Hospital mortality for Norwood and arterial switch operations as a function of institutional volume.

Department of Surgery, Section of Cardiac Surgery, Division of Pediatric Cardiovascular Surgery, University of Michigan Medical Center, 5144 Cardiovascular Center, Ann Arbor, MI, 48109-5864, USA.
Pediatric Cardiology (Impact Factor: 1.55). 07/2008; 29(4):713-7. DOI: 10.1007/s00246-007-9171-2
Source: PubMed

ABSTRACT 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.

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    ABSTRACT: Background The relative impact of center volume and of surgeon volume on early outcomes after the arterial switch operation (ASO) is incompletely understood. Methods Neonates in the Society of Thoracic Surgeons Congenital Heart Surgery Database (2005–2012) undergoing ASO for transposition of the great arteries were included in the analysis. Multivariable logistic regression with adjustment for patient factors and ventricular septal defect closure was used to evaluate relationships between annual center and surgeon volume and a composite end point (in-hospital mortality or major complications). Results The study included 2,357 patients (84 centers, 155 surgeons). Median annual ASO center volume was 4 (range, 1 to 18). Median annual surgeon volume was 2 (range, 0.1 to 11). In-hospital mortality was 3.4%; 14.7% had major morbidity and 15.5% met the composite end point. Analyzed individually, lower center and surgeon volumes were each associated with the composite end point (odds ratios for centers with 2 versus 10 cases/y, 1.92; 95% confidence interval, 1.23 to 2.99); odds ratios for surgeons with 1 versus 6 cases/y, 2.16; 95% confidence interval, 1.42 to 3.26). When analyzed together, the addition of surgeon volume to the center volume models attenuated but did not completely mitigate the association of center volume with outcome (relative attenuation of odds ratio = 31%). Addition of center volume to surgeon volume models attenuated the association of surgeon volume with outcome to a lesser degree (relative attenuation of odds ratio = 11%). Conclusions Center and surgeon volume each influence early outcomes after ASO; however, surgeon volume appears to play a more prominent role. Surgeon and center ASO volume should be considered in the context of initiatives to improve outcomes from ASO for transposition of the great arteries.
    The Annals of Thoracic Surgery 09/2014; · 3.63 Impact Factor
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    ABSTRACT: A significant inverse relationship of surgical institutional and surgeon volumes to outcome has been demonstrated in many high-stakes surgical specialties. By and large, the same results were found in pediatric cardiac surgery, for which a more thorough analysis has shown that this relationship depends on case complexity and type of surgical procedures. Lower-volume programs tend to underperform larger-volume programs as case complexity increases. High-volume pediatric cardiac surgeons also tend to have better results than low-volume surgeons, especially at the more complex end of the surgery spectrum (e.g., the Norwood procedure). Nevertheless, this trend for lower mortality rates at larger centers is not universal. All larger programs do not perform better than all smaller programs. Moreover, surgical volume seems to account for only a small proportion of the overall between-center variation in outcome. Intraoperative technical performance is one of the most important parts, if not the most important part, of the therapeutic process and a critical component of postoperative outcome. Thus, the use of center-specific, risk-adjusted outcome as a tool for quality assessment together with monitoring of technical performance using a specific score may be more reliable than relying on volume alone. However, the relationship between surgical volume and outcome in pediatric cardiac surgery is strong enough that it ought to support adapted and well-balanced health care strategies that take advantage of the positive influence that higher center and surgeon volumes have on outcome.
    Pediatric Cardiology 06/2014; 35(6). · 1.55 Impact Factor
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    ABSTRACT: 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.
    BMC Pediatrics 08/2014; 14(1):198. · 1.92 Impact Factor