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Hospital variation in postoperative mortality among preterm infants
Steven C Mehl1, Jorge I Portuondo2, Yao Tian3
1Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA; Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, USA.
Insights
Hospital variation in infant postoperative mortality exists, especially for extremely premature infants. Higher mortality rates are linked to specific hospitals, highlighting the need to study care processes at high-performing centers.
Area of Science:
- Pediatric Surgery
- Healthcare Quality and Safety
- Neonatal Medicine
Background:
- Significant variation in postoperative mortality among infants across hospitals is not well-documented.
- Gestational age is a potential factor influencing infant postoperative mortality rates.
Purpose of the Study:
- To quantify hospital variation in postoperative mortality for infants undergoing major surgery.
- To investigate the role of gestational age as a contributing factor to this observed variation.
Main Methods:
- Retrospective cohort study using the Pediatric Health Information System® database (2012-2020).
- Identified infants (<365 days) undergoing 38 high-risk operations, stratified by gestational age.
- Hospitals categorized into tertiles based on risk- and reliability-adjusted postoperative mortality.
Main Results:
- Analysis included 69,963 infants across 48 pediatric hospitals; adjusted mortality rates varied significantly between hospitals.
- Infants at high-mortality hospitals (T3) had a 75% increased odds of mortality compared to low-mortality hospitals (T1).
- This association persisted across all gestational ages, with a dose-dependent increase in mortality odds for preterm infants as gestational age decreased.
Conclusions:
- Substantial variation exists in infant postoperative mortality, with greater disparities observed in extremely premature infants (<28 weeks).
- Findings underscore the need to identify and understand care processes at high-performing centers to improve surgical outcomes for vulnerable infants.
Background:
It is unknown if there is hospital variation in postoperative mortality among infants. The purpose of this study is to describe variation in hospital postoperative mortality among infants and the extent to which gestational age may be a contributing factor.
Methods:
The Pediatric Health Information System® database (2012-2020) was used to identify infants (<365 days old at the time of surgery) who underwent one of 38 operations associated with significant postoperative morbidity and mortality. Infants were stratified by gestational age (>36 weeks, 33-36 weeks, 29-32 weeks, 25-28 weeks, <25 weeks). Hospitals were stratified into tertiles of risk and reliability-adjusted postoperative mortality (below average mortality [tertile 1-T1]; above average mortality [tertile 3-T3]). Nonparametric test of trend was used to compare mortality rates across hospital tertiles stratified by gestational age. Multivariable hierarchical regression was used to evaluate the association between mortality, hospital mortality tertile, and gestational age.
Results:
Overall, 69,963 infants were identified across 48 academic, pediatric hospitals. Adjusted hospital mortality rates ranged from 3.4 % [2.5-4.3] to 8.8 % [7.7-10.0]. Relative to infants treated at T1 mortality hospitals, the odds of mortality increased by 75% at T3 mortality hospitals (odds ratio [OR] 1.75 [1.57-1.94]). This relationship was consistent across all gestational ages and demonstrated a dose-dependent association with decreasing gestational age for preterm infants (33-36 weeks, OR 1.52 [1.09-2.13]; 29-32 weeks, OR 1.59 [1.18-2.15]; 25-28 weeks, OR 1.77 [1.37-2.27]; <25 weeks, OR 2.06 [1.39-3.05]).
Conclusions:
There is over 2-fold variation in infant postoperative mortality with variation more pronounced among infants with extreme prematurity (≤28 weeks). These findings suggest future work is needed to understand the care processes at high performing centers associated with better surgical outcomes.
Level Of Evidence:
Level II, Retrospective cohort study.
