Variability in noncardiac surgical procedures in children with congenital heart disease

Abstract

Background: The purpose of this study was to examine the volume and variability of noncardiac surgeries performed in children with congenital heart disease (CHD) requiring cardiac surgery in the first year of life.

Methods: Patients who underwent cardiac surgery by 1 year of age and had a minimum 5-year follow-up at 22 of the hospitals contributing to the Pediatric Health Information System database between 2004 and 2012 were included. Frequencies of noncardiac surgical procedures by age 5 years were determined and categorized by subspecialty. Patients were stratified according to their maximum RACHS-1 (Risk Adjustment in Congenital Heart Surgery) category. The proportions of patients across hospitals who had a noncardiac surgical procedure for each subspecialty were compared using logistic mixed effects models.

Results: 8857 patients underwent congenital heart surgery during the first year of life, 3621 (41%) of whom had 13,894 noncardiac surgical procedures by 5 years. Over half of all procedures were in general surgery (4432; 31.9%) or otolaryngology (4002; 28.8%). There was significant variation among hospitals in the proportion of CHD patients having noncardiac surgical procedures. Compared to children in the low risk group (RACHS-1 categories 1-3), children in the high-risk group (categories 4-6) were more likely to have general, dental, orthopedic, and thoracic procedures.

Conclusions: Children with CHD requiring cardiac surgery frequently also undergo noncardiac surgical procedures; however, considerable variability in the frequency of these procedures exists across hospitals. This suggests a lack of uniformity in indications used for surgical intervention. Further research should aim to better standardize care for this complex patient population.

Keywords: Congenital heart disease; Non-cardiac surgery; PHIS; Pediatric Health Information System Database; Variability.

Figure 1

Strategy used to identify the cohort of patients with critical CHD undergoing cardiac surgery by 1 year of age within the PHIS database.

Figure 2

Variability between PHIS hospitals in the proportion of patients with critical CHD who undergo procedures by the four surgical subspecialties with the highest overall frequencies. (Figure) A) General surgery, B) Otolaryngology, C) Dental surgery, D) Urology, E) Neurologic surgery, F) Orthopedic surgery, G) Plastic surgery, H) Thoracic surgery, I) Ophthalmology. Unadjusted estimates and 95% CI from logistic mixed models are represented by the open circles and solid error bars; adjusted estimates and 95% CI from logistic mixed models are represented by the solid circles and dashed error bars. The asterisks denote hospitals with adjusted estimates that were significantly higher or lower than average (as shown by the reference line). The variables adjusted for were RACHS-1 group, hospital volume of the included procedures in that specialty in all patients under 5 years of age, prematurity, presence of a major non-cardiac structural anomaly, presence of Down Syndrome, presence of another major chromosomal anomaly, gender, age at first heart surgery, race, having had multiple cardiac surgery admissions by age 5, and in-hospital death by age 5. One hospital was excluded because it only contributed 8 patients.