Michael Gaies1,2, Nancy S Ghanayem3, Jeffrey A Alten4, John M Costello5, Javier J Lasa3, Nikhil K Chanani6, Andrew Y Shin7, Lauren Retzloff8, Wenying Zhang2,8, Sara K Pasquali1,2, Mousumi Banerjee2,9, Sarah Tabbutt10. 1. Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI. 2. Center for Health Outcomes and Policy & Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI. 3. Department of Pediatrics, Texas Children's Hospital & Baylor College of Medicine, Houston, TX. 4. Department of Pediatrics and The Heart Institute, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH.Michigan Congenital Heart Outcomes Research and Discovery, PC Data Coordinating Center, University of Michigan, Ann Arbor, MI. 5. Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and Northwestern University Feinberg School of Medicine, Chicago, IL. 6. Department of Pediatrics and Sibley Heart Center, Emory University and Children's Healthcare of Atlanta, Atlanta, GA. 7. Department of Pediatrics, Lucille Packard Children's Hospital and Stanford University School of Medicine, Palo Alto, CA. 8. Michigan Congenital Heart Outcomes Research and Discovery, PC Data Coordinating Center, University of Michigan, Ann Arbor, MI. 9. Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI. 10. Department of Pediatrics, University of California San Francisco School of Medicine and Benioff Children's Hospital, San Francisco, CA.
Abstract
OBJECTIVES: Pediatric cardiac ICUs should be adept at treating both critical medical and surgical conditions for patients with cardiac disease. There are no case-mix adjusted quality metrics specific to medical cardiac ICU admissions. We aimed to measure case-mix adjusted cardiac ICU medical mortality rates and assess variation across cardiac ICUs in the Pediatric Cardiac Critical Care Consortium. DESIGN: Observational analysis. SETTING: Pediatric Cardiac Critical Care Consortium clinical registry. PATIENTS: All cardiac ICU admissions that did not include cardiac surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was cardiac ICU mortality. Based on multivariable logistic regression accounting for clustering, we created a case-mix adjusted model using variables present at cardiac ICU admission. Bootstrap resampling (1,000 samples) was used for model validation. We calculated a standardized mortality ratio for each cardiac ICU based on observed-to-expected mortality from the fitted model. A cardiac ICU was considered a statistically significant outlier if the 95% CI around the standardized mortality ratio did not cross 1. Of 11,042 consecutive medical admissions from 25 cardiac ICUs (August 2014 to May 2017), the observed mortality rate was 4.3% (n = 479). Final model covariates included age, underweight, prior surgery, time of and reason for cardiac ICU admission, high-risk medical diagnosis or comorbidity, mechanical ventilation or extracorporeal membrane oxygenation at admission, and pupillary reflex. The C-statistic for the validated model was 0.87, and it was well calibrated. Expected mortality ranged from 2.6% to 8.3%, reflecting important case-mix variation. Standardized mortality ratios ranged from 0.5 to 1.7 across cardiac ICUs. Three cardiac ICUs were outliers; two had lower-than-expected (standardized mortality ratio <1) and one had higher-than-expected (standardized mortality ratio >1) mortality. CONCLUSIONS: We measured case-mix adjusted mortality for cardiac ICU patients with critical medical conditions, and provide the first report of variation in this quality metric within this patient population across Pediatric Cardiac Critical Care Consortium cardiac ICUs. This metric will be used by Pediatric Cardiac Critical Care Consortium cardiac ICUs to assess and improve outcomes by identifying high-performing (low-mortality) centers and engaging in collaborative learning.
OBJECTIVES: Pediatric cardiac ICUs should be adept at treating both critical medical and surgical conditions for patients with cardiac disease. There are no case-mix adjusted quality metrics specific to medical cardiac ICU admissions. We aimed to measure case-mix adjusted cardiac ICU medical mortality rates and assess variation across cardiac ICUs in the Pediatric Cardiac Critical Care Consortium. DESIGN: Observational analysis. SETTING: Pediatric Cardiac Critical Care Consortium clinical registry. PATIENTS: All cardiac ICU admissions that did not include cardiac surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was cardiac ICU mortality. Based on multivariable logistic regression accounting for clustering, we created a case-mix adjusted model using variables present at cardiac ICU admission. Bootstrap resampling (1,000 samples) was used for model validation. We calculated a standardized mortality ratio for each cardiac ICU based on observed-to-expected mortality from the fitted model. A cardiac ICU was considered a statistically significant outlier if the 95% CI around the standardized mortality ratio did not cross 1. Of 11,042 consecutive medical admissions from 25 cardiac ICUs (August 2014 to May 2017), the observed mortality rate was 4.3% (n = 479). Final model covariates included age, underweight, prior surgery, time of and reason for cardiac ICU admission, high-risk medical diagnosis or comorbidity, mechanical ventilation or extracorporeal membrane oxygenation at admission, and pupillary reflex. The C-statistic for the validated model was 0.87, and it was well calibrated. Expected mortality ranged from 2.6% to 8.3%, reflecting important case-mix variation. Standardized mortality ratios ranged from 0.5 to 1.7 across cardiac ICUs. Three cardiac ICUs were outliers; two had lower-than-expected (standardized mortality ratio <1) and one had higher-than-expected (standardized mortality ratio >1) mortality. CONCLUSIONS: We measured case-mix adjusted mortality for cardiac ICU patients with critical medical conditions, and provide the first report of variation in this quality metric within this patient population across Pediatric Cardiac Critical Care Consortium cardiac ICUs. This metric will be used by Pediatric Cardiac Critical Care Consortium cardiac ICUs to assess and improve outcomes by identifying high-performing (low-mortality) centers and engaging in collaborative learning.
Authors: Michael Gaies; Janet E Donohue; Gina M Willis; Andrea T Kennedy; John Butcher; Mark A Scheurer; Jeffrey A Alten; J William Gaynor; Jennifer J Schuette; David S Cooper; Jeffrey P Jacobs; Sara K Pasquali; Sarah Tabbutt Journal: Cardiol Young Date: 2015-09-11 Impact factor: 1.093
Authors: Howard E Jeffries; Gerardo Soto-Campos; Aaron Katch; Christine Gall; Tom B Rice; Randall Wetzel Journal: Pediatr Crit Care Med Date: 2015-11 Impact factor: 3.624
Authors: Michael G Gaies; Howard E Jeffries; Robert A Niebler; Sara K Pasquali; Janet E Donohue; Sunkyung Yu; Christine Gall; Tom B Rice; Ravi R Thiagarajan Journal: Pediatr Crit Care Med Date: 2014-07 Impact factor: 3.624
Authors: Michael Gaies; David S Cooper; Sarah Tabbutt; Steven M Schwartz; Nancy Ghanayem; Nikhil K Chanani; John M Costello; Ravi R Thiagarajan; Peter C Laussen; Lara S Shekerdemian; Janet E Donohue; Gina M Willis; J William Gaynor; Jeffrey P Jacobs; Richard G Ohye; John R Charpie; Sara K Pasquali; Mark A Scheurer Journal: Cardiol Young Date: 2014-08-28 Impact factor: 1.093
Authors: Michael G Gaies; James G Gurney; Alberta H Yen; Michelle L Napoli; Robert J Gajarski; Richard G Ohye; John R Charpie; Jennifer C Hirsch Journal: Pediatr Crit Care Med Date: 2010-03 Impact factor: 3.624
Authors: Katie M Moynihan; Jennifer M Snaman; Erica C Kaye; Wynne E Morrison; Aaron G DeWitt; Loren D Sacks; Jess L Thompson; Jennifer M Hwang; Valerie Bailey; Deborah A Lafond; Joanne Wolfe; Elizabeth D Blume Journal: Pediatrics Date: 2019-08 Impact factor: 7.124
Authors: Valerie Bailey; Dorothy M Beke; Jennifer M Snaman; Faraz Alizadeh; Sarah Goldberg; Melissa Smith-Parrish; Kimberlee Gauvreau; Elizabeth D Blume; Katie M Moynihan Journal: JAMA Netw Open Date: 2022-05-02
Authors: Joshua M Friedland-Little; Anna Joong; Svetlana B Shugh; Matthew J O'Connor; Neha Bansal; Ryan R Davies; Michelle S Ploutz Journal: Pediatr Cardiol Date: 2022-03-24 Impact factor: 1.838