Re-evaluating Congenital Heart Surgery Center Performance Using Operative Mortality
John E. Mayer, Jr, MD1, Sharon-Lise Normand, PhD2, Katya Zelevinsky, MA2, Meena Nathan, MD1, Haley Abing, BA2, Joseph Dearani, MD3, Mark Galatowicz, MD4, J. William Gaynor, MD5, Robert Habib, PhD6, Jeffrey P. Jacobs, MD7, S Ram Kumar, MD, PhD8, Donna McDonald, RN, MPH6, Sara K. Pasquali, MD, MHS9, David M. Shahian, MD10, James S. Tweddell, MD11, David F. Vener, MD12.
1Boston Children's Hospital, Boston, MA, USA, 2Harvard Medical School/Harvard School of Public Health, Boston, MA, USA, 3Mayo Clinic, Rochester, MN, USA, 4Nationwide Childrens Hospital, Columbus, OH, USA, 5Children's Hospital of Philadelphia, Philadelphia, PA, USA, 6Society of Thoracic Surgeons, Chicago, IL, USA, 7University of Florida Health Sciences Center, Gainesville, FL, USA, 8Children's Hospital of Los Angeles, University of Southern California, Los Angeles, CA, USA, 9University of Michigan Medical Center, Ann Arbor, MI, USA, 10Massachusetts General Hospital, Boston, MA, USA, 11Cincinnati Children's Medical Center, Cincinnati, OH, USA, 12Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
Objective(s): The Society of Thoracic Surgeonsí (STS) Congenital Heart Surgery Database (CHSD) provides observed to expected (O/E) operative mortality ratios to > 100 congenital heart centers in North America. We compared the current approach (STS-CHSD) to those incorporating information on diagnosis, other un-utilized risk factors, and modified method of confidence interval construction used to characterize center performance.
Methods: Expected mortality was estimated using Bayesian additive regression trees (BART) and lasso models linking operative mortality to diagnosis-procedure categories, procedure-specific risk factors, and syndromes/abnormalities. Bootstrapping to account for variation in STS-CHSD estimates was used in confidence interval (CI) construction. Center-specific estimates, interquartile range (IQR) of CI widths, and concordance of center performance categorizations (worse-than-, as-, or better-than-expected operative mortality) were compared to the STS-CHSD approach.
Results: In 110 surgical centers including 98,822 surgical index operative encounters, there were 2818 (2.85%) operative mortalities (Center range- 0.37% to 10%). Compared to the STS-CHSD approach, center-specific O/E ratios varied more and had narrower CIs (IQR of CI: STS-CHSD = 1.11, STS bootstrap = 0.98; lasso = 0.80; BART = 0.96). Center performance categorization concordant with the STS-CHSD ranged from 84% (lasso) to 91% (STS bootstrap), and > 70% of discordant centers improved categories. Discordant centers had smaller total case volumes and fewer operative mortalities.
Conclusions: Relative to the STS-CHSD, up to 16% of hospitals changed performance categories, most improving performance. Given the significance of quality reports for congenital heart centers, the inclusion of additional risk factors and unaddressed variation should be considered.
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