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Development of a Congenital Heart Surgery Composite Quality Metric: Part 2-Analytic Methods.

ABSTRACT: BACKGROUND:We describe the statistical methods and results related to development of the first congenital heart surgery composite quality measure. METHODS:The composite measure was developed using The Society of Thoracic Surgeons Congenital Heart Surgery Database (2012 to 2015), Bayesian hierarchical modeling, and the current Society of Thoracic Surgeons risk model for case-mix adjustment. It consists of a mortality domain (operative mortality) and morbidity domain (major complications and postoperative length of stay). We evaluated several potential weighting schemes and properties of the final composite measure, including reliability (signal-to-noise ratio) and hospital classification in various performance categories. RESULTS:Overall, 100 hospitals (78,425 operations) were included. Each adjusted metric included in the composite varied across hospitals: operative mortality (median, 3.1%; 10th to 90th percentile, 2.1% to 4.4%) major complications (median 11.7%, 10th to 90th percentile, 6.4% to 17.4%), and length of stay (median, 7.0 days; 10th to 90th percentile, 5.9 to 8.2 days). In the final composite weighting scheme selected, mortality had the greatest influence, followed by major complications and length of stay (correlation with overall composite score of 0.87, 0.69, and 0.47, respectively). Reliability of the composite measure was 0.73 compared with 0.59 for mortality alone. The distribution of hospitals across composite measure performance categories (defined by whether the 95% credible interval overlapped The Society of Thoracic Surgeons average) was 75% (same as expected), 9% (worse than expected), and 16% (better than expected). CONCLUSIONS:This congenital heart surgery composite measure incorporates aspects of both morbidity and mortality, has clinical face validity, and greater ability to discriminate hospital performance compared with mortality alone. Ongoing efforts will support the use of the composite measure in benchmarking and quality improvement activities.

SUBMITTER: O'Brien SM

PROVIDER: S-EPMC6559355 | biostudies-literature | 2019 Feb

REPOSITORIES: biostudies-literature

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Development of a Congenital Heart Surgery Composite Quality Metric: Part 2-Analytic Methods.

O'Brien Sean M SM Jacobs Jeffrey P JP Shahian David M DM Jacobs Marshall L ML Gaynor J William JW Romano Jennifer C JC Gaies Michael G MG Hill Kevin D KD Mayer John E JE Pasquali Sara K SK

The Annals of thoracic surgery 20180915 2

<h4>Background</h4>We describe the statistical methods and results related to development of the first congenital heart surgery composite quality measure.<h4>Methods</h4>The composite measure was developed using The Society of Thoracic Surgeons Congenital Heart Surgery Database (2012 to 2015), Bayesian hierarchical modeling, and the current Society of Thoracic Surgeons risk model for case-mix adjustment. It consists of a mortality domain (operative mortality) and morbidity domain (major complica ...[more]

PMID: 30227128

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Project description:INTRODUCTION:Reduced health-related quality of life (HRQOL) has been reported in postoperative patients with congenital heart disease (CHD). However, there is a paucity of data from low-income and middle-income countries (LMIC). Differences in sociodemographics and sociocultural contexts may influence HRQOL. This protocol paper describes a study exploring HRQOL in surgical patients with CHD from a tertiary hospital in Pakistan. The study findings will assist development of strategies to improve HRQOL in a resource-constrained context. METHODS AND ANALYSIS:This prospective, concurrent triangulation, mixed-methods study aims to compare HRQOL of postsurgery patients with CHD with age-matched healthy siblings and to identify HRQOL predictors. A qualitative component aims to further understand HRQOL data by exploring the experiences related to CHD surgery for patients and parents. Participants include patients with CHD (a minimum of n~95) with at least 1-year postsurgery follow-up and no chromosomal abnormality, their parents and age-matched, healthy siblings. PedsQL 4.0 Generic Core Scales, PedsQL Cognitive Functioning Scale and PedsQL 3.0 Cardiac Module will measure HRQOL. Clinical/surgical data will be retrieved from patients' medical files. Student's t-test will be used to compare the difference in the means of HRQOL between CHD and siblings. Multiple regression will identify HRQOL predictors. A subsample of enrolled patients (n~20) and parents (n~20) from the quantitative arm will be engaged in semistructured qualitative interviews, which will be analysed using directed content analysis. Anticipated challenges include patient recruitment due to irregular follow-up compliance. Translation of data collection tools to the Urdu language and back-translation of interviews increases the study complexity. ETHICS AND DISSEMINATION:Ethics approval has been obtained from The Aga Khan University, Pakistan (3737-Ped-ERC-15). Study findings will be published in peer-reviewed journals and presented at national and international conferences.

Project description:Ischemic Heart Disease (IHD) is the leading cause of death worldwide. The Global Burden of Diseases, Injuries and Risk Factors (GBD) 2010 Study estimated IHD mortality and disability burden for 21 world regions for the years 1990 to 2010.Data sources for GBD IHD epidemiology estimates were mortality surveillance, verbal autopsy, and vital registration data (for IHD mortality) and systematic review of IHD epidemiology literature published 1980-2008 (for non-fatal IHD outcomes). An estimation and validation process led to an ensemble model of IHD mortality by country for all 21 world regions, adjusted for country-level covariates. Disease models were developed for the nonfatal sequelae of IHD: myocardial infarction, stable angina pectoris, and ischemic heart failure.Country level covariates including metabolic and nutritional risk factors, education, war, and annual income per capita contributed to the ensemble model for the analysis of IHD death. In the acute myocardial infarction model, inclusion of troponin in the diagnostic criteria of studies published after the year 2000 was associated with a 50% higher incidence. Self-reported diagnosis of angina significantly overestimated stable angina prevalence compared with "definite" angina elicited by the Rose angina questionnaire. For 2010, Eastern Europe and Central Asia had the highest rates of IHD death and the Asia Pacific High-Income, East Asia, Latin American Andean, and sub-Saharan Africa regions had the lowest.Global and regional IHD epidemiology estimates are needed for estimating the worldwide burden of IHD. Using descriptive meta-analysis tools, the GBD 2010 standardized and pooled international data by adjusting for region-level mortality and risk factor data, and study level diagnostic method. Analyses maximized internal consistency, generalizability, and adjustment for known sources of bias. The GBD IHD analysis nonetheless highlights the need for improved IHD epidemiology surveillance in many regions and the need for uniform diagnostic standards.

Project description:BackgroundCombinations of foods that provide suitable levels of nutrients and energy are required for optimum health. Currently, however, it is difficult to define numerically what are 'suitable levels'.ObjectiveTo develop new metrics based on energy considerations-the Nutrient Balance Concept (NBC)-for assessing overall nutrition quality when combining foods and meals.MethodThe NBC was developed using the USDA Food Composition Database (Release 27) and illustrated with their MyPlate 7-day sample menus for a 2000 calorie food pattern. The NBC concept is centered on three specific metrics for a given food, meal or diet-a Qualifying Index (QI), a Disqualifying Index (DI) and a Nutrient Balance (NB). The QI and DI were determined, respectively, from the content of 27 essential nutrients and 6 nutrients associated with negative health outcomes. The third metric, the Nutrient Balance (NB), was derived from the Qualifying Index (QI) and provided key information on the relative content of qualifying nutrients in the food. Because the Qualifying and Disqualifying Indices (QI and DI) were standardized to energy content, both become constants for a given food/meal/diet and a particular consumer age group, making it possible to develop algorithms for predicting nutrition quality when combining different foods.ResultsCombining different foods into composite meals and daily diets led to improved nutrition quality as seen by QI values closer to unity (indicating nutrient density was better equilibrated with energy density), DI values below 1.0 (denoting an acceptable level of consumption of disqualifying nutrients) and increased NB values (signifying complementarity of foods and better provision of qualifying nutrients).ConclusionThe Nutrient Balance Concept (NBC) represents a new approach to nutrient profiling and the first step in the progression from the nutrient evaluation of individual foods to that of multiple foods in the context of meals and total diets.

Project description:BackgroundOptimal strategies to improve national congenital heart surgery outcomes and reduce variability across hospitals remain unclear. Many policy and quality improvement efforts have focused primarily on higher-risk patients and mortality alone. Improving our understanding of both morbidity and mortality and current variation across the spectrum of complexity would better inform future efforts.MethodsHospitals participating in the Society of Thoracic Surgeons Congenital Heart Surgery Database (2014-2017) were included. Case mix-adjusted operative mortality, major complications, and postoperative length of stay were evaluated using Bayesian models. Hospital variation was quantified by the interdecile ratio (IDR, upper versus lower 10%) and 95% credible intervals (CrIs). Stratified analyses were performed by risk group (Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery [STAT] category) and simulations evaluated the potential impact of reductions in variation.ResultsA total of 102 hospitals (n=84 407) were included, representing ≈85% of US congenital heart programs. STAT category 1 to 3 (lower risk) operations comprised 74% of cases. All outcomes varied significantly across hospitals: adjusted mortality by 3-fold (upper versus lower decile 5.0% versus 1.6%, IDR 3.1 [95% CrI 2.5-3.7]), mean length of stay by 1.8-fold (19.2 versus 10.5 days, IDR 1.8 [95% CrI 1.8-1.9]), and major complications by >3-fold (23.5% versus 7.0%, IDR 3.4 [95% CrI 3.0-3.8]). The degree of variation was similar or greater for low- versus high-risk cases across outcomes, eg, ≈3-fold mortality variation across hospitals for STAT 1 to 3 (IDR 3.0 [95% CrI 2.1-4.2]) and STAT 4 or 5 (IDR 3.1 [95% CrI 2.4-3.9]) cases. High-volume hospitals had less variability across outcomes and risk categories. Simulations suggested potential reductions in deaths (n=282), major complications (n=1539), and length of stay (101 183 days) over the 4-year study period if all hospitals were to perform at the current median or better, with 37% to 60% of the improvement related to the STAT 1 to 3 (lower risk) group across outcomes.ConclusionsWe demonstrate significant hospital variation in morbidity and mortality after congenital heart surgery. Contrary to traditional thinking, a substantial portion of potential improvements that could be realized on a national scale were related to variability among lower-risk cases. These findings suggest modifications to our current approaches to optimize care and outcomes in this population are needed.

Dataset Information

Development of a Congenital Heart Surgery Composite Quality Metric: Part 2-Analytic Methods.

Publications

Development of a Congenital Heart Surgery Composite Quality Metric: Part 2-Analytic Methods.

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