Lesion-specific outcomes in neonates undergoing congenital heart surgery are related predominantly to patient and management factors rather than institution.

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Presentation transcript:

Lesion-specific outcomes in neonates undergoing congenital heart surgery are related predominantly to patient and management factors rather than institution or surgeon experience: A Congenital Heart Surgeons Society Study Tara Karamlou, MD, Brian W. McCrindle, MD, MPH, Eugene H. Blackstone, MD, Sally Cai, MSc, Richard A. Jonas, MD, Scott M. Bradley, MD, David A. Ashburn, MD, MSc, Christopher A. Caldarone, MD, William G. Williams, MD The Journal of Thoracic and Cardiovascular Surgery Volume 139, Issue 3, Pages 569-577.e1 (March 2010) DOI: 10.1016/j.jtcvs.2008.11.073 Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Risk-adjusted nomogram of 1-year mortality risk after the Norwood procedure (on the vertical axis) versus annual volume of cases (on the horizontal axis) with all other predictors from the overall model excluding institutions (14) set to the median value. Mortality for all institutions remains constant over the entire range of annual volume, indicating no survival benefit with higher annual case volume. Note, however, that the overall mortality during this era was approximately 40%. The continuous parametric point estimates (solid lines) are enclosed by 70% confidence intervals (dashed lines). The Journal of Thoracic and Cardiovascular Surgery 2010 139, 569-577.e1DOI: (10.1016/j.jtcvs.2008.11.073) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 A, For the TGA cohort, there was a significant decrease in mortality with increasing values for the “experience” domains we investigated. Risk-adjusted nomogram of 1-year mortality risk versus annual volume of cases for the TGA cohort derived from the overall model excluding institutions (25) shows a significant association between decreased mortality and increasing annual case volume. Less then 50 TGA cases per year is associated with a rising mortality risk, indicating a potential threshold value. Continuous parametric point estimates (solid line) enclosed by 70% confidence intervals (dashed lines). B, Stratifying the nomogram by procedure type, either arterial switch (n = 516) or atrial switch (n = 276) demonstrates that the relationship between increased experience and better outcome is due to improved results with the arterial switch. The Journal of Thoracic and Cardiovascular Surgery 2010 139, 569-577.e1DOI: (10.1016/j.jtcvs.2008.11.073) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 A, Institutional performance in the Norwood operation is shown as the mathematic difference between 5-year predicted survival after risk adjustment and actual 5-year survival (14). Institutions above the zero line are performing better than expected, whereas those below the zero line are performing worse than expected. Institution code is listed on the bottom, and the number of patients enrolled is listed in the enclosed box. Institutions enrolling less than 10 patients are grouped together as less than 10. There is no relationship between increasing patient volume (surrogated by patient enrollment) and improved outcomes. For example, institution 18, enrolling just 43 patients, performs better than institution 30 with 155 patients. B, Institutional performance for the PAIVS cohort. Note that performance in this diagnostic group also is independent of total patient volume. Those institutions that performed the best in the Norwood series (ie, institution 18) did not perform as well in this diagnostic group. C, Institutional performance for the TGA cohort measured at 15 years from admission to hospital. The number of patients enrolled per institution is listed at the top horizontal, and the institution code is listed at the bottom horizontal. Note that the highest volume institution is performing at the same level as an institution enrolling one eighth of the volume, but also notice that for this diagnostic group, those institutions with higher volume generally have performance that exceeds expected levels. D, Institutional performance for the IAA cohort. Note the overlapping confidence intervals. PAIVS, Pulmonary atresia with intact ventricular septum; TGA, transposition of the great arteries; IAA, interrupted aortic arch. The Journal of Thoracic and Cardiovascular Surgery 2010 139, 569-577.e1DOI: (10.1016/j.jtcvs.2008.11.073) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 There were 6 CHSS institutions that contributed patients to all 4 diagnostic groups and had more than 10 patients within each group. These institutions were ranked out of a total number of 31 institutions based on the magnitude of difference between the predicted mortality at that institution after risk adjustment and the actual mortality at that institution. Institutions with the largest differential were ranked from lowest to highest, with a lower number indicating superior performance. The institution number is listed along the horizontal axis. Each geometric shape represents the individual institution's performance within a particular diagnostic group. Institutional excellence in managing certain diagnostic groups does not translate into excellence in managing all diagnostic groups. Note that institution 18 has excellent performance in the Norwood and IAA groups, but has the worst performance in the PAIVS group. PAIVS, Pulmonary atresia with intact ventricular septum; TGA, transposition of the great arteries; IAA, interrupted aortic arch. The Journal of Thoracic and Cardiovascular Surgery 2010 139, 569-577.e1DOI: (10.1016/j.jtcvs.2008.11.073) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 There was a significant positive association between increased surgeon experience and improved outcomes for the TGA cohort that was specific for the arterial switch operation. This nomogram shows a decline in risk-adjusted 5-year mortality as a function of increasing case rank-order per surgeon stratified by procedure type. Although mortality declines for both procedures, there was a significant decrease in mortality only for the arterial switch. The Journal of Thoracic and Cardiovascular Surgery 2010 139, 569-577.e1DOI: (10.1016/j.jtcvs.2008.11.073) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Figure 6 Outcomes after the Norwood operation were not associated with increased surgeon experience. Risk-adjusted nomogram shows that 5-year mortality after the Norwood operation is independent of the number of cases done per year (annual case volume) per surgeon. Note the widening confidence intervals once the annual volume reaches more than 30. The Journal of Thoracic and Cardiovascular Surgery 2010 139, 569-577.e1DOI: (10.1016/j.jtcvs.2008.11.073) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Figure 7 Risk-adjusted nomogram depicting 1-year mortality after the Norwood operation as a function of increasing birth weight stratified by whether a neonate was treated in institution 18 (the institution with the best results) compared with all others. A 2.5-kg neonate undergoing the Norwood operation in institution 18 fares significantly better than the same neonate treated at any other institution. Favorable results in this particular institution may derive from their management of a patient characteristic, low birth weight, which was a risk factor for all other institutions, but has been neutralized by institution 18. Continuous parametric point estimates (solid lines) enclosed by 70% confidence limits (dashed lines). The Journal of Thoracic and Cardiovascular Surgery 2010 139, 569-577.e1DOI: (10.1016/j.jtcvs.2008.11.073) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Figure 8 Risk-adjusted competing-risks nomogram adapted from Ashburn and colleagues22 for 1 institution on the basis of the morphologic spectrum of PAIVS. This institution is one of two whose adoption of a morphologically driven protocol allowed them to achieve comparably excellent survival, with a higher prevalence of 2-ventricle and Fontan repair, with few patients remaining unrepaired at 5 years. The Journal of Thoracic and Cardiovascular Surgery 2010 139, 569-577.e1DOI: (10.1016/j.jtcvs.2008.11.073) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions