In-Hospital Mortality for Surgical Repair of Congenital Heart Defects: Preliminary Observations of Variation by Hospital Caseload
1 Department of Cardiology, Children's Hospital; Department of Pediatrics, Harvard Medical School
2 Division of General Medicine and Primary Care, Department of Medicine, Harvard Medical School, Beth Israel Hospital, the Charles A. Dana Research Institute, and the Harvard-Thorndike Laboratory
3 Boston University School of Public Health
Objective. To examine the impact of hospital caseload on in-hospital mortality for pediatric congenital heart surgery.
Design. Population-based, retrospective cohort study.
Setting. Acute care hospitals in California and Massachusetts.
Patients. Children undergoing surgery for congenital heart disease, identified by the presence of procedure codes indicating surgical repair of a congenital heart defect in computerized statewide hospital discharge abstract databases. Cases were grouped into four categories based on the complexity of the procedure.
Main outcome measures. Adjusted odds ratios (OR) for in-hospital death were estimated using generalized estimating equations that account for the intra-institutional correlation among patients.
Results. A total of 2833 cases at 37 centers were identified. Compared with centers performing >300 cases per year, after controlling for patient characteristics, centers performing <10 cases per year had an OR for in-hospital death of 7.7 (95% confidence interval (CI) [1.6-37.8]); 10 to 100 cases, OR = 2.9 (95% CI [1.6-5.3]); 101 to 300 cases, OR = 3.0 (95% CI [1.8-4.9]). Independent risk factors for mortality included procedure complexity category (P < .0001), use of cardiopulmonary bypass (P < .0001), young age at surgery (P = .001), and transfer from another acute care hospital (P < .0001). Few differences were found by hospital caseload in length of stay or total hospital charges.
Conclusions. For children with a congenital heart defect who underwent surgery in California in 1988 or Massachusetts in 1989, the risk of dying in-hospital was much lower if the surgery was performed at an institution performing >300 cases annually. This study was limited by the absence of clinical detail in discharge abstract databases. If these findings are corroborated by other studies, health care delivery strategies that direct children requiring surgical correction of congenital heart defects to high-volume centers may substantially reduce overall mortality.
Submitted on August 24, 1994Accepted on December 29, 1994
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