Bates Katherine E, Yu Sunkyung, Lowery Ray, Pasquali Sara K, Brown David W, Manning Peter B, Uzark Karen
1Department of Pediatrics and Communicable Diseases,Congenital Heart Center,C.S. Mott Children's Hospital,Ann Arbor,MI,USA.
2Department of Cardiology,Boston Children's Hospital,Boston,MA,USA.
Cardiol Young. 2018 Aug;28(8):1031-1036. doi: 10.1017/S1047951118000926. Epub 2018 Jun 21.
Although interstage mortality for infants with hypoplastic left heart syndrome has declined within the National Pediatric Cardiology Quality Improvement Collaborative, variation across centres persists. It remains unclear whether centres with lower interstage mortality have lower-risk patients or whether differences in care may explain this variation. We examined previously established risk factors across National Pediatric Cardiology Quality Improvement Collaborative centres with lower and higher interstage mortality rates.
Lower-mortality centres were defined as those with >25 consecutive interstage survivors. Higher-mortality centres were defined as those with cumulative interstage mortality rates >10%, which is a collaborative historic baseline rate. Baseline risk factors and perioperative characteristics were compared.
Seven lower-mortality centres were identified (n=331 patients) and had an interstage mortality rate of 2.7%, as compared with 13.3% in the four higher-mortality centres (n=173 patients, p<0.0001). Of all baseline risk factors examined, the only factor that differed between the lower- and higher-mortality centres was postnatal diagnosis (18.4 versus 31.8%, p=0.001). In multivariable analysis, there remained a significant mortality difference between the two groups of centres after adjusting for this variable: adjusted mortality rate was 2.8% in lower-mortality centres compared with 12.6% in higher-mortality centres, p=0.003. Secondary analyses identified multiple differences between groups in perioperative practices and other variables.
Variation in interstage mortality rates between these two groups of centres does not appear to be explained by differences in baseline risk factors. Further study is necessary to evaluate variation in care practices to identify targets for improvement efforts.
尽管在国家儿科心脏病质量改进协作组中，左心发育不全综合征婴儿的过渡期死亡率有所下降，但各中心之间仍存在差异。目前尚不清楚过渡期死亡率较低的中心是否拥有低风险患者，或者护理差异是否可以解释这种差异。我们研究了国家儿科心脏病质量改进协作组中过渡期死亡率较低和较高的中心之间先前确定的风险因素。
死亡率较低的中心定义为连续有超过25名过渡期存活者的中心。死亡率较高的中心定义为累积过渡期死亡率>10%的中心，这是协作组的历史基线率。比较了基线风险因素和围手术期特征。
确定了7个死亡率较低的中心（n=331例患者），过渡期死亡率为2.7%，而4个死亡率较高的中心（n=173例患者）为13.3%，p<0.0001。在所有检查的基线风险因素中，死亡率较低和较高的中心之间唯一不同的因素是出生后诊断（18.4%对31.8%，p=0.001）。在多变量分析中，调整该变量后，两组中心之间仍存在显著的死亡率差异：死亡率较低的中心调整后死亡率为2.8%，而死亡率较高的中心为12.6%，p=0.003。二次分析确定了两组在围手术期实践和其他变量方面的多个差异。
这两组中心之间过渡期死亡率的差异似乎不能用基线风险因素的差异来解释。有必要进一步研究以评估护理实践的差异，从而确定改进工作的目标。
