July 1998

Pediatric cardiac surgery: The effect of hospital and surgeon volume on in-hospital mortality.
Hannan EL, Racz M, Kavey R-E, Quaegebeur JM, Williams R. Pediatrics. 1998;101:963-969.
[ see abstract below ]

Hannan et al analyzed the relationship between "annual provider (hospital and surgeon) volume of pediatric cardiac surgery and in-hospital mortality". They examined 16 different centers within New York state from 1992 to 1995 for a total of 7,169 cases. The authors found a significant increase in mortality in those centers which performed fewer than 100 cardiac surgical cases per year when compared with centers performing a greater number of cases annually (8.26 versus 5.59 percent). In addition, surgeons with case loads of fewer than 75 cases per year also had a higher mortality rate (8.77 versus 5.9 percent). More importantly, higher volume surgeons and hospitals experienced lower risk-adjusted rates than lower volume facilities and surgeons, suggesting that risk was lower regardless of the severity of the procedure. Hospital facility and operating surgeon were found to be independent risk factors for in-hospital mortality associated with pediatric cardiac surgery. If my thought process and mathematical calculations are correct, this translates into a 1.49 times higher hospital-associated mortality rate and a 1.49 times higher surgeon-associated mortality rate.

These findings are very worrisome because they imply that some centers perhaps should not be performing pediatric cardiac surgery. We do not know if this relates to anesthesiology care, intensive care, experience of the surgeon, experience of the support services, etc. This study is reminiscent, however, of the pediatric anesthesia 'closed claims' study (and others), which found a higher anesthetic complication rate for hospitals or practitioners performing relatively smaller numbers of pediatric anesthetic procedures, and/or practitioners who were not subspecialty-trained in the care of neonates and infants. All of these studies make me wonder if the current push for "preferred provider" care and to perform more and more complex procedures in outpatient settings may not have contributed to these bumps in mortality and morbidity. Were some of these cardiac facilities bidding contracts on the basis of decreased ICU or hospital stay which in turn increased mortality? Were these facilities and surgeons biting off more than they could chew in order to win a preferred provider contract?

These are important issues to think about for all of us who care for children. Taking into account the complexity of the procedure, the age of the patient, and the comfort level and skill of the surgical/anesthesia/intensive care team, we must recognize our limitations and refer children to the most appropriate facility.

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ABSTRACT