 

  18. Karamichalis JM, Thiagarajan RR, Liu H et al (2010) Stage I Norwood: optimal technical performance improves outcomes irrespective of preoperative physiologic status or case complexity. J Thorac Cardiovasc Surg 139:962–968

    Article  PubMed  Google Scholar 

  19. Karamlou T, McCrindle BW, Blackstone EH et al (2010) Lesion-specific outcomes in neonates undergoing congenital heart surgery are related predominantly to patient and management factors rather than institution or surgeon experience: a Congenital Heart Surgeons Society Study. J Thorac Cardiovasc Surg 139:569–577

    Article  PubMed  Google Scholar 

  20. Khuri SF, Henderson WG (2005) The case against volume as a measure of quality of surgical care. World J Surg 29:1222–1229

    Article  PubMed  Google Scholar 

  21. Kilic A, Weiss ES, Yuh DD et al (2012) Institutional factors beyond procedural volume significantly impact center variability in outcomes after orthotopic heart transplantation. Ann Surg 256:616–623

    Article  PubMed  Google Scholar 

  22. Larrazabal LA, del Nido PJ, Jenkins KJ et al (2007) Measurement of technical performance in congenital heart surgery: a pilot study. Ann Thorac Surg 83:179–184

    Article  PubMed  Google Scholar 

  23. Likosky DS, Nugent WC, Ross CS et al (2005) Improving outcomes of cardiac surgery through cooperative efforts: the northern New England experience. Semin Cardiothorac Vasc Anesth 9:119–121

    Article  PubMed  Google Scholar 

  24. Lundstrom NR, Berggren H, Bjorkhem G et al (2000) Centralization of pediatric heart surgery in Sweden. Pediatr Cardiol 21:353–357

    Article  CAS  PubMed  Google Scholar 

  25. Mainwaring RD, Reddy VM, Reinhartz O et al (2008) Outcome analysis for a small, start-up congenital heart surgery program. J Card Surg 23:622–626

    Article  PubMed  Google Scholar 

  26. McPhee JT, Robinson WP 3rd, Eslami MH et al (2011) Surgeon case volume, not institution case volume, is the primary determinant of in-hospital mortality after elective open abdominal aortic aneurysm repair. J Vasc Surg 53:591–599

    Article  PubMed  Google Scholar 

  27. Mosca RS (2012) Invited commentary. Ann Thorac Surg 93:1562

    Article  PubMed  Google Scholar 

  28. Nathan M, Karamichalis JM, Liu H et al (2012) Surgical technical performance scores are predictors of late mortality and unplanned reinterventions in infants after cardiac surgery. J Thorac Cardiovasc Surg 144:1095–1101

    Article  PubMed  Google Scholar 

  29. Oster ME, Strickland MJ, Mahle WT (2011) Impact of prior hospital mortality versus surgical volume on mortality following surgery for congenital heart disease. J Thorac Cardiovasc Surg 142:882–886

    Article  PubMed  Google Scholar 

  30. 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

    Article  PubMed Central  PubMed  Google Scholar 

  31. Pasquali SK, Jacobs JP, He X et al (2012) The complex relationship between center volume and outcome in patients undergoing the Norwood operation. Ann Thorac Surg 93:1556–1562

    Article  PubMed Central  PubMed  Google Scholar 

  32. Prager RL, Armenti FR, Bassett JS et al (2009) Cardiac surgeons and the quality movement: the Michigan experience. Semin Thorac Cardiovasc Surg 21:20–27

    Article  PubMed  Google Scholar 

  33. Shahian DM, Normand SL (2003) The volume–outcome relationship: from Luft to leapfrog. Ann Thorac Surg 75:1048–1058

    Article  PubMed  Google Scholar 

  34. Shuhaiber J, Gauvreau K, Thiagarjan R et al (2012) Congenital heart surgeon’s technical proficiency affects neonatal hospital survival. J Thorac Cardiovasc Surg 144:1119–1124

    Article  PubMed  Google Scholar 

  35. Smith PC, Powell KR (2002) Can regionalization decrease the number of deaths for children who undergo cardiac surgery? A theoretical analysis. Pediatrics 110:849–850

    Article  PubMed  Google Scholar 

  36. Sollano JA, Gelijns AC, Moskowitz AJ et al (1999) Volume–outcome relationships in cardiovascular operations: New York State, 1990–1995. J Thorac Cardiovasc Surg 117:419–428

    Article  CAS  PubMed  Google Scholar 

  37. Srinivasan C, Sachdeva R, Morrow WR et al (2009) Standardized management improves outcomes after the Norwood procedure. Congenit Heart Dis 4:329–337

    Article  PubMed  Google Scholar 

  38. Stark JF, Gallivan S, Davis K et al (2001) Assessment of mortality rates for congenital heart defects and surgeons’ performance. Ann Thorac Surg 72:169–174

    Article  CAS  PubMed  Google Scholar 

  39. Tweddell JS, Sleeper LA, Ohye RG et al (2012) Intermediate-term mortality and cardiac transplantation in infants with single-ventricle lesions: risk factors and their interaction with shunt type. J Thorac Cardiovasc Surg 144:152–159

    Article  PubMed Central  PubMed  Google Scholar 

  40. Vinocur JM, Menk JS, 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

    Article  PubMed Central  PubMed  Google Scholar 

  41. Welke KF, Jacobs JP, Jenkins KJ (2005) Evaluation of quality of care for congenital heart disease. Semin Thorac Cardiovasc Surg 8:157–167

    Article  Google Scholar 

  42. Welke KF, Peterson ED, Vaughan-Sarrazin MS et al (2007) Comparison of cardiac surgery volumes and mortality rates between the Society of Thoracic Surgeons and Medicare databases from 1993 through 2001. Ann Thorac Surg 84:1538–1546

    Article  PubMed  Google Scholar 

  43. Welke KF, Diggs BS, Karamlou T et al (2008) The relationship between hospital surgical case volumes and mortality rates in pediatric cardiac surgery: a national sample, 1988–2005. Ann Thorac Surg 86:889–896

    Article  PubMed  Google Scholar 

  44. 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

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Pediatric Cardiac Surgery, Columbia University Medical Center, Morgan Stanley Children’s Hospital of New York-Presbyterian, 3959 Broadway, New York, NY, 10032, USA

    David Kalfa, Paul Chai & Emile Bacha

Authors
  1. David Kalfa
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Paul Chai
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Emile Bacha
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to David Kalfa.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kalfa, D., Chai, P. & Bacha, E. Surgical Volume-to-Outcome Relationship and Monitoring of Technical Performance in Pediatric Cardiac Surgery. Pediatr Cardiol 35, 899–905 (2014). https://doi.org/10.1007/s00246-014-0938-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00246-014-0938-y

Keywords

Search

Navigation