title: The Norwood operation: Relative effects of surgeon and institutional volumes on outcomes and resource utilization.
abstract: BACKGROUND
  Hypoplastic left heart syndrome is the most expensive birth defect managed in the United States, with a 5-year survival rate below 70%. Increasing evidence suggests that hospital volumes are inversely associated with mortality for infants with single ventricles undergoing stage 1 surgical palliation. Our aim was to examine the relative effects of surgeon and institutional volumes on outcomes and resource utilisation for these children.
  
  
  METHODS
  A retrospective study was conducted using the Pediatric Health Information System database to examine the effects of the number of procedures performed per surgeon and per centre on mortality, costs, and post-operative length of stay for infants undergoing Risk Adjustment for Congenital Heart Surgery risk category six operations at tertiary-care paediatric hospitals, from 1 January, 2004 to 31 December, 2013. Multivariable modelling was used, adjusting for patient and institutional characteristics. Gaussian kernel densities were constructed to show the relative distributions of the effects of individual institutions and surgeons, before and after adjusting for the number of cases performed.
  
  
  RESULTS
  A total of 2880 infants from 35 institutions met the inclusion criteria. Mortality was 15.0%. Median post-operative length of stay was 24 days (IQR 14-41). Median standardized inpatient hospital costs were $156,000 (IQR $108,000-$248,000) in 2013 dollars. In the multivariable analyses, higher institutional volume was inversely associated with mortality (p=0.001), post-operative length of stay (p=0.004), and costs (p=0.001). Surgeon volume was associated with none of the measured outcomes. Neither institutional nor surgeon volumes explained much of the wide variation in outcomes and resource utilization observed between institutions and between surgeons.
  
  
  CONCLUSIONS
  Increased institutional - but not surgeon - volumes are associated with reduced mortality, post-operative length of stay, and costs for infants undergoing stage 1 palliation.
authors.affiliation: 1Division of Pediatric Cardiology,NewYork-Presbyterian/Morgan Stanley Children's Hospital,Columbia University Medical Center,New York,New York,United States of America.
authors.forename: Brett R
authors.initials: BR
authors.lastname: Anderson
authors.affiliation: 2Division of Biostatistics in the Division of Child and Adolescent Psychiatry,New York University,New York,New York,United States of America.
authors.forename: Adam J
authors.initials: AJ
authors.lastname: Ciarleglio
authors.affiliation: 3Division of Cardiology,St. Luke's Mid America Heart Institute and University of Missouri-Kansas City,Kansas City,Missouri,United States of America.
authors.forename: David J
authors.initials: DJ
authors.lastname: Cohen
authors.affiliation: 1Division of Pediatric Cardiology,NewYork-Presbyterian/Morgan Stanley Children's Hospital,Columbia University Medical Center,New York,New York,United States of America.
authors.forename: Wyman W
authors.initials: WW
authors.lastname: Lai
authors.affiliation: 4Department of Health Policy and Management,Mailman School of Public Health,New York,New York,United States of America.
authors.forename: Matthew
authors.initials: M
authors.lastname: Neidell
authors.affiliation: 5Children's Hospital Association,Overland Park,Kansas,United States of America.
authors.forename: Matthew
authors.initials: M
authors.lastname: Hall
authors.affiliation: 6Robert F. Wagner Graduate School of Public Service,New York University,New York,New York,United States of America.
authors.forename: Sherry A
authors.initials: SA
authors.lastname: Glied
authors.affiliation: 7Division of Cardiothoracic Surgery,Columbia University College of Physicians and Surgeons,New York,New York,United States of America.
authors.forename: Emile A
authors.initials: EA
authors.lastname: Bacha
mesh_terms: D003365:Costs and Cost Analysis; D005260:Female; D006295:Health Resources / Q000706:statistics & numerical data*; D061847:Hospitals, High-Volume; D006801:Humans; D018636:Hypoplastic Left Heart Syndrome / Q000191:economics / Q000601:surgery*; D007231:Infant, Newborn; D008297:Male; D058327:Norwood Procedures / Q000191:economics / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D013903:Thoracic Surgery; D016896:Treatment Outcome; D000078329:Workforce
keywords: Hypoplastic left heart syndrome; Norwood; costs; outcomes; surgeon volume