Elsevier

The Annals of Thoracic Surgery

Volume 92, Issue 6, December 2011, Pages 2184-2192
The Annals of Thoracic Surgery

Richard E. Clark award
Variation in Outcomes for Benchmark Operations: An Analysis of The Society of Thoracic Surgeons Congenital Heart Surgery Database

Winner of one of the Richard E. Clark Awards presented at the Forty-seventh Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2011.
https://doi.org/10.1016/j.athoracsur.2011.06.008Get rights and content

Background

We evaluated outcomes for common operations in The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSDB) to provide contemporary benchmarks and examine variation between centers.

Methods

Patients undergoing surgery from 2005 to 2009 were included. Centers with greater than 10% missing data were excluded. Discharge mortality and postoperative length of stay (PLOS) among patients discharged alive were calculated for 8 benchmark operations of varying complexity. Power for analyzing between-center variation in outcome was determined for each operation. Variation was evaluated using funnel plots and Bayesian hierarchical modeling.

Results

Eighteen thousand three hundred seventy-five index operations at 74 centers were included in the analysis of 8 benchmark operations. Overall discharge mortality was: ventricular septal defect (VSD) repair = 0.6% (range, 0% to 5.1%), tetralogy of Fallot (TOF) repair = 1.1% (range, 0% to 16.7%), complete atrioventricular canal repair (AVC) = 2.2% (range, 0% to 20%), arterial switch operation (ASO) = 2.9% (range, 0% to 50%), ASO + VSD = 7.0% (range, 0% to 100%), Fontan operation = 1.3% (range, 0% to 9.1%), truncus arteriosus repair = 10.9% (0% to 100%), and Norwood procedure = 19.3% (range, 0% to 100%). Funnel plots revealed that the number of centers characterized as outliers were VSD = 0, TOF = 0, AVC = 1, ASO = 3, ASO + VSD = 1, Fontan operation = 0, truncus arteriosus repair = 4, and Norwood procedure = 11. Power calculations showed that statistically meaningful comparisons of mortality rates between centers could be made only for the Norwood procedure, for which the Bayesian-estimated range (95% probability interval) after risk-adjustment was 7.0% (3.7% to 10.3%) to 41.6% (30.6% to 57.2%). Between-center variation in PLOS was analyzed for all operations and was larger for more complex operations.

Conclusions

This analysis documents contemporary benchmarks for common pediatric cardiac surgical operations and the range of outcomes among centers. Variation was most prominent for the more complex operations. These data may aid in quality assessment and quality improvement initiatives.

Section snippets

Study Population

The study population included patients who underwent operations with one of the primary procedures listed in Table 1 and who met the inclusionary and exclusionary criteria also listed in Table 1. Patients undergoing arterial switch operation (ASO) are in a separate cohort from those undergoing ASO + ventricular septal defect (VSD) repair because the outcomes of these 2 groups are quite different [6]. Furthermore the presence or absence of a VSD is a nonmodifiable variable that is an intrinsic

Results

From 2005 to 2009 inclusive, 85 centers (United States and Canada) submitted data to STS-CHSDB, and the discharge mortality of index cardiac operations was 4.0% (3,418/86,297). For patients younger than 18 years, from 2005 to 2009 inclusive, 85 centers submitted data to STS-CHSDB, and the discharge mortality of index cardiac operations was 4.1% (3,309/81,062). Eighteen thousand three hundred seventy-five index operations at 74 centers were included in this analysis of 8 benchmark operations.

Comment

The STS-CHSDB is the largest congenital heart surgery database in North America. This analysis documents (1) contemporary benchmarks for common pediatric cardiac surgical operations of varying levels of complexity and (2) the degree of variation in outcome between centers. Variation in outcome was most prominent for the more complex operations. These data can aid in quality assessment and quality improvement initiatives. Variation in outcomes across centers demonstrates opportunities for

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