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The complex relationship between pediatric cardiac surgical case volumes and mortality rates in a national clinical
Karl F Welke1, Sean M O'Brien, Eric D Peterson
1Division of Cardiothoracic Surgery, Oregon Health and Science University, Portland, Ore. 97239-3098, USA. welkek@ohsu.edu
Insights
Higher pediatric cardiac surgical volume is linked to lower mortality, especially for complex procedures. Lower-volume centers underperformed larger ones for difficult operations, indicating a volume-outcome relationship in pediatric cardiac surgery.
Area of Science:
- Cardiovascular Surgery
- Pediatric Surgery
- Health Services Research
Background:
- Pediatric cardiac surgical volume is a debated factor influencing patient outcomes.
- Understanding the relationship between surgical volume and mortality is crucial for quality improvement.
Purpose of the Study:
- To determine the association between pediatric cardiac surgical volume and mortality.
- To assess the impact of case complexity on the volume-outcome relationship.
Main Methods:
- Analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database (2002-2006).
- Inclusion of 32,413 pediatric cardiac operations from 48 programs.
- Logistic regression used for case-mix and risk factor adjustment.
Main Results:
- An inverse relationship was found between surgical volume and mortality (P = .002).
- For complex operations, mortality decreased significantly with increasing volume (e.g., Norwood procedures: 36.5% vs 16.9%).
- Volume was not associated with mortality for low-complexity cases, but lower-volume programs underperformed for difficult procedures.
Conclusions:
- Pediatric cardiac surgical volume is inversely associated with mortality, particularly for complex cases.
- Higher surgical volume is associated with better outcomes for complex pediatric cardiac operations.
- Volume-outcome relationships are critical for evaluating and improving pediatric cardiac surgery programs.
Objective:
We sought to determine the association between pediatric cardiac surgical volume and mortality using sophisticated case-mix adjustment and a national clinical database.
Methods:
Patients 18 years of age or less who had a cardiac operation between 2002 and 2006 were identified in the Society of Thoracic Surgeons Congenital Heart Surgery Database (32,413 patients from 48 programs). Programs were grouped by yearly pediatric cardiac surgical volume (small, <150; medium, 150-249; large, 250-349; and very large, >or=350 cases per year). Logistic regression was used to adjust mortality rates for volume, surgical case mix (Aristotle Basic Complexity and Risk Adjustment for Congenital Heart Surgery, Version 1 categories), patient risk factors, and year of operation.
Results:
With adjustment for patient-level risk factors and surgical case mix, there was an inverse relationship between overall surgical volume as a continuous variable and mortality (P = .002). When the data were displayed graphically, there appeared to be an inflection point between 200 and 300 cases per year. When volume was analyzed as a categorical variable, the relationship was most apparent for difficult operations (Aristotle technical difficulty component score, >3.0), for which mortality decreased from 14.8% (60/406) at small programs to 8.4% (157/1858) at very large programs (P = .02). The same was true for the subgroup of patients who underwent Norwood procedures (36.5% [23/63] vs 16.9% [81/479], P < .0001). After risk adjustment, all groups performed similarly for low-difficulty operations. Conversely, for difficult procedures, small programs performed significantly worse. For Norwood procedures, very large programs outperformed all other groups.
Conclusion:
There was an inverse association between pediatric cardiac surgical volume and mortality that became increasingly important as case complexity increased. Although volume was not associated with mortality for low-complexity cases, lower-volume programs underperformed larger programs as case complexity increased.
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