Abstract
BackgroundGuidelines recommend that adults with congenital heart disease (CHD) undergo noncardiac surgery in regionalized centers of expertise, but no studies have assessed whether this occurs in the United States. We hypothesized that adults with CHD are less likely than children to receive care at specialized CHD centers.MethodsUsing a comprehensive state ambulatory surgical registry (California Ambulatory Surgery Database, 2005–2011), we calculated the proportion of adult and pediatric patients with CHD who had surgery at a CHD center, distance to the nearest CHD center, and distance to the facility where surgery was performed.ResultsPatients with CHD accounted for a larger proportion of the pediatric population (n = 11,254, 1.0%) than the adult population (n = 10,547, 0.07%). Only 2,741 (26.0%) adults with CHD had surgery in a CHD center compared to 6,403 (56.9%) children (p<0.0001). Adult CHD patients who had surgery at a non-specialty center (11.9±15.4 miles away) lived farther from the nearest CHD center (37.9±43.0 miles) than adult CHD patients who had surgery at a CHD center (23.2±28.4 miles; p<0.0001). Pediatric CHD patients who had surgery at a non-specialty center (18.0±20.7 miles away) lived farther from the nearest CHD center (35.7±45.2 miles) than pediatric CHD patients who had surgery at a CHD center (22.4±26.0 miles; p<0.0001).ConclusionsUnlike children with CHD, most adults with CHD (74%) do not have outpatient surgery at a CHD center. For both adults and children with CHD, greater distance from a CHD center is associated with having surgery at a non-specialty center. These results have significant public health implications in that they suggest a failing to achieve adequate regional access to specialized ACHD care. Further studies will be required to evaluate potential strategies to more reliably direct this vulnerable population to centers of expertise.
Highlights
Improved survival has resulted in dramatic growth in the prevalence of adult congenital heart disease (ACHD) [1,2]
Prior studies have demonstrated that ACHD is a risk factor for adverse outcomes at the time of noncardiac surgery [3], and a large cross-sectional study of ACHD patients found that perioperative death is the third most common cause of mortality [4]
American College of Cardiology/American Heart Association consensus guidelines recommend that ACHD patients should receive perioperative care in specialized ACHD centers
Summary
Improved survival has resulted in dramatic growth in the prevalence of adult congenital heart disease (ACHD) [1,2]. ACHD patients are addressed both as a special population at risk in the guidelines for evaluation of cardiovascular disease for all patients undergoing noncardiac surgery [5] and by a more focused set of guidelines for the care of ACHD patients (in which noncardiac surgery is discussed as a potentially high-risk event) [6] These guidelines establish the standard that preoperative evaluation, risk assessment, and surgery for ACHD patients should occur in regional centers because of access to congenital cardiology care, experienced surgeons and cardiac anesthesiologists. Guidelines recommend that adults with congenital heart disease (CHD) undergo noncardiac surgery in regionalized centers of expertise, but no studies have assessed whether this occurs in the United States. We hypothesized that adults with CHD are less likely than children to receive care at specialized CHD centers
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