Surgical treatment of congenital heart disease represents a major cause of pediatric hospitalization and healthcare resource use. Larger centers may provide more efficient care with resulting shorter length of postoperative hospitalization (LOH). Data from 46 centers over 25 years were used to evaluate whether surgical volume was an important determinant of LOH using a competing risk regression strategy that concurrently accounted for deaths, transfers, and discharges with some time interactions. Earlier discharge was more likely for infants and older children compared to neonates [subhazard ratios at postoperative day 6 of 1.64 (99 % confidence interval (CI) 1.57, 1.72) and 2.67 (99 % CI 2.53, 2.80), respectively], but less likely for patients undergoing operations in Risk Adjustment for Congenital Heart Surgery categories 2, 3, 4, and 5/6 compared to category 1 [subhazard ratios at postoperative day 6 of 0.66 (99 % CI 0.64, 0.68), 0.34 (95 % CI 0.33, 0.35), 0.28 (99 % CI 0.27, 0.30), and 0.10 (99 % CI 0.09, 0.11), respectively]. There was no difference by sex [non-time-dependent subhazard ratio 1.019 (99 % CI 0.995, 1.040)]. For every 100-operation increase in center annual surgical volume, the non-time-dependent subhazard for discharge was 1.035 (99 % CI 1.006, 1.064) times greater, and center-specific exponentiated random effects ranged from 0.70 to 1.42 with a variance of 0.023. The conditional discharge rate increased with increasing age and later era. No sex-specific difference was found. Centers performing more operations discharged patients sooner than lower volume centers, but this difference appears to be too small to be of clinical significance. Interestingly, unmeasured institutional characteristics estimated by the center random effects were variable, suggesting that these played an important role in LOH and merit further investigation.
Bibliographical noteFunding Information:
None of the authors has any conflict of interest. L. Kochilas is supported by NIH/NHLBI (R01 HL122392-01). B. J. S. al-Haddad was supported by NIH MSTP grant T32 GM008244. J. Menk is supported by the NIH Clinical and Translational Science Award at the University of Minnesota: 8 UL1 TR000114-02. The following statement is required for all projects using resources from the University of Minnesota Clinical and Translational Science Institute (CTSI): This publication was supported by Grant Number 1 UL1 RR033183 from the National Center for Research Resources (NCRR) and by Grant Number 8 UL1 TR000114-02 from the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH) to the University of Minnesota CTSI. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CTSI or the NIH. The University of Minnesota CTSI is part of a national Clinical and Translational Science Award (CTSA) consortium created to accelerate laboratory discoveries into treatments for patients.
© 2016, Springer Science+Business Media New York.
- Competing risk regression
- Congenital heart disease
- Length of hospitalization
- Pediatric Cardiac Care Consortium