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Ann Thorac Surg 2011;92:2184-2192. doi:10.1016/j.athoracsur.2011.06.008
© 2011 The Society of Thoracic Surgeons
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Jeffrey Phillip Jacobs
Sean M. O'Brien
Marshall Lewis Jacobs
Francois G. Lacour-Gayet
Christo I. Tchervenkov
Erle H. Austin, III
Christian Pizarro
Kamal K. Pourmoghadam
Frank G. Scholl
Karl F. Welke
Constantine Mavroudis
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Right arrow Congenital - acyanotic
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Richard E. Clark Award

Variation in Outcomes for Benchmark Operations: An Analysis of The Society of Thoracic Surgeons Congenital Heart Surgery Database

Jeffrey Phillip Jacobs, MDa,*, Sean M. O'Brien, PhDb, Sara K. Pasquali, MDb, Marshall Lewis Jacobs, MDc, Francois G. Lacour-Gayet, MDd, Christo I. Tchervenkov, MDe, Erle H. Austin, III, MDf, Christian Pizarro, MDg, Kamal K. Pourmoghadam, MDh, Frank G. Scholl, MDi, Karl F. Welke, MDj, Constantine Mavroudis, MDc

a The Congenital Heart Institute of Florida (CHIF), All Children’s Hospital, University of South Florida College of Medicine, Cardiac Surgical Associates of Florida (CSAoF), Saint Petersburg and Tampa, Florida
b Duke University School of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
c Cleveland Clinic Lerner School of Medicine, Cleveland, Ohio
d Children's Hospital at Montefiore, New York, New York
e Montreal Children's Hospital, Montreal, Quebec, Canada
f Kosair Children's Hospital, University of Louisville, Louisville, Kentucky
g Alfred I. duPont Hospital for Children, Wilmington, Delaware
h University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
i Joe DiMaggio Children's Hospital, Hollywood, Florida
j Seattle Children's Hospital, Seattle, Washington

Accepted for publication June 1, 2011.

* Address correspondence to Dr Jacobs, The Congenital Heart Institute of Florida (CHIF), Cardiac Surgery, 625 Sixth Ave S, Ste 475, St. Petersburg, Florida 33701 (Email: jeffjacobs{at}msn.com).

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.

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.




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