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Impact of Confounding on Cost, Survival, and Length-of-Stay Outcomes for Neonates with Hypoplastic Left Heart
Cynthia L Gong1,2,3, Ashley Y Song4,5, Robin Horak6,7
1Division of Neonatology, Department of Pediatrics, Fetal & Neonatal Institute, Children's Hospital Los Angeles, 4650 Sunset Boulevard, MS #31, Los Angeles, CA, 90027, USA. gongc@usc.edu.
Insights
Neonates with hypoplastic left heart syndrome (HLHS) undergoing stage 1 palliation surgery show significant resource utilization, especially with extracorporeal membrane oxygenation (ECMO). Differences in costs and length of stay by region/volume may be due to unmeasured factors.
Area of Science:
- Pediatric Cardiac Surgery
- Neonatal Intensive Care
- Health Services Research
Background:
- Hypoplastic left heart syndrome (HLHS) is a severe congenital heart defect requiring complex surgical palliation.
- Stage 1 palliation, often the Norwood procedure, is a critical intervention for HLHS neonates.
- Understanding resource utilization, including length of stay (LOS) and costs, is vital for healthcare management.
Purpose of the Study:
- To analyze trends in LOS and costs for neonates with HLHS undergoing stage 1 palliation.
- To compare resource utilization based on survivorship and the use of extracorporeal membrane oxygenation (ECMO).
- To assess the impact of hospital factors (region, case volume) on outcomes using 2016 data.
Main Methods:
- Utilized the Healthcare Cost and Utilization Project Kids' Inpatient Database (2016).
- Identified neonates (≤28 days) with HLHS undergoing Stage 1 surgery (Norwood procedure variants).
- Employed multivariable regression and E-value analysis to assess LOS, costs, and confounding factors.
Main Results:
- Significant variations in total costs, LOS, and mortality were observed based on hospital region, ECMO use, and case volume.
- E-value analysis indicated that differences related to hospital region and case volume could be attributed to unmeasured confounding (e.g., socioeconomic factors).
- Extracorporeal membrane oxygenation (ECMO) use was strongly associated with increased resource utilization and mortality.
Conclusions:
- Findings confirm substantial resource utilization in Norwood procedure patients, particularly those requiring ECMO.
- Observed differences in outcomes by hospital region and case volume are likely influenced by unmeasured confounding, not solely quality of care.
- Future surgical quality analyses must incorporate unobserved factors for accurate quality improvement insights.
Abstract:
The objective of this analysis was to update trends in LOS and costs by survivorship and ECMO use among neonates with hypoplastic left heart syndrome (HLHS) undergoing stage 1 palliation surgery using 2016 data from the Healthcare Cost and Utilization Project Kids' Inpatient Database. We identified neonates ≤ 28 days old with HLHS undergoing Stage 1 surgery, defined as a Norwood procedure with modified Blalock-Taussig (BT) shunt, Sano modification, or both. Multivariable regression with year random effects was used to compare LOS and costs by hospital region, case volume, survivorship, and ECMO vs. no ECMO. An E-value analysis, an approach for conducting sensitivity analysis for unmeasured confounding, was performed to determine if unmeasured confounding contributed to the observed effects. Significant differences in total costs, LOS, and mortality were noted by hospital region, ECMO use, and sub-analyses of case volume. However, other than ECMO use and mortality, the maximum E-value confidence interval bound was 1.71, suggesting that these differences would disappear with an unmeasured confounder 1.71 times more associated with both the outcome and exposure (e.g., socioeconomic factors, environment, etc.) Our findings confirm previous literature demonstrating significant resource utilization among Norwood patients, particularly those undergoing ECMO use. Based on our E-value analysis, differences by hospital region and case volume can be explained by moderate unobserved confounding, rather than a reflection of the quality of care provided. Future analyses on surgical quality must account for unobserved factors to provide meaningful information for quality improvement.
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