Michael Gaies1, David K Werho2, Wenying Zhang3, Janet E Donohue4, Sarah Tabbutt5, Nancy S Ghanayem6, Mark A Scheurer7, John M Costello8, J William Gaynor9, Sara K Pasquali10, Justin B Dimick11, Mousumi Banerjee12, Steven M Schwartz13. 1. Division of Cardiology, Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan; Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan. Electronic address: mgaies@med.umich.edu. 2. Division of Critical Care Medicine, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California. 3. Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan. 4. Michigan Congenital Heart Outcomes Research and Discovery Unit, University of Michigan, Ann Arbor, Michigan. 5. Division of Critical Care Medicine, Department of Pediatrics, Benioff Children's Hospital, University of California San Francisco, San Francisco, California. 6. Division of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas. 7. Division of Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina. 8. Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois. 9. Division of Cardiac Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania. 10. Division of Cardiology, Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan; Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan. 11. Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, School of Public Health, University of Michigan, Ann Arbor, Michigan. 12. Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan; Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan. 13. Departments of Critical Care Medicine and Paediatrics, The Hospital for Sick Children, University of Toronto School of Medicine, Toronto, Ontario, Canada.
Abstract
BACKGROUND: Few metrics exist to assess quality of care at pediatric cardiac surgical programs, limiting opportunities for benchmarking and quality improvement. Postoperative duration of mechanical ventilation (POMV) may be an important quality metric because of its association with complications and resource utilization. In this study we modelled case-mix-adjusted POMV duration and explored hospital performance across POMV metrics. METHODS: This study used the Pediatric Cardiac Critical Care Consortium clinical registry to analyze 4,739 hospitalizations from 15 hospitals (October 2013 to August 2015). All patients admitted to pediatric cardiac intensive care units after an index cardiac operation were included. We fitted a model to predict duration of POMV accounting for patient characteristics. Robust estimates of SEs were obtained using bootstrap resampling. We created performance metrics based on observed-to-expected (O/E) POMV to compare hospitals. RESULTS: Overall, 3,108 patients (65.6%) received POMV; the remainder were extubated intraoperatively. Our model was well calibrated across groups; neonatal age had the largest effect on predicted POMV. These comparisons suggested clinically and statistically important variation in POMV duration across centers with a threefold difference observed in O/E ratios (0.6 to 1.7). We identified 1 hospital with better-than-expected and 3 hospitals with worse-than-expected performance (p < 0.05) based on the O/E ratio. CONCLUSIONS: We developed a novel case-mix-adjusted model to predict POMV duration after congenital heart operations. We report variation across hospitals on metrics of O/E duration of POMV that may be suitable for benchmarking quality of care. Identifying high-performing centers and practices that safely limit the duration of POMV could stimulate quality improvement efforts.
BACKGROUND: Few metrics exist to assess quality of care at pediatric cardiac surgical programs, limiting opportunities for benchmarking and quality improvement. Postoperative duration of mechanical ventilation (POMV) may be an important quality metric because of its association with complications and resource utilization. In this study we modelled case-mix-adjusted POMV duration and explored hospital performance across POMV metrics. METHODS: This study used the Pediatric Cardiac Critical Care Consortium clinical registry to analyze 4,739 hospitalizations from 15 hospitals (October 2013 to August 2015). All patients admitted to pediatric cardiac intensive care units after an index cardiac operation were included. We fitted a model to predict duration of POMV accounting for patient characteristics. Robust estimates of SEs were obtained using bootstrap resampling. We created performance metrics based on observed-to-expected (O/E) POMV to compare hospitals. RESULTS: Overall, 3,108 patients (65.6%) received POMV; the remainder were extubated intraoperatively. Our model was well calibrated across groups; neonatal age had the largest effect on predicted POMV. These comparisons suggested clinically and statistically important variation in POMV duration across centers with a threefold difference observed in O/E ratios (0.6 to 1.7). We identified 1 hospital with better-than-expected and 3 hospitals with worse-than-expected performance (p < 0.05) based on the O/E ratio. CONCLUSIONS: We developed a novel case-mix-adjusted model to predict POMV duration after congenital heart operations. We report variation across hospitals on metrics of O/E duration of POMV that may be suitable for benchmarking quality of care. Identifying high-performing centers and practices that safely limit the duration of POMV could stimulate quality improvement efforts.
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