Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA, United States; Department of Surgery, University of California Irvine Medical Center, Orange, CA, United States.
Department of Pediatric Surgery, McGovern Medical School, Children's Memorial Hermann Hospital, University of Texas, Houston, TX, United States.
J Pediatr Surg. 2022 Nov;57(11):606-613. doi: 10.1016/j.jpedsurg.2022.01.022. Epub 2022 Jan 31.
We sought to elucidate the degree of variation across centers by calculating center-specific standardized mortality ratios (SMRs) for infants with congenital diaphragmatic hernia (CDH) requiring extracorporeal life support (ECLS).
The Extracorporeal Life Support Organization (ELSO) registry data (2000-2019) were used to estimate SMRs. Center-specific SMRs and their 95% confidence intervals (CIs) were used to identify centers with mortality as significantly worse (SW), significantly better (SB), or not different (ND) relative to the median standardized mortality rate.
We identified 4,223 neonates with CDH from 109 centers. SMRs were risk-adjusted for pre-ECLS case-mix (birthweight, sex, race, 5 min Apgar, blood gases, gestational age, hernia side, prenatal diagnosis, pre-ECLS arrest, and comorbidities). Observed (unadjusted) mortality rates across centers varied substantially (range: 14.3%-90.9%; interquartile range [IQR]: 42.9%-62.1%). Thirteen centers (11.9%) had SB SMRs< 1 (SMR 0.52 to 0.84), 7 centers (6.4%) had SW SMRs>1 (SMR 1.25 to 1.43), and 89 centers (81.7%) had SMRs ND relative to the median SMR rate across all centers (i.e., SMR not different from one). Descriptive analyses demonstrated that SB centers had a lower proportion of cases with renal complications, infectious complications and discontinuation of ECLS owing to complications, as well as differences in pre-ECLS treatments and timing of CDH repair, compared to SW and ND centers.
This study specifically identified ECLS centers with higher and lower survival for patients with CDH, which may serve as a benchmark for institutional quality improvement. Future studies are needed to identify those specific processes at those centers that leads to favorable outcomes with the goal of improving care globally.
Level III.
我们通过计算需要体外生命支持（ECLS）的先天性膈疝（CDH）婴儿的中心特异性标准化死亡率比（SMR），旨在阐明各中心之间的变异程度。
使用体外生命支持组织（ELSO）登记数据（2000-2019 年）来估计 SMR。使用中心特异性 SMR 及其 95%置信区间（CI）来识别死亡率明显较差（SW）、明显更好（SB）或与中位数标准化死亡率无差异（ND）的中心。
我们从 109 个中心中确定了 4223 例患有 CDH 的新生儿。在 ECLS 前对病例组合（出生体重、性别、种族、5 分钟 Apgar 评分、血气、胎龄、疝侧、产前诊断、ECLS 前停搏和合并症）进行了风险调整。各中心的观察（未调整）死亡率差异很大（范围：14.3%-90.9%；四分位间距[IQR]：42.9%-62.1%）。13 个中心（11.9%）的 SB SMR<1（SMR 0.52 至 0.84），7 个中心（6.4%）的 SW SMR>1（SMR 1.25 至 1.43），89 个中心（81.7%）的 SMR 与所有中心的中位数 SMR 率无差异（即 SMR 与 1 无差异）。描述性分析表明，与 SW 和 ND 中心相比，SB 中心的肾并发症、感染并发症和因并发症停止 ECLS 的病例比例较低，以及 ECLS 前的治疗和 CDH 修复的时机也有所不同。
本研究专门确定了 ECLS 中心治疗 CDH 患者的生存率更高和更低的中心，这可能作为机构质量改进的基准。需要进一步的研究来确定这些中心的具体过程，以实现有利的结果，并最终改善全球的护理。
III 级。
