Can Regionalization Decrease the Number of Deaths for Children Who Undergo Cardiac Surgery? A Theoretical Analysis

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Abstract
Objective. The association between high case volumes and better patient outcomes has been demonstrated for many surgical procedures and medical treatments, including surgery for children with congenital heart disease. To simulate the effects of regionalization of pediatric cardiac surgery, we assessed the impact of reducing the number of pediatric cardiac centers on surgical mortality and patient's travel distance. Methods. This study used abstracted statewide hospital discharge data from California from 1995 to 1997. Case volume and in-hospital mortality for pediatric cardiac surgeries at each hospital were calculated. All hospitals that performed greater than or equal to 10 pediatric cardiac surgeries in 1995 to 1997 were included in the analysis. To simulate regionalization, we "closed" the hospital with the lowest case volume and redistributed patients from this hospital to the nearest remaining hospitals. The number of in-hospital deaths was then recalculated using the original mortality rate of each remaining hospital multiplied by its new case volume. A multivariate logistic regression was conducted to determine the odds ratios of mortality of various types of surgery compared with closure of ventricular septal defect. This result was used for adjusting for the case-mix of the hospitals. Regionalization simulation analysis was repeated, and the number of deaths was recalculated using this adjustment of hospital case-mix. We also examined the increase in travel distance of patients to the hospitals as a result of the regionalization simulation. Results. In California, 6592 children underwent cardiac surgeries in 1995 to 1997 with 352 in-hospital deaths (overall mortality rate: 5.34%). A quadratic regression model demonstrated that a high surgical volume was associated with a low mortality rate. We found demarcations between low- and medium-volume hospitals at 70 cases per year and medium- and high-volume hospitals at 170 cases per year. With adjustment for hospital case-mix, we found that 41 deaths could be avoided when all patients from low- volume hospitals were referred, and 83 deaths could be avoided when all patients from low- and medium- volume hospitals were referred to high-volume hospitals (overall mortality rate decreased to 4.08%). The average travel distance for pediatric cardiac surgery was 45.4 miles, which increased by 12.7 miles when all surgeries were referred to high-volume hospitals. When only the 733 high-risk patients were referred from low- and medium- volume hospitals to high-volume hospitals, 49 deaths could be avoided, yielding an overall mortality rate of 4.60%. Conclusions. Theoretical regionalization of pediatric cardiac surgery is associated with a reduction in surgical mortality from 5.34% to 4.08% when all cases were referred to high-volume hospitals, or decrease to 4.60% when high-risk cases were referred. Although regionalization is associated with an important decrease in the number of deaths, it also increases the travel distance for patients. Additional studies on the costs and benefits of regionalization are needed to determine the best strategies to improve outcomes for children who undergo cardiac surgery.