Regionalization of complex surgical procedures to high-volume centers is a model for improving hospital survival. We analyzed the effect of institutional volume on hospital mortality for the Norwood and arterial switch operations (ASO) as representative high-complexity neonatal cardiac procedures. Analysis of discharge data from the 2003 Kids' Inpatient Database (KID) was conducted. Association between institutional volume and in-hospital mortality was examined for the ASO or Norwood procedure. Logistic regression analysis was performed to calculate the probability of hospital mortality for both procedures.Significant inverse associations between institutional volume and in-hospital mortality for the Norwood procedure (p </= 0.001) and the ASO (p = 0.006) were demonstrated. In-hospital mortality decreased for the ASO as institutional volume increased, with mortality rates of 9.4% for institutions performing two ASOs/year, 3.2% for 10 ASOs/year, and 0.8% for 20 ASOs/year. Similarly, in-hospital mortality rates for hypoplastic left heart syndrome were 34.8% for two Norwood procedures/year, 25.7% for 10 Norwood procedures/year, and 16.7% for 20 Norwood procedures/year. An inverse relation was observed between in-hospital mortality and institutional volume for ASO and the Norwood procedure. These results suggest that selective regionalization of complex neonatal cardiac procedures might result in significant improvement in hospital survival nationally.
"Hirsch et al.  analyzed 60 hospitals based on the Kids Inpatient Database 2003 and found the hospital mortality to be lowest in urban teaching hospitals (24.4%). This is more than 7 and 9% points lower than for urban non-teaching and rural hospitals, respectively. "
[Show abstract][Hide abstract] ABSTRACT: Background
The volume-outcome relationship is supposed to be stronger in high risk, low volume procedures. The aim of this systematic review is to examine the available literature on the effects of hospital and surgeon volume, specialization and regionalization on the outcomes of the Norwood procedure.
A systematic literature search was performed in Medline, Embase, and the Cochrane Library. On the basis of titles and abstracts, articles of comparative studies were obtained in full-text in case of potential relevance and assessed for eligibility according to predefined inclusion criteria. All relevant data on study design, patient characteristics, hospital volume, surgeon volume and other institutional characteristics, as well as results were extracted in standardized tables. Study selection, data extraction and critical appraisal were carried out independently by two reviewers.
We included 10 studies. All but one study had an observational design. The number of analyzed patients varied from 75 to 2555. Overall, the study quality was moderate with a huge number of items with an unclear risk of bias. All studies investigating hospital volume indicated a hospital volume-outcome relationship, most of them even having significant results. The results were very heterogeneous for surgeon volume.
The volume-outcome relationship in the Norwood procedure can be supported. However, the magnitude of the volume effect is difficult to assess.
[Show abstract][Hide abstract] ABSTRACT: Background: The arterial switch operation (ASO) is the gold-standard surgical procedure for transposition of the great arteries (TGA) in newborns and small infants. The goal of this current study is to describe the postoperative respiratory care and the current outcomes of the patients that underwent ASO for TGA at our institute. Method: We retrospectively enrolled 28 patients (23 males and 5 females) with TGA, who underwent ASO in this institution between January 2006 and December 2008, and analyzed some parameters. The outcome measurements were length of ventilator support, re-intervention rate and survival during hospitalization. Results: Ages and body weights at ASO were 17.2 ± 32.3 days (median, 5 days; range, 0-158 days) and 3.1 ± 0.6 kg (median, 3; 1.3-5 kg), respectively. Partial cardio-pulmonary bypass (CPB) time was 231.8 ± 56.9 (163.0-377.0) minutes, total CPB time 192.8 ± 56.1 (134.0-308.0) minutes and aortic cross-clamp time 125.3 ± 36.0 (62.0-194.0) minutes. In this cohort, the mean ventilator duration was 12.8 ± 14.3 days (median, 7; range, 2-61) for all patients and 11.2 ± 11.3 days (median, 7; range, 3-50) for survivors. Yearly report showed that median ventilator duration was 17.5 days and survival was 73% in 2006, 8.6 days of ventilation and 100% survival in 2007, and 6.4 days of ventilation and 91% survival in 2008. Multivariate analysis showed patients with aortic coarctation had longer ventilation durations, possibly related to increased lung fluid caused by cardiopulmolnary bypass and increased left ventricular afterload. A higher re-intervention rate was found in patients with ventilation support > 14 days (p < 0.05). Conclusion: Ventilation duration shortened and survival rate increased gradually from 2006 to 2008. Patients with aortic coartation had longer ventilator support. Cardiorespiratory investigation or intervention was indicated in patients who required ventilation support more than 14 days postoperatively.
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