Abstract 13689: The Center-Volume Effect on Congenital Heart Surgery Revised: Is It Time to Consider Regionalization of Care?

Abstract

Introduction: Regionalization of congenital heart surgery (CHS) has been debated in the U.S. and other countries. Previous reports demonstrated a variable effect of a center’s volume on in-hospital postoperative mortality. However, the volume-outcome relationship for CHS remains incompletely understood without considering outcomes beyond hospital discharge. Hypothesis: We sought to determine, whether procedure-specific center volume predicts postoperative mortality for infants undergoing three complex benchmark procedures (Norwood procedure, arterial switch operation and complete atrioventricular canal repair) and used ventricular septal defect (VSD) closure as a simple benchmark procedure comparison. Methods: We used data from the Pediatric Cardiac Care Consortium, a multi-center U.S.-based clinical registry of CHS, enriched with post-discharge death data after linkage with the National Death Index. We used generalized estimating equations to assess the association between procedure-specific volume and mortality from the time of CHS and up to three years after CHS. Models were adjusted for patient age and weight at CHS, presence of a chromosomal abnormality, and surgical era and accounted for clustering at the center-level. Results: Analysis included 6,656 infants operated at 42 centers between 1982 and 2003. We found an absolute reduction in post-operative risk of death ranging from 6-12% for every additional surgery performed in the same center for Norwood, ASO, and CAVC repair and at all time points examined (Table). There was no statistically significant association between VSD center volume and mortality at any time point. Conclusions: In-hospital and longer-term survival after infantile CHS is improved with increased center case volume for complex CHS. These findings support the regionalization of complex CHS in the U.S.. Decision-makers should consider feasibility of such regionalization to improve outcomes after complex CHS.