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Evaluating variation in pre-operative evaluation and planning for children undergoing atrial or ventricular septal
Catherine C Dawson-Gore1,2, Andrew Well1,3,4, Scott Wallace4
1Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin / Dell Children's Medical Center, AustinTX, USA.
Insights
Significant variation exists in pre-operative care for children undergoing congenital heart defect (CHD) repair. This variability in evaluating atrial septal defect (ASD) and ventricular septal defect (VSD) may impact patient outcomes and healthcare costs.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Surgery
- Healthcare Process Improvement
Background:
- Congenital heart defect (CHD) care is resource-intensive, with unwarranted variation potentially increasing costs and negatively impacting health outcomes.
- This study investigates process variation in the pre-operative evaluation and planning for pediatric atrial septal defect (ASD) and ventricular septal defect (VSD) surgical repair.
- Hypothesizes that significant variation exists within this pre-operative process, particularly at key care points.
Purpose of the Study:
- To identify and characterize variations in the pre-operative evaluation and planning process for pediatric ASD and VSD surgical repair.
- To assess the extent of variability at specific points within the pre-operative pathway.
- To lay the groundwork for future research into the impact of these variations on outcomes and costs.
Main Methods:
- Constructed an initial process map based on interviews with integrated congenital heart center staff.
- Revised the process map using a retrospective chart review of 32 patients undergoing isolated surgical ASD or VSD repair between July 2018 and November 2020.
- Assessed the revised process map for points of consistency and variability.
Main Results:
- Ten patients (31%) underwent interventional cardiology review prior to surgical evaluation, with reasons including failed catheter-based closure (60%) or ineligibility (40%).
- While initial interviews suggested surgery rescheduling as a major variability, chart review indicated pre-operative interventional cardiology review was a more prominent source of variation.
- Most patients (94%) were reviewed in case conference, attended surgical clinic, and were not admitted prior to surgery.
Conclusions:
- Significant variability was identified in the pre-operative evaluation and planning for pediatric ASD/VSD surgical repair.
- This process variation may contribute to previously documented variations in outcomes and costs within CHD surgery.
- Future research should determine if identified variations are warranted and quantify their impact on health outcomes and costs.
Background:
CHD care is resource-intensive. Unwarranted variation in care may increase cost and result in poorer health outcomes. We hypothesise that process variation exists within the pre-operative evaluation and planning process for children undergoing repair of atrial septal defect or ventricular septal defect and that substantial variation occurs in a small number of care points.
Methods:
From interviews with staff of an integrated congenital heart centre, an initial process map was constructed. A retrospective chart review of patients with isolated surgical atrial septal defect and ventricular septal defect repair from 7/1/2018 through 11/1/2020 informed revisions of the process map. The map was assessed for points of consistency and variability.
Results:
Thirty-two surgical atrial septal defect/ventricular septal defect repair patients were identified. Ten (31%) were reviewed by interventional cardiology before surgical review. Of these, 6(60%) had a failed catheter-based closure and 4 (40%) were deemed inappropriate for catheter-based closure. Thirty (94%) were reviewed in case conference, all attended surgical clinic, and none were admitted prior to surgery. The process map from interviews alone identified surgery rescheduling as a point of major variability; however, chart review revealed this was not as prominent a source of variability as pre-operative interventional cardiology review.
Conclusions:
Significant variation in the pre-operative evaluation and planning process for surgical atrial septal defect/ventricular septal defect patients was identified. If such process variation is widespread through CHD care, it may contribute to variations in outcome and cost previously documented within CHD surgery. Future research will focus on determining whether the variation is warranted or unwarranted, associated health outcomes and cost variation attributed to these variations in care processes.
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