1. Adults or Big Kids: What Is the Ideal Clinical Environment for Management of Grown-Up Patients With Congenital Heart Disease? 
Tara Karamlou, MD, Brian S. Diggs, PhD, Ross M. Ungerleider, MD, MBA, Karl F. Welke, MD, MS 
The Annals of Thoracic Surgery 
Volume 90, Issue 2, Pages (August 2010)
DOI: /j.athoracsur
Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

2. Fig 1
Case mix among the four clinical environments varied significantly. In general, the congenital heart surgeons (CHS) operating within either practice setting (children's hospitals (CH) or general hospitals (GH)) performed fewer atrial septal defect (ASD) repairs and more complex operations. On the other end of the spectrum, the noncongenital heart surgeons (NCHS) operating within either practice setting performed more than 80% ASD repairs with few complex procedures. (Blue sections = ASD; green sections = tetralogy of Fallot; red sections = ventricular septal defect; purple sections = other.)
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

3. Fig 2
A significant increase in the number of grown-up congenital heart disease (GUCH) cases occurred over time, with 564 cases (3,247 ± 212 [8%]) performed in the earliest quartile (1988 to 1991) and 3,251 cases (15,895 ± 1,010 [40%]) performed in the most recent quartile (2000 to 2003). Examined by hospital type, however, we found no significant increase in the proportion of patients treated at general hospitals (gray bars) compared with children's hospitals (black bars) over the duration of the study period.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

4. Fig 3
There was a significant change in treatment of grown-up congenital heart disease (GUCH) patients when we examined the four clinical environments. Specifically, we found a dramatic rise in the number of patients treated by noncongenital heart surgeons (NCHS), irrespective of hospital type—either children's hospital (CH) or general hospital (GH)—suggesting that the shift in practice setting is provider specific rather than hospital-type specific. In contrast, the number of GUCH patients operated on by congenital heart surgeons (CHS) in either practice setting remained fairly constant. (Blue bars = CH + CHS; gray bars = CH + NCHS; open bars = GH + CHS; black bars = GH + NCHS.)
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

5. Fig 4
Estimated in-hospital mortality for grown-up congenital heart disease (GUCH) patients operated on within children's hospital (CH) and by congenital heart surgeons (CHS) was lower (1.1% [0.1% to 2.1%]) than for all other clinical environments, whereas estimated in-hospital mortality was highest for GUCH patients operated on within GH plus CHS (9.9% [5.3% to 5.7%]; p = 0.001). Examined by hospital type, there was a trend toward improved survival for GUCH patients operated on in CH compared with patients operated on in GH (3.9% [2.9% to 4.8%] versus 5.0% [4.3% to 5.8%]; p = 0.06). Accordingly, GUCH patients in CH plus NCHS had a small reduction in mortality (4.3% [3.3% to 5.4%]) compared with GUCH patients in GH plus NCHS (5.0 [4.2% to 5.7%]; p = 0.35), suggesting a possible benefit to the children's hospital environment.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions