Historically, hospitals with a “low volume” of pediatric heart operations – in this case, those that perform 103 surgeries or fewer a year – have been associated with worse outcomes for patients. However, a team led by D. Chauhan, MD, from WVU Medicine Children’s Heart Center, found that “overperformers” and “underperformers” exist in all volume categories.
“Contrary to conventional wisdom regarding the relationship between institutional volume and quality outcomes, there are high-performing, low-volume centres in paediatric cardiac surgery, for even the most complex operations,” said senior author Christopher Mascio, MD, a paediatric cardiothoracic surgeon, professor, and executive director at WVU Medicine Children’s Heart Center. “There are also underperforming high-volume programmes. Judging programme quality is more complex than a single volume number.”
The team examined a total of 25,749 heart operations performed by 235 paediatric hospitals across the country. They divided the centres into three volume categories: low-volume (103 or fewer cases per year), mid-volume (104 to 194 cases per year), and high-volume (more than 194 cases per year). They included only “on-pump” procedures, meaning those that used a cardiopulmonary bypass machine, which takes over temporarily for the heart and lungs while the operation is performed.
According to coauthor J. Hunter Mehaffey, MD, an assistant professor and director of cardiac surgery research at WVU, the study included variables commonly used and validated in evaluating risk in paediatric cardiac surgery including age, race, birth weight, genetic diagnosis, history of re-operation, the urgency of the procedure, the patient’s length of hospital stay before the surgery, and the presence of heterotaxy (an abnormal arrangement of the internal organs).
Looking at hospital mortality rates, the researchers found that all three volume groups had both “overperforming” and “underperforming” hospitals. For six “benchmark” operations as defined by The Society of Thoracic Surgeons, they found no statistically significant difference in hospital mortality when comparing low- and mid-volume centres to high-volume centres.
The benchmark operations included tetralogy of Fallot repair, arterial switch with ventricular septal defect (VSD), arterial switch without VSD, Glenn and Fontan procedures, and truncus arteriosus repair.
This new research study will be presented at The Society of Thoracic Surgeons’ 2024 Annual Meeting in San Antonio, Texas. The Society selected the presentation as its 2024 James S. Tweddell Memorial Paper in Congenital Surgery.
Underscoring the study’s importance, Dr Mascio added: “When parents consider which centre is best for their child, there are many other factors at play, including care team coordination, proximity, surgical team, and personal interactions. The time is ripe for the congenital community to develop better methods for evaluating programme quality. We hope this contribution provides a nidus for continued discussion around this issue, providing a voice to programmes of all sizes.”