番茄社区

Hospitals specializing in adult cardiac surgeries were not necessarily the ones providing the best care for adults with congenital heart disease (CHD), according to national data.

As most adults needing CHD surgery went to hospitals that were high-volume for coronary artery bypass grafting (CABG) or valve surgery in adults, pediatric congenital heart centers performed less than 12% of over 50,000 such operations logged in the Nationwide Readmissions Database (NRD) from 2010 to 2017.

While mortality rates were similar between the two types of institutions (2.17% vs 2.67%, respectively; adjusted OR 1.06, 95% CI 0.80-1.40), the pediatric centers were associated with superior clinical outcomes after adult CHD surgery according to other metrics:

• Fewer perioperative complications (adjusted OR 0.85, 95% CI 0.73-0.99)
• Fewer non-home discharges (adjusted OR 0.67, 95% CI 0.51-0.87)
• Reduction in 90-day emergent readmissions (adjusted OR 0.69, 95% CI 0.55-0.85)

The finding of shorter hospital stays and similar adjusted costs also suggests enhanced surgical and perioperative management -- "value-based care" -- at pediatric CHD centers, medical student Catherine Williamson, BS, of the University of California Los Angeles, said during the Society of Thoracic Surgeons virtual meeting.

These are notable findings at a time when more and more children with CHD are surviving into adulthood; the number of adults with CHD, a group with unique anatomic complexities, has doubled in the last decade, Williamson noted.

"Which hospital is better for care for these patients? I would argue the nature of patients diagnosed with adult CHD, the procedures, and associated risk are highly variable. We find processes with multiple specialists working together to share expertise and render care as really an ideal approach," said session discussant Stephanie Fuller, MD, of the Children's Hospital of Philadelphia.

Williamson suggested that centralization of care to pediatric specialty centers may improve outcomes for adults with CHD. However, there are concerns that this could hurt access to high-quality care for marginalized groups, namely underinsured people and those with lower incomes, she acknowledged.

The retrospective cohort study analyzed adult CHD surgeries at high-volume centers participating in the NRD, including 45,652 procedures at high-volume adult cardiac surgical sites (hospitals in the top tertile in CABG or valve surgery in adults) and 6,074 at high-volume pediatric sites (top tertile in congenital operations in children).

Average age of patients was 56.7 at adult centers and 48.7 at pediatric centers; 48.1% and 50.5% were women.

Pediatric CHD centers performed somewhat higher-risk procedures (RACHS-1 score 1.13 vs 1.53, P<0.001), such as transposition of great vessels, whereas adult specialists logged more atrial and ventricular septal defect repairs.

Factors associated with treatment at a pediatric center were higher RACHS-1 score, household income in the highest quartile, and private insurance.

Williamson cautioned that the NRD lacks key granular clinical and anatomic information and did not allow her group to adjust for individual surgeon experience. Moreover, such administrative databases may be influenced by local billing practices.

There was also room for bias, since patients had to have survived to discharge to be included in the database. Surgeries on bicuspid aortic valves were not included in the present analysis, Fuller observed.

Comment