Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario M5 G 1X8, Canada.
J Thorac Cardiovasc Surg. 2010 Mar;139(3):569-577.e1. doi: 10.1016/j.jtcvs.2008.11.073. Epub 2009 Nov 11.
To identify the role of institution and surgeon factors, including case volume and experience, on survival of neonates with complex congenital heart disease.
A total of 2421 neonates from 4 groups-transposition of the great arteries (n = 829), pulmonary atresia with intact ventricular septum (n = 408), Norwood (n = 710), and interrupted aortic arch (n = 474)-were prospectively enrolled from Congenital Heart Surgeons Society institutions. Multivariable analysis of risk-adjusted survival was performed for each group, entering each institution or surgeon into the multivariable analysis separately. Institutional performance was defined as [predicted survival - actual survival]. Neutralization of risk factors within each institution was evaluated using complex interaction terms. Institution and surgeon experience, defined by 5 domains (total case volume, total time each operation was performed, cases per year, rank-order of cases, case velocity), were also investigated.
Institutional performance varied among all groups. Improved outcomes in Norwood and pulmonary atresia with intact ventricular septum were unrelated to any "experience" domains, whereas improved outcomes in transposition of the great arteries were significantly related to increased experience in most domains. No institution enrolling in all 4 studies ranked number 1 in performance for all groups. Neutralization of low birth weight as a risk factor contributed to decreased mortality after Norwood in one institution.
Survival of neonates with complex congenital heart disease is influenced more by patient and management factors than by institution or surgeon experience. Institutional excellence in managing some diagnostic groups does not indicate similar performance for all diagnostic groups. Weighted risk-adjusted comparisons could provide a mechanism to improve results in institutions with less than optimal outcomes.
确定机构和外科医生因素（包括病例量和经验）对患有复杂先天性心脏病的新生儿生存率的影响。
从先天性心脏外科医生协会的 4 个组中前瞻性纳入了 2421 例新生儿：大动脉转位（n=829）、肺动脉闭锁伴完整室间隔（n=408）、Norwood 手术（n=710）和主动脉弓中断（n=474）。对每组进行了风险调整后生存的多变量分析，将每个机构或外科医生分别纳入多变量分析。通过复杂的交互项评估了每个机构内危险因素的中和情况。还研究了机构和外科医生的经验，定义为[预测生存率-实际生存率]，包括 5 个领域（总病例量、每次手术的总时间、每年的病例数、病例排序、病例速度）。
所有组的机构表现均存在差异。Norwood 手术和肺动脉闭锁伴完整室间隔的结果改善与任何“经验”领域无关，而大动脉转位的结果改善与大多数领域的经验增加显著相关。在所有 4 项研究中都有参与的机构没有一个在所有组的表现都排名第一。在一个机构中，将低出生体重作为一个风险因素进行中和有助于降低 Norwood 手术后的死亡率。
患有复杂先天性心脏病的新生儿的生存率受患者和管理因素的影响大于机构或外科医生经验的影响。在管理某些诊断组方面的卓越机构并不意味着在所有诊断组中都具有相同的表现。加权风险调整比较可以为改善结果不理想的机构提供一种机制。
