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Discharge Barriers and Length of Stay Following Congenital Heart Surgery: A Mixed-Methods Approach
Zofia Zdanowicz1,2,3, Christina Laternser4, Colin J Crilly4
1Ann & Robert H. Lurie Children's Hospital of Chicago Chicago IL USA.
Insights
Discharge barriers significantly increase length of stay (LOS) for infants after congenital heart surgery, impacting outcomes as much as clinical complexity. Addressing these barriers is key to improving patient recovery.
Area of Science:
- Pediatric Cardiology
- Health Services Research
- Healthcare Management
Background:
- Infants with severe congenital heart defects face complex postoperative care.
- Identifying discharge barriers is crucial for understanding length of stay (LOS) variation.
Purpose of the Study:
- To identify discharge barriers in infants post-congenital heart surgery.
- To compare the impact of discharge barriers versus clinical factors on postoperative LOS variation.
Main Methods:
- Retrospective cohort study of 752 infants (2015-2021) undergoing cardiac surgery at ≤12 months.
- Discharge barriers and clinical factors (complexity, complications, demographics) were analyzed for association with postoperative LOS.
- Shorrocks-Shapley decomposition quantified contributions to LOS variation.
Main Results:
- 24.3% of infants experienced discharge barriers, most commonly related to medical equipment or prior authorization delays.
- Median postoperative LOS was significantly longer for infants with barriers (26 days) vs. without (8 days).
- Discharge barriers and surgical complexity explained similar proportions of LOS variation (21.2% and 22.2%, respectively).
Conclusions:
- Discharge barriers are as influential as surgical complexity in explaining postoperative LOS variation.
- Mitigating modifiable discharge barriers may improve postoperative LOS for infants undergoing congenital heart surgery.
Background:
This study aimed to identify granular discharge barriers after congenital heart surgery and compare the contributions of discharge barriers versus clinical factors to postoperative length of stay (LOS) variation among infants with severe congenital heart defects.
Methods:
This was a retrospective cohort study of patients who underwent initial cardiac surgery at ≤12 months, from 2015 to 2021, at a high-volume congenital heart defect surgical center. The outcome was postoperative LOS. The exposure was discharge barrier category, a 7-level categorical variable determined a priori using a mixed-methods approach. Covariates included surgical/anatomic complexity, postoperative complications, sociodemographics, and comorbidities. Associations between discharge barrier categories and postoperative LOS were estimated with log-linear models. A Shorrocks-Shapley decomposition estimated each covariate's contribution to outcome variation.
Results:
A total of 752 infants met the inclusion criteria; 24.3% experienced a discharge barrier. The most common discharge barrier category was medical equipment delivery or prior authorization delays (52/752, 6.9%). Median postoperative LOS for those without and with barriers was 8 (interquartile range, 5-15) and 26 (interquartile range, 14-52) days, respectively (P<0.001). In a multivariable analysis, 4 of the 6 barrier categories were associated with higher postoperative LOS when compared with patients without barriers (31%-242%, P=0.000-0.030). Surgical complexity and discharge barriers accounted for similar amounts of variation in postoperative LOS (22.2% [95% CI, 17.3%-26.8%] and 21.2% [95% CI, 14.9%-27.0%], respectively).
Conclusions:
Discharge barriers are as influential as surgical and anatomic complexity in explaining variation in postoperative LOS among infants undergoing congenital heart surgery. Future research and clinical efforts to mitigate modifiable discharge barriers may yield improvements in postoperative LOS.
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