Prabhu Neel K, Nellis Joseph R, Moya-Mendez Mary, Hoover Anna, Medina Cathlyn, Meza James M, Allareddy Veerajalandhar, Andersen Nicholas D, Turek Joseph W
Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, NC.
Duke Children's Pediatric and Congenital Heart Center, Durham, NC.
JTCVS Open. 2023 May 30;15:394-405. doi: 10.1016/j.xjon.2023.05.003. eCollection 2023 Sep.
To develop a more holistic measure of center performance than operative mortality, we created a composite "textbook outcome" for the Norwood operation using several postoperative end points. We hypothesized that achieving the textbook outcome would have a positive prognostic and financial impact.
This was a single-center retrospective study of primary Norwood operations from 2005 to 2021. Through interdisciplinary clinician consensus, textbook outcome was defined as freedom from operative mortality, open or catheter-based reintervention, 30-day readmission, extracorporeal membrane oxygenation, cardiac arrest, reintubation, length of stay >75%ile from Society of Thoracic Surgeons data report (66 days), and mechanical ventilation duration >75%ile (10 days). Multivariable logistic regression and Cox proportional hazards modeling were used to determine predictive factors for textbook outcome achievement and association of the outcome with long-term survival, respectively.
Overall, 30% (58/196) of patients met the textbook outcome. Common reasons for failure to attain textbook outcome were prolonged ventilation (68/138, 49%) and reintubation (63/138, 46%). In multivariable analysis, greater weight (odds ratio [OR], 2.11; 95% confidence interval [CI], 1.17-3.95; = .02) was associated with achieving the textbook outcome whereas preoperative shock (OR, 0.36; 95% CI, 0.13-0.87; = .03) and longer bypass time (OR, 0.99; 95% CI, 0.98-1.00; = .002) were negatively associated. Patients who met the outcome incurred fewer hospital costs ($152,430 [141,798-177,983] vs $269,070 [212,451-372,693], < .001), and after adjusting for patient factors, achieving textbook outcome was independently associated with decreased risk of all-cause mortality (hazard ratio, 0.45; 95% CI, 0.22-0.89; = .02).
Outcomes continue to improve within congenital heart surgery, making operative mortality a less-sensitive metric. The Norwood textbook outcome may represent a balanced measure of a successful episode of care.
为了开发一种比手术死亡率更全面的衡量中心手术效果的方法，我们使用多个术后终点指标为诺伍德手术创建了一个综合的“教科书式结局”。我们假设实现教科书式结局会对预后和财务产生积极影响。
这是一项对2005年至2021年原发性诺伍德手术的单中心回顾性研究。通过跨学科临床医生的共识，教科书式结局被定义为无手术死亡、无需进行开放性或基于导管的再次干预、无30天再入院、无体外膜肺氧合、无心脏骤停、无需再次插管、住院时间短于胸外科医师协会数据报告中第75百分位数（66天），以及机械通气时间短于第75百分位数（10天）。多变量逻辑回归和Cox比例风险模型分别用于确定实现教科书式结局的预测因素以及该结局与长期生存的关联。
总体而言，30%（58/196）的患者达到了教科书式结局。未达到教科书式结局的常见原因是通气时间延长（68/138，49%）和再次插管（63/138，46%）。在多变量分析中，体重增加（优势比[OR]，2.11；95%置信区间[CI]，1.17 - 3.95；P = 0.02）与实现教科书式结局相关，而术前休克（OR，0.36；95% CI，0.13 - 0.87；P = 0.03）和体外循环时间延长（OR，0.99；95% CI，0.98 - 1.00；P = 0.002）与之呈负相关。达到该结局的患者住院费用更低（152,430美元[141,798 - 177,983] vs 269,070美元[212,451 - 372,693]，P < 0.001），并且在调整患者因素后，实现教科书式结局与全因死亡率风险降低独立相关（风险比，0.45；95% CI，0.22 - 0.89；P = 0.02）。
先天性心脏病手术的结局持续改善，使得手术死亡率成为一个不太敏感的指标。诺伍德手术的教科书式结局可能代表了一次成功治疗过程的平衡衡量标准。
