Division of Pediatric Cardiology, Duke University Medical Center, Durham, NC.
Duke Clinical Research Institute, Durham, NC.
Am Heart J. 2023 Nov;265:143-152. doi: 10.1016/j.ahj.2023.08.003. Epub 2023 Aug 10.
Stage 1 single ventricle palliation (S1P) has the longest length of stay (LOS) of all benchmark congenital heart operations. Center-level factors contributing to prolonged hospitalization are poorly defined.
We analyzed data from infants status post S1P included in the National Pediatric Cardiology Quality Improvement Collaborative Phase II registry. Our primary outcome was patient-level LOS with days alive and out of hospital before stage 2 palliation (S2P) used as a balancing measure. We compared patient and center-level characteristics across quartiles for median center LOS, and used multivariable regression to calculate center-level factors associated with LOS after adjusting for case mix.
Of 2,510 infants (65 sites), 2037 (47 sites) met study criteria (61% male, 61% white, 72% hypoplastic left heart syndrome). There was wide intercenter variation in LOS (first quartile centers: median 28 days [IQR 19, 46]; fourth quartile: 62 days [35, 95], P < .001). Mortality prior to S2P did not differ across quartiles. Shorter LOS correlated with more pre-S2P days alive and out of hospital, after accounting for readmissions (correlation coefficient -0.48, P < .001). In multivariable analysis, increased use of Norwood with a right ventricle to pulmonary artery conduit (aOR 2.65 [1.1, 6.37]), shorter bypass time (aOR 0.99 per minute [0.98,1.0]), fewer additional cardiac operations (aOR 0.46 [0.22, 0.93]), and increased use of NG tubes rather than G tubes (aOR 7.03 [1.95, 25.42]) were all associated with shorter LOS centers.
Modifiable center-level practices may be targets to standardize practice and reduce overall LOS across centers.
在所有基准先天性心脏病手术中，一期单心室姑息术（S1P）的住院时间（LOS）最长。导致住院时间延长的中心级因素定义较差。
我们分析了国家儿科心脏病学质量改进合作组织第二期登记册中接受 S1P 治疗的婴儿的数据。我们的主要结果是患者 LOS 与接受二期姑息术（S2P）前的存活天数和出院天数（作为平衡措施）。我们比较了四分位数中心 LOS 的患者和中心水平特征，并使用多变量回归在调整病例组合后计算与 LOS 相关的中心水平因素。
在 2510 名婴儿（65 个中心）中，有 2037 名（47 个中心）符合研究标准（61%为男性，61%为白人，72%为左心发育不全综合征）。LOS 在中心间存在广泛的差异（第一四分位数中心：中位数 28 天[IQR 19, 46]；第四四分位数：62 天[35, 95]，P<.001）。在 S2P 之前的死亡率在四分位数之间没有差异。在考虑再入院后，LOS 与 S2P 前更多的存活和出院天数相关（相关系数 -0.48，P<.001）。在多变量分析中，使用右心室肺动脉吻合术的 Norwood 术式（OR 2.65[1.1, 6.37]）、较短的体外循环时间（OR 每分钟 0.99[0.98,1.0]）、较少的附加心脏手术（OR 0.46[0.22, 0.93]）和增加使用 NG 管而不是 G 管（OR 7.03[1.95, 25.42]）均与 LOS 中心较短相关。
可修改的中心级实践可能是标准化实践和减少中心间总体 LOS 的目标。
