Abstract 216: Leveraging the First Statewide Congenital Cardiac Consortium to Reduce Variation in Modifiable Preoperative Management Among Neonates Undergoing Arterial Switch Operation

Abstract

Objective: Seven public and private California cardiac centers have joined to form the first statewide consortium created to improve the quality and value of congenital cardiac care. The overall goals of the consortium are: 1) to understand variation in modifiable perioperative processes of care among participating hospitals, and 2) to determine whether standardization of those process measures will reduce adverse events and cost. In this pilot study, preoperative management of neonates undergoing arterial switch operation (ASO) within one center was analyzed for variation and these process measures were then associated with increased inpatient costs and length of stay. Methods: Through retrospective analysis of neonates undergoing ASO for Transposition of the Great Arteries with Intact Ventricular Septum (TGA/IVS) (n=34) at one center between 2004-2014, variation within the following preoperative process measures was described: feeding protocols, ventilation management, use of balloon atrial septostomy (BAS) and prostaglandin, and timing of surgery. Independent review by echocardiologists (SS, SP, AMG) confirmed preoperative and discharge diagnoses. Risk factors for increased total hospital length of stay (TLOS), postoperative length of stay (PLOS) and inpatient hospital costs were analyzed by univariable linear regression. Results: The population (N=34) was predominantly male (80%, 27/34) with low overall prenatal diagnosis rate (27%, 9/34). Birth weight was 3295±521 grams and gestational age (GA) was 39.1±1.4 weeks. Variation was found in duration of preoperative hospital stay (7.1±3.7 days), proportion of preoperative stay spent in the Cardiac ICU (0.58±0.35), use of BAS (53%, 18/34), preoperative enteral feeding (50%, 17/34) and preoperative extubation (24%, 8/34). Increased birth weight was negatively associated with costs (p=0.01), TLOS (p=0.14) and PLOS (p=0.02). Delayed timing of surgery was positively associated with TLOS (p=0.0004) and total costs (p=0.01) but not PLOS (p=0.93). Preoperative Cardiac ICU management trended towards negative association with total costs (p=0.20) but not TLOS (p=0.35) or PLOS (p=0.99) when compared with preoperative Neonatal ICU management. Lower GA, preoperative BAS, preoperative enteral feeding and preoperative extubation were not significantly associated with increased costs, TLOS, and PLOS. Conclusions: Variations in preoperative management of neonates undergoing ASO for TGA/IVS are significantly associated with total healthcare costs and hospital LOS. Concatenated data from the remaining consortium members will be critical to validate these findings and to power morbidity and mortality analysis. Integrated findings will allow the consortium to develop and implement consensus based recommendations regarding standardization of those process measures that will reduce major complications and cost.