Original article
Pediatric cardiac
Variation in Outcomes for Risk-Stratified Pediatric Cardiac Surgical Operations: An Analysis of the STS Congenital Heart Surgery Database

Presented at the Fifty-eighth Annual Meeting of the Southern Thoracic Surgical Association, San Antonio, TX, Nov 9–12, 2011.
https://doi.org/10.1016/j.athoracsur.2012.01.105Get rights and content

Background

We evaluated outcomes for groups of risk-stratified operations in The Society of Thoracic Surgeons Congenital Heart Surgery Database to provide contemporary benchmarks and examine variation between centers.

Methods

Patients undergoing surgery from 2005 to 2009 were included. Centers with more than 10% missing data were excluded. Discharge mortality and postoperative length of stay (PLOS) among patients discharged alive were calculated for groups of risk-stratified operations using the five Society of Thoracic Surgeons–European Association for Cardio-Thoracic Surgery Congenital Heart Surgery mortality categories (STAT Mortality Categories). Power for analyzing between-center differences in outcome was determined for each STAT Mortality Category. Variation was evaluated using funnel plots and Bayesian hierarchical modeling.

Results

In this analysis of risk-stratified operations, 58,506 index operations at 73 centers were included. Overall discharge mortality (interquartile range among programs with more than 10 cases) was as follows: STAT Category 1 = 0.55% (0% to 1.0%), STAT Category 2 = 1.7% (1.0% to 2.2%), STAT Category 3 = 2.6% (1.1% to 4.4%), STAT Category 4 = 8.0% (6.3% to 11.1%), and STAT Category 5 = 18.4% (13.9% to 27.9%). Funnel plots with 95% prediction limits revealed the number of centers characterized as outliers by STAT Mortality Categories was as follows: Category 1 = 3 (4.1%), Category 2 = 1 (1.4%), Category 3 = 7 (9.7%), Category 4 = 13 (17.8%), and Category 5 = 13 (18.6%). Between-center variation in PLOS was analyzed for all STAT Categories and was greatest for STAT Category 5 operations.

Conclusions

This analysis documents contemporary benchmarks for risk-stratified pediatric cardiac surgical operations grouped by STAT Mortality Categories and the range of outcomes among centers. Variation was greatest for the more complex operations. These data may aid in the design and planning of quality assessment and quality improvement initiatives.

Section snippets

Study Population

The study population consists of patients who underwent operations that met the inclusionary and exclusionary criteria listed in Table 1.

STAT Mortality Categories

The methodology of the development of the STAT Mortality Score and the STAT Mortality Categories was previously described [6]. Briefly, mortality risk was estimated for 148 types of operative procedures using data from 77,294 operations entered into the EACTS Congenital Heart Surgery Database (33,360 operations) and the STS-CHSD (43,934 patients) between 2002

Results

From 2005 to 2009, inclusive, 85 centers (United States and Canada) submitted data to STS-CHSDB, and discharge mortality of index cardiac operations was 4.0% (3,418 of 86,297). For patients aged less than 18 years, from 2005 to 2009, inclusive, 85 centers submitted data to STS-CHSDB, and discharge mortality of index cardiac operations was 4.1% (3,309 of 81,062). Overall, 58,506 index operations at 73 centers were included in this analysis of risk-stratified operations.

Comment

The STS-CHSDB is the largest congenital heart surgery database in North America. This analysis documents contemporary benchmarks for risk-stratified pediatric cardiac surgical operations of varying levels of risk, and 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 [14]. Variation in outcomes across centers demonstrates opportunities for

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