title: Improvement in congenital heart surgery in a developing country: the Guatemalan experience.
abstract: BACKGROUND
  In 1997, an effort was made to disseminate US pediatric cardiac surgical practices to create a new comprehensive program in Guatemala. The objective of this study was to describe the improvement of the program by exploring the reduction in risk-adjusted in-hospital mortality.
  
  
  RESULTS
  A retrospective cohort study of surgical procedures performed in Guatemala from February 1997 to July 2004 was conducted. Data were divided into 3 time periods (1997 to 1999, 2000 to 2002, and 2003 to 2004) and compared with a US benchmark (2000 Kids' Inpatient Database of 27 states and 313 institutions). The risk adjustment for congenital heart surgery (RACHS-1) method was used to adjust for case mix. Mortality rates, standardized mortality ratios, and 95% confidence intervals were calculated. A total of 1215 surgical procedures were included. Median age was 3.1 years (range, 1 day to 17.9 years). The overall mortality was 10.7% (n=130). The RACHS-1 method showed better discrimination than in prior reports (area under receiver operating characteristic curve=0.854). A decreasing trend in mortality rate was observed in every RACHS-1 risk category over the 3 time periods. When compared against the US benchmark, the reduction in risk-adjusted mortality was noted by a decrease of standardized mortality ratio from 10.0 (95% confidence interval, 7.2 to 13.7) in 1997-1999, to 7.8 (95% confidence interval, 5.9 to 10.0) in 2000-2002, and to 5.7 (95% confidence interval, 3.8 to 8.3) in 2003-2004.
  
  
  CONCLUSIONS
  In a short time period, mortality after congenital heart surgery has been reduced substantially in Guatemala. Measurement of risk-adjusted mortality is a useful method to assess pediatric cardiac program improvement in the developing world.
authors.affiliation: Department of Cardiology, Children's Hospital Boston, Harvard Medical School, Boston, MA 02115, USA.
authors.forename: Luis A
authors.initials: LA
authors.lastname: Larrazabal
authors.forename: Kathy J
authors.initials: KJ
authors.lastname: Jenkins
authors.forename: Kimberlee
authors.initials: K
authors.lastname: Gauvreau
authors.forename: Vladimiro L
authors.initials: VL
authors.lastname: Vida
authors.forename: Oscar J
authors.initials: OJ
authors.lastname: Benavidez
authors.forename: Guillermo A
authors.initials: GA
authors.lastname: Gaitán
authors.forename: Flor
authors.initials: F
authors.lastname: Garcia
authors.forename: Aldo R
authors.initials: AR
authors.lastname: Castañeda
mesh_terms: D006348:Cardiac Surgical Procedures / Q000401:mortality; D003906:Developing Countries; D005260:Female; D006166:Guatemala; D006330:Heart Defects, Congenital / Q000401:mortality* / Q000601:surgery*; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D009313:National Health Programs; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate; D014481:United States