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
Presented at the American Heart Association Scientific Sessions, November 2005, Dallas, Tex.
Received 7 February 2008; received in revised form 25 September 2008; accepted 23 November 2008. published online 12 November 2009.
Objective
To identify the role of institution and surgeon factors, including case volume and experience, on survival of neonates with complex congenital heart disease.
Methods
A total of 2421 neonates from 4 groups—transposition of the great arteries (n = 829), pulmonary atresia with intact ventricular septum (n = 408), Norwood (n = 710), and interrupted aortic arch (n = 474)—were prospectively enrolled from Congenital Heart Surgeons Society institutions. Multivariable analysis of risk-adjusted survival was performed for each group, entering each institution or surgeon into the multivariable analysis separately. Institutional performance was defined as [predicted survival – actual survival]. Neutralization of risk factors within each institution was evaluated using complex interaction terms. Institution and surgeon experience, defined by 5 domains (total case volume, total time each operation was performed, cases per year, rank-order of cases, case velocity), were also investigated.
Results
Institutional performance varied among all groups. Improved outcomes in Norwood and pulmonary atresia with intact ventricular septum were unrelated to any “experience” domains, whereas improved outcomes in transposition of the great arteries were significantly related to increased experience in most domains. No institution enrolling in all 4 studies ranked number 1 in performance for all groups. Neutralization of low birth weight as a risk factor contributed to decreased mortality after Norwood in one institution.
Conclusion
Survival of neonates with complex congenital heart disease is influenced more by patient and management factors than by institution or surgeon experience. Institutional excellence in managing some diagnostic groups does not indicate similar performance for all diagnostic groups. Weighted risk-adjusted comparisons could provide a mechanism to improve results in institutions with less than optimal outcomes.
ABSTRACT