title: Morbidity and mortality prediction in pediatric heart surgery: Physiological profiles and surgical complexity.
abstract: Outcome prediction for pediatric heart surgery has focused on mortality but mortality has been significantly reduced over the past 2 decades. Clinical care practices now emphasize reducing morbidity. Physiology-based profiles assessed by the Pediatric Risk of Mortality (PRISM) score are associated with new significant functional morbidity detected at hospital discharge. Our aims were to assess the relationship between new functional morbidity and surgical risk categories (Risk Adjustment for Congenital Heart Surgery [RACHS] and Society for Thoracic Surgery Congenital Heart Surgery Database Mortality Risk [STAT]), measure the performance of 3-level (intact survival, survival with new functional morbidity, or death) and 2-level (survival or death) PRISM prediction algorithms, and assess whether including RACHS or STAT complexity categories improves the PRISM predictive performance.
  
  
  
  Patients (newborn to age 18 years) were randomly selected from 7 sites (December 2011-April 2013). Morbidity (using the Functional Status Scale) and mortality were assessed at hospital discharge. The most recently published PRISM algorithms were tested for goodness of fit, and discrimination with and without the RACHS and STAT complexity categories.
  
  
  
  The mortality rate in the 1550 patients was 3.2%. Significant new functional morbidity rate occurred in 4.8%, increasing from 1.8% to 13.9%, 1.7%, and 12.9% from the lowest to the highest RACHS and STAT categories, respectively. The 3-level and 2-level PRISM models had satisfactory goodness of fit and substantial discriminative ability. Inclusion of RACHS and STAT complexity categories did not improve model performance.
  
  
  
  Both mortality and new, functional morbidity are important outcomes associated with surgical complexity and can be predicted using PRISM algorithms. Adding surgical complexity to the physiologic profiles does not improve predictor performance.
authors.affiliation: Department of Pediatrics, Children's National Medical Center, Washington, DC.
authors.forename: John T
authors.initials: JT
authors.lastname: Berger
authors.affiliation: Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah.
authors.forename: Richard
authors.initials: R
authors.lastname: Holubkov
authors.affiliation: Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah.
authors.forename: Ron
authors.initials: R
authors.lastname: Reeder
authors.affiliation: Department of Pediatrics, Children's National Medical Center, Washington, DC.
authors.forename: David L
authors.initials: DL
authors.lastname: Wessel
authors.affiliation: Department of Pediatrics, Children's Hospital of Michigan, Detroit, Mich.
authors.forename: Kathleen
authors.initials: K
authors.lastname: Meert
authors.affiliation: Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pa.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Berg
authors.affiliation: Department of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pa.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Bell
authors.affiliation: Pediatric Trauma and Critical Illness Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institutes of Health, Bethesda, Md.
authors.forename: Robert
authors.initials: R
authors.lastname: Tamburro
authors.affiliation: Department of Pediatrics, Children's Hospital of Michigan, Detroit, Mich.
authors.forename: J Michael
authors.initials: JM
authors.lastname: Dean
authors.affiliation: Department of Pediatrics, Children's National Medical Center, Washington, DC; George Washington University School of Medicine and Health Sciences, Washington, DC. Electronic address: mpollack@childrensnational.org.
authors.forename: Murray M
authors.initials: MM
authors.lastname: Pollack
mesh_terms: D000293:Adolescent; D000367:Age Factors; D000465:Algorithms; D006348:Cardiac Surgical Procedures / Q000009:adverse effects* / Q000379:methods / Q000401:mortality; D002648:Child; D002675:Child, Preschool; D006330:Heart Defects, Congenital / Q000601:surgery; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D012372:ROC Curve; D018570:Risk Assessment; D012307:Risk Factors; D016019:Survival Analysis
keywords: congenital heart disease; critical care; intensive care; morbidity; outcome prediction; pediatric critical care; pediatric heart surgery; pediatric intensive care; pediatric risk of mortality; pediatrics; physiological status; quality; quality assessment; severity of illness