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The Norwood operation: Relative effects of surgeon and institutional volumes on outcomes and resource utilization

Published online by Cambridge University Press:  14 July 2015

Brett R. Anderson ,
Adam J. Ciarleglio ,
David J. Cohen ,
Wyman W. Lai ,
Matthew Neidell ,
Matthew Hall ,
Sherry A. Glied  and
Emile A. Bacha
Brett R. Anderson*
Affiliation:
Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, New York, United States of America
Adam J. Ciarleglio
Affiliation:
Division of Biostatistics in the Division of Child and Adolescent Psychiatry, New York University, New York, New York, United States of America
David J. Cohen
Affiliation:
Division of Cardiology, St. Luke’s Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri, United States of America
Wyman W. Lai
Affiliation:
Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, New York, United States of America
Matthew Neidell
Affiliation:
Department of Health Policy and Management, Mailman School of Public Health, New York, New York, United States of America
Matthew Hall
Affiliation:
Children’s Hospital Association, Overland Park, Kansas, United States of America
Sherry A. Glied
Affiliation:
Robert F. Wagner Graduate School of Public Service, New York University, New York, New York, United States of America
Emile A. Bacha
Affiliation:
Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, New York, United States of America
*
Correspondence to: B. R. Anderson, MD, MBA, Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children’s Hospital, Columbia University Medical Center, 3959 Broadway, CH-2N, New York, NY 10032-3784, United States of America. Tel: 212 305 4432; Fax: 212 305 4408; E-mail: bra2113@cumc.columbia.edu
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Abstract

Background

Hypoplastic left heart syndrome is the most expensive birth defect managed in the United States, with a 5-year survival rate below 70%. Increasing evidence suggests that hospital volumes are inversely associated with mortality for infants with single ventricles undergoing stage 1 surgical palliation. Our aim was to examine the relative effects of surgeon and institutional volumes on outcomes and resource utilisation for these children.

Methods

A retrospective study was conducted using the Pediatric Health Information System database to examine the effects of the number of procedures performed per surgeon and per centre on mortality, costs, and post-operative length of stay for infants undergoing Risk Adjustment for Congenital Heart Surgery risk category six operations at tertiary-care paediatric hospitals, from 1 January, 2004 to 31 December, 2013. Multivariable modelling was used, adjusting for patient and institutional characteristics. Gaussian kernel densities were constructed to show the relative distributions of the effects of individual institutions and surgeons, before and after adjusting for the number of cases performed.

Results

A total of 2880 infants from 35 institutions met the inclusion criteria. Mortality was 15.0%. Median post-operative length of stay was 24 days (IQR 14–41). Median standardized inpatient hospital costs were $156,000 (IQR $108,000–$248,000) in 2013 dollars. In the multivariable analyses, higher institutional volume was inversely associated with mortality (p=0.001), post-operative length of stay (p=0.004), and costs (p=0.001). Surgeon volume was associated with none of the measured outcomes. Neither institutional nor surgeon volumes explained much of the wide variation in outcomes and resource utilization observed between institutions and between surgeons.

Conclusions

Increased institutional – but not surgeon – volumes are associated with reduced mortality, post-operative length of stay, and costs for infants undergoing stage 1 palliation.

Keywords

Hypoplastic left heart syndromeNorwoodsurgeon volumeoutcomescosts
Type
Original Articles
Information
Cardiology in the Young , Volume 26 , Issue 4 , April 2016 , pp. 683 - 692
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Copyright
© Cambridge University Press 2015 

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References

1. Robbins, JM, Bird, TM, Tilford, JM, et al. Hospital stays, hospital charges, and in-hospital deaths among infants with selected birth defects – United States, 2003. Morbidity and Mortality Weekly Report 2007; 56: 25–29.Google Scholar
2. Dean, PN, Hillman, DG, McHugh, KE, et al. Inpatient costs and charges for surgical treatment of hypoplastic left heart syndrome. Pediatrics 2011; 128: e1181–e1186.CrossRefGoogle ScholarPubMed
3. Bazzani, LG, Marcin, JP. Case volume and mortality in pediatric cardiac surgery patients in California, 1998-2003. Circulation 2007; 115: 2652–2659.CrossRefGoogle ScholarPubMed
4. Jenkins, KJ, Newburger, JW, Lock, JE, et al. In-hospital mortality for surgical repair of congenital heart defects: preliminary observations of variation by hospital caseload. Pediatrics 1995; 95: 323–330.CrossRefGoogle ScholarPubMed
5. Pasquali, SK, Li, JS, Burstein, DS, et al. Association of center volume with mortality and complications in pediatric heart surgery. Pediatrics 2012; 129: e370–e376.CrossRefGoogle ScholarPubMed
6. Sollano, JA, Gelijns, AC, Moskowitz, AJ, et al. Volume-outcome relationships in cardiovascular operations: New York State, 1990-1995. J Thorac Cardiovasc Surg 1999; 117: 419–428; discussion 428–430.CrossRefGoogle ScholarPubMed
7. Welke, KF, Diggs, BS, Karamlou, T, et al. The relationship between hospital surgical case volumes and mortality rates in pediatric cardiac surgery: a national sample, 1988-2005. Ann Thorac Surg 2008; 86: 889–896; discussion 889–896.CrossRefGoogle ScholarPubMed
8. Welke, KF, O'Brien, SM, Peterson, ED, et al. The complex relationship between pediatric cardiac surgical case volumes and mortality rates in a national clinical database. J Thorac Cardiovasc Surg 2009; 137: 1133–1140.CrossRefGoogle Scholar
9. Hirsch, JC, Gurney, JG, Donohue, JE, et al. Hospital mortality for Norwood and arterial switch operations as a function of institutional volume. Pediatr Cardiol 2008; 29: 713–717.CrossRefGoogle ScholarPubMed
10. Pasquali, SK, Jacobs, JP, He, X, et al. The complex relationship between center volume and outcome in patients undergoing the Norwood operation. Ann Thorac Surg 2012; 93: 1556–1562.CrossRefGoogle ScholarPubMed
11. Checchia, PA, McCollegan, J, Daher, N, et al. The effect of surgical case volume on outcome after the Norwood procedure. J Thorac Cardiovasc Surg 2005; 129: 754–759.CrossRefGoogle ScholarPubMed
12. Hannan, EL, Racz, M, Kavey, RE, et al. Pediatric cardiac surgery: the effect of hospital and surgeon volume on in-hospital mortality. Pediatrics 1998; 101: 963–969.CrossRefGoogle ScholarPubMed
13. Hornik, CP, He, X, Jacobs, JP, et al. Relative impact of surgeon and center volume on early mortality after the Norwood operation. Ann Thorac Surg 2012; 93: 1992–1997.CrossRefGoogle ScholarPubMed
14. Karamlou, T, McCrindle, BW, Blackstone, EH, et al. 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. J Thorac Cardiovasc Surg 2010; 139: 569.e1–577.e1.CrossRefGoogle ScholarPubMed
15. Tabbutt, S, Ghanayem, N, Ravishankar, C, et al. Risk factors for hospital morbidity and mortality after the Norwood procedure: a report from the Pediatric Heart Network Single Ventricle Reconstruction trial. J Thorac Cardiovasc Surg 2012; 144: 882–895.CrossRefGoogle ScholarPubMed
16. Jenkins, KJ, Gauvreau, K, Newburger, JW, et al. Consensus-based method for risk adjustment for surgery for congenital heart disease. J Thorac Cardiovasc Surg 2002; 123: 110–118.CrossRefGoogle ScholarPubMed
17. Keren, R, Luan, X, Localio, R, et al. Prioritization of comparative effectiveness research topics in hospital pediatrics. Arch Pediatr Adolesc Med 2012; 166: 1155–1164.CrossRefGoogle ScholarPubMed
18. Feudtner, C, Hays, RM, Haynes, G, et al. Deaths attributed to pediatric complex chronic conditions: national trends and implications for supportive care services. Pediatrics 2001; 107: E99.CrossRefGoogle ScholarPubMed
19. Cameron, AC, Trivedi, PK. Microeconometrics using Stata. Stata Press, College Station, TX, 2010.Google Scholar
20. Tobin, J. Estimation of relationships for limited dependent variables. Econometrica 1958; 26: 24–36.CrossRefGoogle Scholar
21. Miglioretti, DL, Heagerty, PJ. Marginal modeling of nonnested multilevel data using standard software. Am J Epidemiol 2007; 165: 453–463.CrossRefGoogle ScholarPubMed
22. Neidell, MJ, Cohen, B, Furuya, Y, et al. Costs of healthcare- and community-associated infections with antimicrobial-resistant versus antimicrobial-susceptible organisms. Clin Infect Dis 2012; 55: 807–815.CrossRefGoogle ScholarPubMed