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Risk Factors for Unanticipated Readmissions During the Interstage: A Report From the National Pediatric Cardiology
Samuel P Hanke1, Brian Joy2, Elise Riddle3
1Cincinnati Children׳s Hospital Medical Center, Cincinnati, Ohio.
Insights
Unanticipated interstage readmissions are common in hypoplastic left heart syndrome patients, often due to minor clinical changes. Risk factors like genetic syndromes and center volume influence readmission rates, with significant variation across centers.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Disease Research
- Healthcare Quality Improvement
Background:
- Hypoplastic left heart syndrome (HLHS) requires complex surgical palliation.
- The interstage period (between initial palliation and definitive repair) is critical for patient outcomes.
- Unanticipated readmissions during this period impact resource utilization and patient management.
Purpose of the Study:
- To describe unanticipated interstage readmissions in HLHS patients.
- To identify independent risk factors associated with these readmissions.
- To evaluate variations in readmission rates among collaborative centers.
Main Methods:
- Retrospective analysis of 815 HLHS patients from the National Pediatric Cardiology Quality Improvement Collaborative registry (2008-2013).
- Competing risks time to event analyses to determine associations between interstage risk factors and readmission.
- Funnel plots used to examine center variation in readmission rates.
Main Results:
- 66% of HLHS patients experienced unanticipated interstage readmissions.
- Most readmissions (64%) were for minor clinical status changes, not major adverse events.
- Independent risk factors included genetic syndrome, center volume, preoperative ventricular dysfunction, tricuspid regurgitation, circulatory arrest duration, and Hybrid procedure use.
Conclusions:
- Unanticipated interstage readmissions are frequent in HLHS patients, with considerable variation among centers.
- Readmissions are typically short and rarely due to major adverse events.
- Identifying risk factors and understanding center variation can inform quality improvement initiatives.
Abstract:
This study describes unanticipated interstage readmissions in patients with hypoplastic left heart syndrome, identifies independent risk factors for unanticipated interstage readmissions, and evaluates variation in unanticipated readmission rates among collaborative centers. Retrospective data of patients enrolled in the National Pediatric Cardiology Quality Improvement Collaborative registry from July 2008 to July 2013 were analyzed. Risk factors present at the beginning of the interstage were captured. Competing risks time to event analyses determined the association between these factors and unanticipated interstage readmission. Readmission center variation was examined using funnel plots. Unanticipated interstage readmissions occurred in 66% of 815 patients at 50 centers. The median readmission length of stay was 2 days (interquartile range: 0-6) and median time to first readmission was 29 days (interquartile range: 9-63). Most readmissions were prompted by minor changes in clinical status (64%), whereas only 6% were major adverse event readmissions. Independent readmission risk factors included genetic syndrome (HR = 1.40, 95% CI: 1.05-1.88), center volume (small vs large HR = 1.32, CI: 1.04-1.66, medium vs large HR = 1.35, CI: 1.09-1.68), preoperative ventricular dysfunction (HR = 2.02, CI: 1.31-3.10), tricuspid regurgitation (HR = 1.36, CI: 1.08-1.72), duration of circulatory arrest (HR = 0.99, CI: 0.989-0.998), and undergoing Hybrid procedure relative to Norwood/right ventricle to pulmonary artery conduit (HR = 1.40, CI: 1.02-1.93). There was significant center variation in the number of readmissions and duration of readmissions. Unanticipated readmissions are common during the interstage period with notable center variation. However, these readmissions are short and are rarely in response to major adverse events.