National Variation in Congenital Heart Surgery Outcomes.
National Variation in Congenital Heart Surgery Outcomes.
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DOI：
10.1161/circulationaha.120.046962
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发表时间：
2020-10-06
期刊：
影响因子：
37.8
通讯作者：
Mayer JE
中科院分区：
文献类型：
--
作者：
Pasquali SK;Thibault D;O'Brien SM;Jacobs JP;Gaynor JW;Romano JC;Gaies M;Hill KD;Jacobs ML;Shahian DM;Backer CL;Mayer JE
改善国家先天性心脏病手术结果和减少医院间变异性的最佳战略仍不清楚。许多政策和质量改进工作主要集中在高风险患者和死亡率上。改善我们对发病率和死亡率以及当前复杂性变化的了解，将更好地为未来的努力提供信息。参加胸外科医生学会(STS)先天性心脏病手术数据库(2014-2017)的医院包括在内。使用贝叶斯模型评估病例组合调整的手术死亡率、主要并发症和术后住院时间(LOS)。医院变化通过十进制数比率(IDR-上下10%的比率)和95%的可信区间来量化。按风险组[STS-欧洲心胸外科协会(STAT)分类]进行分层分析，模拟评估变异减少的潜在影响。共纳入102家医院(n=84,407)，占美国先天性心脏病项目的85%左右。STAT第1-3类(低风险)手术占病例的74%。不同医院的结果差异很大：调整后的死亡率增加了3倍[上下角5.0%比1.6%，IDR 3.1(2.5-3.7)]，平均LOS降低1.8倍[19.2比10.5 d，IDR 1.8(1.8-1.9)]，主要并发症增加3倍[23.5%比7.0%，IDR 3.4(3.0-3.8)]。在不同结果的低风险病例和高风险病例中，差异程度相似或更大，例如，统计数据1-3[IDR 3.0(2.1-4.2)]和统计数据4-5[IDR 3.1(2.4-3.9)]的死亡率在不同医院之间的差异约为3倍。大容量医院在不同结果和风险类别之间的变异性较小。模拟显示，如果所有医院的表现都达到目前的中位数或更好，在4年的研究期内，死亡(n=282)、主要并发症(n=1,539)和损失(101,183 d)可能会减少，其中37%-60%的改善与统计数据1-3(较低风险)组有关。我们在先天性心脏病手术后的发病率和死亡率方面显示出显著的医院差异。与传统思维相反，可以在全国范围内实现的潜在改善的很大一部分与较低风险案例的可变性有关。这些发现表明，需要对我们目前的方法进行修改，以优化这一人群的护理和结果。
Optimal strategies to improve national congenital heart surgery outcomes and reduce variability across hospitals remain unclear. Many policy and quality improvement efforts have focused primarily on higher risk patients and mortality alone. Improving our understanding of both morbidity and mortality and current variation across the spectrum of complexity would better inform future efforts. Hospitals participating in the Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database (2014–2017) were included. Case-mix adjusted operative mortality, major complications, and post-operative length of stay (LOS) were evaluated using Bayesian models. Hospital variation was quantified by the inter-decile ratio (IDR-ratio of upper vs. lower 10%) and 95% credible intervals. Stratified analyses were performed by risk group [STS-European Association for Cardiothoracic Surgery (STAT) category], and simulations evaluated the potential impact of reductions in variation. A total of 102 hospitals (n=84,407) were included, representing ~85% of US congenital heart programs. STAT category 1-3 (lower risk) operations comprised 74% of cases. All outcomes varied significantly across hospitals: adjusted mortality by 3-fold [upper vs. lower decile 5.0% vs. 1.6%, IDR 3.1 (2.5-3.7)], mean LOS by 1.8-fold [19.2 vs 10.5 d, IDR 1.8 (1.8-1.9)], and major complications by >3-fold [23.5% vs 7.0%, IDR 3.4 (3.0-3.8)]. The degree of variation was similar or greater for low vs. high risk cases across outcomes, e.g. ~3-fold mortality variation across hospitals for both STAT 1-3 [IDR 3.0 (2.1-4.2)] and STAT 4-5 [IDR 3.1 (2.4-3.9)] cases. High volume hospitals had less variability across outcomes and risk categories. Simulations suggested potential reductions in deaths (n=282), major complications (n=1,539), and LOS (101,183 d) over the 4-year study period if all hospitals were to perform at the current median or better, with 37-60% of the improvement related to the STAT 1-3 (lower risk) group across outcomes. We demonstrate significant hospital variation in both morbidity and mortality following congenital heart surgery. Contrary to traditional thinking, a substantial portion of potential improvements that could be realized on a national scale were related to variability among lower risk cases. These findings suggest modifications to our current approaches to optimize care and outcomes in this population are needed.