Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California.
Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California; Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California; Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado.
Ann Thorac Surg. 2024 Mar;117(3):552-559. doi: 10.1016/j.athoracsur.2023.05.001. Epub 2023 May 12.
Although failure to rescue (FTR) is increasingly recognized as a quality metric, studies in congenital cardiac surgery remain sparse. Within a national cohort of children undergoing cardiac operations, we characterized the presence of center-level variation in FTR and hypothesized a strong association with mortality but not complications.
All children undergoing congenital cardiac operations were identified in the 2013 to 2019 Nationwide Readmissions Database. FTR was defined as in-hospital death after cardiac arrest, ventricular tachycardia/fibrillation, prolonged mechanical ventilation, pneumonia, stroke, venous thromboembolism, or sepsis, among other complications. Hierarchical models were used to generate hospital-specific, risk-adjusted rates of mortality, complications, and FTR. Centers in the highest decile of FTR were identified and compared with others.
Of an estimated 74,070 patients, 1.9% died before discharge, at least 1 perioperative complication developed in 43.0%, and 4.1% experienced FTR. After multilevel modeling, decreasing age, nonelective admission, and increasing operative complexity were associated with greater odds of FTR. Variations in overall mortality and FTR exhibited a strong, positive relationship (r = 0.97), whereas mortality and complications had a negligible association (r = -0.02). Compared with others, patients at centers with high rates of FTR had similar distributions of age, sex, chronic conditions, and operative complexity.
In the present study, center-level variations in mortality were more strongly explained by differences in FTR than complications. Our findings suggest the utility of FTR as a quality metric for congenital heart surgery, although further study is needed to develop a widely accepted definition and appropriate risk-adjustment models.
尽管未能抢救（FTR）作为一种质量指标越来越受到关注，但在先天性心脏手术方面的研究仍然很少。在一项对接受心脏手术的儿童的全国性队列研究中，我们描述了中心层面 FTR 存在的差异，并假设其与死亡率而非并发症密切相关。
在美国 2013 年至 2019 年的全国再入院数据库中确定了所有接受先天性心脏手术的儿童。FTR 定义为心脏骤停、室性心动过速/颤动、长时间机械通气、肺炎、中风、静脉血栓栓塞或败血症等并发症后住院期间死亡。采用分层模型生成医院特定的死亡率、并发症和 FTR 的风险调整率。确定 FTR 最高的中心，并与其他中心进行比较。
在估计的 74070 名患者中，有 1.9%在出院前死亡，至少有 43.0%的患者发生了 1 种围手术期并发症，有 4.1%的患者发生了 FTR。在多水平模型分析后，年龄越小、非选择性入院和手术复杂性增加与 FTR 的发生几率更大相关。总体死亡率和 FTR 的变化呈强正相关（r=0.97），而死亡率和并发症之间的相关性很小（r=-0.02）。与其他中心相比，高 FTR 中心的患者在年龄、性别、慢性疾病和手术复杂性方面的分布相似。
在本研究中，中心层面死亡率的差异更多地由 FTR 而不是并发症来解释。我们的研究结果表明，FTR 作为先天性心脏病手术的质量指标具有一定的应用价值，尽管还需要进一步研究来制定广泛接受的定义和适当的风险调整模型。
