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Consensus-based method for risk adjustment for surgery for congenital heart disease
Kathy J Jenkins1, Kimberlee Gauvreau, Jane W Newburger
1Department of Cardiology, Children's Hospital, Boston, MA 02115, USA. jenkins@cardio.tch.harvard.edu
Insights
A new risk adjustment method, RACHS-1 (Risk Adjustment for Congenital Heart Surgery), was developed for pediatric cardiac surgery patients. This consensus-based approach effectively categorizes surgical procedures to predict in-hospital mortality in children with congenital heart disease.
Area of Science:
- Pediatric Cardiology
- Cardiac Surgery
- Health Services Research
Background:
- In-hospital mortality after congenital heart surgery varies significantly among pediatric patients.
- Accurate risk adjustment is crucial for comparing outcomes and improving care quality.
- Existing methods may not adequately capture the complexity of congenital heart disease surgery.
Framework:
- The Risk Adjustment for Congenital Heart Surgery (RACHS-1) method was developed using a consensus-based approach.
- An 11-member expert panel categorized surgical procedures into six distinct risk strata.
- The framework was refined using data from the Pediatric Cardiac Care Consortium and state hospital discharge datasets.
Implementation:
- The RACHS-1 method was applied to over 9,000 pediatric surgical cases.
- The system successfully assigned 89-98% of cases to one of the six defined risk categories.
- Mortality rates demonstrated a clear increasing trend across the RACHS-1 categories (e.g., 0.4% in category 1 to 47.7% in category 6).
Implications:
- The RACHS-1 method provides a standardized tool for risk adjustment in pediatric congenital heart surgery.
- It enables more meaningful comparisons of in-hospital mortality rates across different institutions and patient groups.
- The study identified younger age, prematurity, and noncardiac anomalies as additional risk factors beyond surgical category.
Objective:
The aim was to develop a consensus-based method of risk adjustment for in-hospital mortality among children younger than 18 years after surgery for congenital heart disease (designated RACHS-1).
Methods:
An 11-member national panel of pediatric cardiologists and cardiac surgeons used clinical judgment to place surgical procedures into six risk categories. Categories were refined after review of information from the Pediatric Cardiac Care Consortium and three statewide hospital discharge data sets. The effects of including additional clinical variables were explored by comparing areas under receiver-operator characteristic curves.
Results:
Among 4602 surgical patients in the Pediatric Cardiac Care Consortium data set and 4493 in the hospital discharge data, 3767 (81.9%) and 3832 (85.3%), respectively, had a single cardiac procedure, and 98.5% and 89.2%, respectively, were able to be assigned to one of six risk categories defined by the panel. Mortality rates showed expected trends (P <.001). For the Pediatric Cardiac Care Consortium data, mortality rates were 0.4% in category 1, 3.8% in 2, 8.5% in 3, 19.4% in 4, and 47.7% in 6; rates were similar in the hospital discharge data. There were too few cases in category 5 to estimate mortality rates. In multivariable models, younger age, prematurity, and the presence of a major noncardiac structural anomaly added to the risk of in-hospital death predicted by risk category alone. Best performance was obtained when cases with multiple procedures were placed in the risk category of the most complex procedure.
Conclusion:
The RACHS-1 method should adjust for baseline risk differences and allow meaningful comparisons of in-hospital mortality for groups of children undergoing surgery for congenital heart disease.