Adult CHD: Risk factors for death in pediatric hospitals

Risk Factors for Death After Adult Congenital Heart Surgery in Pediatric Hospitals

1. Yuli Y. Kim, MD,
2. Kimberlee Gauvreau, ScD,
3. Emile A. Bacha, MD,
4. Michael J. Landzberg, MD and
5. Oscar J. Benavidez, MD, MPP

CIRCOUTCOMES.110.958256Published online before print June 21, 2011

1. From the Divisions of Cardiology (Y.Y.K.), Hospital of the University of Pennsylvania and Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA; the Department of Cardiology (K.G., M.J.L., O.J.B.), Children's Hospital Boston, Harvard Medical School, Boston, MA; Boston Adult Congenital Heart (BACH) Program (M.J.L.), the Department of Cardiology, Children's Hospital Boston, Boston, MA; the Division of Cardiology (M.J.L.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and the Department of Surgery (E.A.B.), Morgan Stanley Children's Hospital of New York, Columbia University College of Physicians and Surgeons, New York, NY.

1. Correspondence to Oscar J. Benavidez, MD, Department of Cardiology, Children's Hospital Boston, 300 Longwood Ave, Boston, MA 02115. E-mailOscar.Benavidez@cardio.chboston.org

Abstract

Background Despite the central role that pediatric hospitals play in the surgical treatment of congenital heart disease, little is known about outcomes of adult congenital cardiac surgical care in pediatric hospitals. Risk factors for inpatient death, including adult congenital heart (ACH) surgery volume, are poorly described.

Methods and Results We obtained inpatient data from 42 free-standing pediatric hospitals using the Pediatric Health Information System data base 2000 to 2008 and selected ACH surgery admissions (ages 18 to 49 years). We examined admission characteristics and hospital surgery volume. Of 97 563 total (pediatric and adult) congenital heart surgery admissions, 3061 (3.1%) were ACH surgery admissions. Median adult age was 22 years and 39% were between ages 25 to 49 years. Most frequent surgical procedures were pulmonary valve replacement, secundum atrial septal defect repair, and aortic valve replacement. Adult mortality rate was 2.2% at discharge. Multivariable analyses identified the following risk factors for death: age 25 to 34 years (adjusted odds ratio [AOR], 2.1; P=0.009), age 35 to 49 years (AOR, 3.2; P=0.001), male sex (AOR, 1.8; P=0.04), government-sponsored insurance (AOR, 1.8; P=0.03), and higher surgical risk categories 4+ (AOR, 21.5; P=0.001). After adjusting for case mix, pediatric hospitals with high ACH surgery volume had reduced odds for death (AOR, 0.4; P=0.003). There was no relationship between total congenital heart surgery volume and ACH inpatient mortality.

Conclusions Older adults, male sex, government-sponsored insurance, and greater surgical case complexity have the highest likelihood of in-hospital death when adult congenital surgery is performed in free-standing pediatric hospitals. After risk-adjustment, pediatric hospitals with high ACH surgery volume have the lowest inpatient mortality.