Evaluation of failure to rescue as a quality metric in pediatric heart surgery: an analysis of the STS Congenital Heart Surgery Database.
BACKGROUND
Failure to rescue (FTR; the probability of death after a complication) has been adopted as a quality metric in adult cardiac surgery, in which it has been shown that high-performing centers with low mortality rates do not have fewer complications, but rather lower mortality in those who experience a complication (lower FTR). It is unknown whether this holds true in pediatric heart surgery. We characterized the relationship between complications, FTR, and mortality in this population.


METHODS
Children (0 to 18 years) undergoing heart surgery at centers participating in the Society of Thoracic Surgeons Congenital Heart Surgery Database (2006 to 2009) were included. Outcomes were examined in multivariable analysis adjusting for patient characteristics, surgical risk category, and within-center clustering.


RESULTS
This study included 40,930 patients from 72 centers. Overall in-hospital mortality was 3.7%, 39.3% had a postoperative complication, and the FTR rate (number of deaths in those with a complication) was 9.1%. When hospitals were characterized by in-hospital mortality rate, there was no difference across hospital mortality tertiles in the complication rate in adjusted analysis; however, hospitals in the lowest mortality tertile had significantly lower FTR rates (6.6% versus 12.4%; p<0.0001). Similar results were seen when evaluating high-severity complications and across surgical risk groups.


CONCLUSIONS
This analysis suggests that hospitals with low mortality rates do not have fewer complications after pediatric heart surgery, but instead have lower mortality in those who experience a complication (lower FTR). Further investigation into FTR as a quality metric in pediatric heart surgery is warranted.
Department of Pediatrics, Duke University School of Medicine, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina 27715, USA. sara.pasquali@duke.edu
Sara K
SK
Pasquali
Xia
X
He
Jeffrey P
JP
Jacobs
Marshall L
ML
Jacobs
Sean M
SM
O'Brien
J William
JW
Gaynor
D000293:Adolescent; D006348:Cardiac Surgical Procedures / Q000592:standards*; D002648:Child; D002675:Child, Preschool; D016208:Databases, Factual; D005260:Female; D006330:Heart Defects, Congenital / Q000601:surgery*; D006331:Heart Diseases / Q000151:congenital* / Q000601:surgery*; D017052:Hospital Mortality; D006801:Humans; D007223:Infant; D008297:Male; D010372:Pediatrics; D011183:Postoperative Complications / Q000401:mortality*; D011787:Quality of Health Care