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Using Mixed-Methods Research to Address Stagnant Operative Mortality Rates in Congenital Heart Surgery
Alyssia Venna1,2, Mitchell C Haverty1,2, Areen Almarkhan1,2
1Division of Cardiovascular Surgery, Children's National Hospital, Washington, DC.
Importance:
Operative mortality rates in the congenital heart disease population have remained stagnant at 2.8% for the last decade, prompting a mixed-methods exploration into what institutional factors might be at play.
Objectives:
After experiencing 0% operative mortality for 365 days, we aimed to qualitatively identify institutional factors impacting operative mortality and compare them to perceived reasons for operative mortality.
Design:
A convergent mixed-methods design was used to compare quantitative and qualitative data.
Setting:
This study was performed in a single-center pediatric heart center by a multidisciplinary cardiac research team between January 2020 and June 2024.
Participants:
A retrospective review of 43 operative mortality records was conducted to determine patient characteristics and reasons for operative mortality. Semi-structured interviews were conducted with staff.
Analysis:
Quantitative data were analyzed using descriptive statistics to describe patient characteristics and reasons for perceived operative mortality. Qualitative data were analyzed using reflexive thematic analysis to identify themes related to institutional factors influencing operative mortality. Quantitative and qualitative data were compared by matching reasons for each operative mortality to qualitative themes in a joint display. A post hoc descriptive analysis was performed to identify additional perceived reasons for operative mortality following the 0% operative mortality period.
Results:
Records were assigned up to five reasons for operative mortality: technical failure, communication issues, intractable disease, management strategy, and decision-making. Semi-structured interviews identified institutional factors influencing operative mortality. Reasons for operative mortality were technical failure (n = 19 [22%]), intractable disease (n = 19 [22%]), communication (n = 18 [21%]), management strategy (n = 15 [18%]), and decision-making (n = 14 [16%]). Three qualitative themes emerged: 1) Implementing Best Medical Practices, 2) Fostering Healthy Interpersonal Relationships, and 3) Building a Responsive Organizational Structure. Upon comparison, factors encompassed by theme 1 were most comparable when the reason for operative mortality was technical failure, intractable disease, management strategy, or decision-making); theme 2 was most comparable when the reason was communication. Theme 3 was only related to one instance of operative mortality. A post hoc analysis revealed most subsequent deaths following the 0% operative mortality period were attributed to intractable disease.
Conclusions:
Efforts to implement best medical practices are critical to improve operative mortality. A considerable effort should also be made to foster healthy relationships among staff. Building a responsive organizational structure may indirectly influence outcomes and should be further explored.
