Learning About Small vs Large Congenital Heart Programs

Recent debates comparing quality in low-volume vs high-volume congenital heart programs are increasingly adversarial - and are focusing on the wrong question.

Rather than ask the overly simplistic question: “Which type of program is better?”, we should be studying high-performing programs to learn how they achieve high-quality outcomes. Examination of publicly reported data demonstrates that some low-volume programs consistently outperform high-volume programs in risk-adjusted comparisons. Therefore, the question we should be asking is: What are the attributes associated with superior performance in low-volume congenital heart programs?

The Congenital Heart Surgeons Society (CHSS) is taking a leadership role with an exciting study to better understand how some low-volume programs consistently perform so very well. Addressing this question will provide important information that can help to improve care in all programs.

The CHSS Quality and Outcomes Committee is leading this project with generous funding from the Brett Boyer Foundation. The Committee will focus on the 38 programs that perform between 75-200 STS index cases per year. This volume range is cited in a recent multi-society manuscript describing these centers as ‘Essential Care Centers’ (Backer et al; Recommendations for centers performing pediatric heart surgery in the United States. J Thor Cardiovasc Surg (166) 6, 2023 pp 1782-1820).

To tackle our research question, the CHSS Quality and Outcomes Committee will examine two types of data:

1. Conventional attributes will focus on easily measurable and widely recognized variables commonly cited in studies of this sort. Examples include the organizational characteristics of the ICU, nursing staffing ratios, perfusion practices, ECMO availability, surgeon experience, anesthesia coverage, and cardiology programmatic support etc… This quantitative data can be analyzed using standard statistical techniques.

2. Unconventional attributes that the Committee feels are likely to be important include examination of the relationship between the clinical teams and the hospital administration, stability of the clinical team (e.g. ‘revolving door’ or consistent team), availability of shared discretionary funds available for the heart program leadership, core competencies of high performing teams (trust, common purpose, shared consciousness, empowered execution) etc… These qualitative data will be obtained through a structured interview process with participating clinical leaders led by Erle Austin (a trusted colleague and past-President of the CHSS).

The CHSS Quality and Outcomes Committee is heavily engaged in getting this project off the ground and includes (alphabetically) Petros Anagnostopoulos, Robert Dabal, Bill Douglas, Kristine Guleserian, Jeremy Herrmann, Jeff Jacobs, Jim Kirklin, Sara Pasquali, Jim St Louis, and Ram Subramanyan. Michael-Alice Moga serves as the committee’s liaison with the CHSS Center for Research and Quality. The project’s organization and execution is being led by Karl Welke who has a long history of publications focused on quality in surgical outcomes.

This exciting initiative is an example of how the CHSS is constantly seeking ways to improve care for our patients. If we can identify the attributes associated with superior performance in low-volume programs, we can share the information and improve care across the board.