Larger Centers May Produce Better Outcomes: Is Regionalization in Congenital Heart Surgery a Superior Model?

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Abstract

Efforts to correlate outcomes of children undergoing heart surgery with center volume and characteristics are not novel. In the current era, outcomes are defined as, and in many cases limited to, mortality rates. Over the past two decades, several investigators have explored various aspects of the volume–mortality relationship. The association between center volume and mortality, although not uniform, is highly implicated by the current literature. Notwithstanding, varied population densities in the United States makes regionalization of specialized services, such as pediatric cardiac surgery, undeniably challenging. There may be an unfortunate reality that larger centers have some advantage in achieving, at the very least, timely measures. However, as pediatric cardiac surgery progresses as a specialty, the definition of ‘outcomes’ must be expanded beyond simplified, dichotomous parameters. While mortality has been our historical primary focus, as it should be, it is reasonable to propose that our focus should be increasingly refined towards patient- and family-centric measures, including morbidity, cost/value ratio, and overall hospital experience.

Introduction

The effort to correlate outcomes of children undergoing heart surgery with center volume and characteristics is not a novel concept. In the early 1990s, Jenkins and colleagues1 reported their observations on the relationship between outcomes of pediatric cardiac surgery and hospital caseload. Subsequent reports consist largely of single-center studies, often based on administrative data.2, 3 In the current era, “outcomes” are defined as, and in many cases limited to, mortality rates. However, as pediatric cardiac surgery progresses as a specialty, the definition of outcomes must be expanded beyond simplified, dichotomous parameters. While excellent care may be provided in smaller volume programs, there does appear to be a correlation between program size and resource commitment. This may translate into outcomes variability.

The subject we have been asked to discuss may be divided into two distinct issues; the first relates to whether larger centers secure better outcomes for pediatric cardiac surgery patients; the latter, concerning regionalization, may be challenging to practically implement and merits independent consideration.

Section snippets

Center Size and Relevance to Decision Making

The Society of Thoracic Surgeons (STS) designates congenital heart surgery program size based on the number of index cases performed annually. The cutoff thresholds for the number of operations necessary to fall in each category (that is, small, medium, or large), are essentially arbitrary. ‘Large’ programs are defined as programs performing over 250 index cases per year, whereas ‘small’ programs perform less than 100.4 In other words, a small program can expect to perform about two procedures

Benefits Available to Texas Children’s Hospital as a Large Center

For the past two decades, we have been fortunate to be a part of a very large hospital center (Texas Medical Center) in a large city (Houston, TX). As part of this conglomerate, Texas Children’s Hospital (TCH) has experienced steady growth over the preceding 20 years: from $2.6M in annual revenue in 1995 to $2.6B in 2014, with over $3B dollars projected this year. Additionally, in response to increasing demands, we have had exponential increases in both admissions and facilities in square feet.

Current State of the Evidence

As noted earlier, several investigators have explored the link between center volume and mortality.4, 5, 6, 7, 8, 9 In 2002, Chang and Klitzner of UCLA10 studied the effect of theoretically ‘closing’ low-volume pediatric cardiac surgery centers with the poorest outcomes and redirecting those patients to surrounding higher-volume centers in the state of California. Their model was based on abstracted statewide hospital discharge data between 1995 and 1997, and consisted of 6,592 patients in 20

Regionalization

Of great importance to the topic of debate is the dearth of established data regarding the influence of regionalization on outcomes of cardiac surgery in children. Two published studies focus on the results of experiences following regionalization of services in European countries including Sweden,12 Slovenia, and Slovakia.13 Pediatric cardiac surgery services were provided in four cities across Sweden prior to 1993, and subsequently centralized to two centers with the lowest surgical

Patient-Centric Outcomes: The ‘Ideal Program’ and Center Volume

As the focus of surgical outcomes shifts away from mortality, other benchmarks must be considered. It is reasonable to propose that our focus should be increasingly refined towards patient- and family-centric measures.

What are some ‘ideal outcomes’ in the view of the ultimate “consumers” of surgical care? Mortality has been our historical primary focus, as it should be. Yet, from the perspective of our patients, other areas of our focus might include morbidity (ventilator times,

A New Paradigm: Tiered-Care Children’s Surgical Centers

The aforementioned questions are the subject of much deliberation by a multitude of surgeons and physicians. Recently, a Task Force for Children’s Surgical Care, championed primarily by Dr. Keith Oldham from Wisconsin Children’s Hospital, has been convened by the American College of Surgeons to examine these very issues.15 While their focus is not exclusively on congenital heart disease, the question of what optimal resources are needed for the safe and effective provision of children’s

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