(From the March 2015 Issue of PediatricsOnline)
Congenital heart disease (CHD) occurs in up to 1 percent of all live births and causes more deaths in the first year of life than any other birth defect. In a recent study, a team of clinician-scientists at Nationwide Children’s Hospital and collaborating institutions examined the frequency of non-cardiac surgeries performed in children with critical CHD. They found significant variability across hospitals, suggesting a need for standardization to improve clinical management for this pediatric patient population.
Children with CHD who undergo a major cardiac surgery procedure by one year of age are considered to have critical CHD. These children often also have non-cardiac surgical procedures to correct comorbidities or other health concerns.
“It was important to conduct this study to characterize the non-cardiac burden of disease associated with critical CHD in children, since there is little information regarding the types and frequencies of non-cardiac procedures performed in these patients,” says Katherine J. Deans, MD, a pediatric surgeon at Nationwide Children’s and senior author of the study, which was published in the Journal of Pediatric Surgery. “It was also important to assess for variability in practice, as these children are at a higher risk for complications from surgical procedures.”
Dr. Deans and her colleagues examined 8,857 patients who underwent cardiac surgery during the first year of life and were followed for a minimum of five years between 2004 and 2012. They used data from 22 hospitals that contributed to the Pediatric Health Information System database. The team determined the type and frequency of non-cardiac surgical procedures performed by 5 years of age, then compared the proportions of patients across hospitals that had a non-cardiac surgical procedure for each subspecialty.
Of the patients who underwent cardiac surgery during their first year of life, 41 percent had undergone non-cardiac surgical procedures by 5 years of age, and over half of these non-cardiac surgical procedures were in general surgery or otolaryngology. The data also revealed significant variation among hospitals with respect to the proportion of critical CHD patients having non-cardiac surgical procedures in all subspecialties. Specifically, the following ranges of variability remained after adjustment for patient and hospital-level factors, with the exception of neurosurgery: 15-32 percent of patients underwent procedures classified as general surgery, 5-28 percent as otolaryngology, 1-10 percent as dental and 4-28 percent as urology.
“If variability exists, as was demonstrated in this study, then there is room for improvement in clinical practice,” says Peter C. Minneci, MD, pediatric surgeon at Nationwide Children’s and co-author of the study. “Specifically, by standardizing indications for procedures, the number of procedures that are performed could potentially be decreased for this complex patient population.”
According to Drs. Deans and Minneci, most prior studies have presented the experience of a single health care institution and therefore have limited generalizability. Such studies also cannot adequately assess the practice variability that exists across institutions. Acquiring a more comprehensive understanding of the non-cardiac surgical procedures performed at a multitude of tertiary children’s hospitals is crucial in identifying variations in practice and can help set better expectations for families of children with CHD, they say.
“This study provides clinicians with data that can be used when counseling patients of children with critical CHD, by presenting estimates of the potential need for and types of additional non-cardiac surgical procedures in children with critical CHD,” explains Dr. Deans, who is also a principal investigator in the Center for Innovation in Pediatric Practice in The Research Institute, along with Dr. Minneci.
With more than 90 percent of children with CHD now surviving into adulthood due to improvements in medical care, this growing population of patients may undergo additional surgical procedures by non-cardiac surgical specialists for reasons that may or may not be related to their CHD diagnosis. The researchers state that future studies examining specific high-volume procedures in children with CHD are necessary in order to determine the reasons for variability among hospitals and potentially identify best practices that can be used in all institutions.
Sulkowski JP, Cooper JN, McConnell PI, Pasquali SK, Shah SS, Minneci PC, Deans KJ. Variability in noncardiac surgical procedures in children with congenital heart disease. Journal of Pediatric Surgery. 2014 Nov, 49(11):1564-9.