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Association of center volume with mortality and complications in pediatric heart surgery
Sara K Pasquali1, Jennifer S Li, Danielle S Burstein
1Division of Cardiology, Department of Pediatrics, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC 27715, USA. sara.pasquali@duke.edu
Insights
Lower volume pediatric heart surgery centers have higher mortality rates, not due to more complications, but increased mortality in patients who experience complications. This impacts surgical outcomes for children.
Area of Science:
- Pediatric Cardiac Surgery
- Health Outcomes Research
- Hospital Quality Improvement
Background:
- Center volume in pediatric heart surgery may influence patient outcomes.
- Limited data exist on how center volume relates to postoperative complications and mortality, especially in patients experiencing complications.
Purpose of the Study:
- To examine the association between annual center volume and outcomes in children undergoing heart surgery.
- To investigate if center volume affects postoperative complication rates and mortality, particularly in patients who develop complications.
Main Methods:
- Analysis of a large multicenter cohort of 35,776 children (0-18 years) undergoing heart surgery from 2006-2009.
- Multivariable analysis evaluated outcomes associated with annual center volume, adjusting for patient factors and surgical risk.
Main Results:
- Lower center volume was significantly associated with higher in-hospital mortality.
- No association was found between center volume and the rate of postoperative complications.
- Lower center volume was significantly associated with higher mortality in patients who experienced complications (OR 1.59 for <150 vs >350 cases/year).
Conclusions:
- Higher mortality at lower volume pediatric heart surgery centers may be attributed to increased mortality among patients with complications, not a higher complication rate.
- These findings highlight the importance of managing complications effectively in lower-volume centers to improve survival rates in pediatric cardiac surgery.
Objective:
Previous analyses have suggested center volume is associated with outcome in children undergoing heart surgery. However, data are limited regarding potential mediating factors, including the relationship of center volume with postoperative complications and mortality in those who suffer a complication. We examined this association in a large multicenter cohort.
Methods:
Children 0 to 18 years undergoing heart surgery at centers participating in the Society of Thoracic Surgeons Congenital Heart Surgery Database (2006-2009) were included. In multivariable analysis, we evaluated outcomes associated with annual center volume, adjusting for patient factors and surgical risk category.
Results:
A total of 35 776 patients (68 centers) were included. Overall, 40.6% of patients had ≥1 complication, and the in-hospital mortality rate was 3.9%. The mortality rate in those patients with a complication was 9.0%. In multivariable analysis, lower center volume was significantly associated with higher in-hospital mortality. There was no association of center volume with the rate of postoperative complications, but lower center volume was significantly associated with higher mortality in those with a complication (P = .03 when volume examined as a continuous variable; odds ratio in centers with <150 vs >350 cases per year = 1.59 [95% confidence interval: 1.16-2.18]). This association was most prominent in the higher surgical risk categories.
Conclusions:
These data suggest that the higher mortality observed at lower volume centers in children undergoing heart surgery may be related to a higher rate of mortality in those with postoperative complications, rather than a higher rate of complications alone.
