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Evidence-based referral results in significantly reduced mortality after congenital heart surgery
Steven W Allen1, Kimberlee Gauvreau, Barry T Bloom
1Pediatric Cardiology, Wichita Clinic, Wichita, Kansas 67208, USA. allensamk@aol.com
Insights
Referring patients from a small pediatric cardiac center to high-volume centers significantly reduced mortality after congenital heart surgery. This evidence-based referral strategy improved patient outcomes by leveraging specialized expertise.
Area of Science:
- Pediatric Cardiology
- Cardiac Surgery Outcomes
- Healthcare Quality Improvement
Background:
- Interinstitutional variation in mortality rates following congenital heart surgery is a documented concern.
- Higher surgical case volumes are associated with reduced mortality.
- A small Midwestern pediatric cardiology practice aimed to improve outcomes by referring patients to high-volume centers.
Purpose of the Study:
- To evaluate the impact of an evidence-based referral strategy on mortality rates for congenital heart surgery.
- To assess the effectiveness of referring patients from a low-volume center to high-volume surgical centers.
- To determine if selective referral based on published mortality rates improves patient outcomes.
Main Methods:
- Retrospective cohort study of pediatric patients (<18 years) undergoing congenital heart surgery over a 10-year period (August 1992-July 2002).
- Data divided into three 3-year periods, with the final period (August 1998-July 2002) reflecting the implementation of evidence-based referrals.
- Risk adjustment using the Risk Adjustment in Congenital Heart Surgery-1 method to compare in-hospital mortality, controlling for case-mix differences.
Main Results:
- A total of 514 cases were analyzed, with 507 assigned to a risk category.
- Unadjusted in-hospital mortality rates decreased from 9.3% (period 1) to 1.3% (period 3).
- Risk-adjusted mortality in period 3 was significantly superior to benchmark data (odds ratio = 0.24), indicating improved outcomes.
Conclusions:
- Evidence-based referrals from a small-volume pediatric cardiac center to high-volume institutions demonstrably reduced mortality.
- This strategy represents an effective approach to improving outcomes in congenital heart surgery for smaller practices.
- Selective referral practices can enhance patient safety and surgical success rates.
Objective:
Significant interinstitutional variation in mortality after congenital heart surgery has been demonstrated. Noting an association between reduced mortality and higher volume, a center with a small annual case volume began in August 1998 to selectively refer to high-volume surgical centers based on published or "apparent" low mortality rates for specific cardiac lesions. This study was undertaken to evaluate the effect of evidence-based referral in this practice.
Design, Setting, And Participants:
A retrospective cohort comparison over a 10-year period for a small Midwestern pediatric cardiology practice. The institutional database was retrospectively reviewed for children (<18 years) undergoing surgery from August 1992 to July 2002. Data were divided into 3 time periods (August 1992 to July 1995, period 1; August 1995 to July 1998, period 2; and August 1998 to July 2002, period 3). Hospital discharge abstract data from 5 states (California, Illinois, Massachusetts, Pennsylvania, and Washington) in 1992, 1996, and 1998 provided contemporaneous benchmarks. Risk adjustment was performed using the Risk Adjustment in Congenital Heart Surgery-1 method. Risk category, age at surgery, prematurity, and major noncardiac structural anomaly were entered into a multivariate logistic regression model to compare in-hospital mortality adjusting for case-mix differences.
Results:
A total of 514 congenital heart surgical cases were identified from August 1992 to July 2002; 507 cases (98.6%) were assigned to a risk category and analyzed further. Unadjusted in-hospital mortality rates were 9.3% in period 1, 5.9% in period 2, and 1.3% in period 3. Unadjusted mortality rates for cases from benchmark data were 6.4% in 1992, 4.8% in 1996, and 3.7% in 1998. Risk adjusted mortality was comparable to the benchmark data in periods 1 and 2, but superior outcomes (odds ratio = 0.24) were demonstrated in period 3.
Conclusions:
Evidence-based referrals from a small-volume pediatric cardiac center to large-volume institutions resulted in a reduction in mortality after congenital heart surgery.