CAPS Original Papers
Effect of hospital case volume on outcome in congenital diaphragmatic hernia: the experience of the Canadian Pediatric Surgery Network

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Abstract

Purpose

Despite advances in neonatal care of congenital diaphragmatic hernia (CDH), a significant variation exists in the mortality rates reported by individual centers. Center experience (reflected by case volume) may contribute to this variation in outcome. The aim of the study was to determine whether CDH mortality is affected by hospital case volume.

Methods

The CDH cases were abstracted from a disease-specific, 16-hospital, national network. Thirteen hospitals participated in this study. Anonymized hospitals were categorized as either high (>6 cases) or low-volume (≤6 cases) centers (HVC, n = 6; LVC, n = 7) according to the median case number per center. Risk-adjusted (Score for Neonatal Acute Physiology, version II [SNAP-II] score) mortality rates were compared between HVC and LVC.

Results

One hundred twenty-one CDH cases were identified. Overall in-hospital survival was 81%. No significant difference in SNAP-II score was observed between HVC and LVC. Of 97 (15%) infants treated in 6 HVC, 15 (15%) died compared to 8 (33%) of 24 in 7 LVC (P < .05).

Conclusion

Hospital case volume may be partially responsible for mortality rate variation in CDH. This result requires careful analysis, as case volume may merely be a surrogate for other predictive variables.

Section snippets

Study population

Congenital diaphragmatic hernia cases were accrued between May 1, 2005, and January 1, 2008, at 13 CAPSNet centers. Cases were identified at prenatal diagnosis (if one was made) or after birth, and data were abstracted from diagnosis to death or discharge from the CAPSNet center.

The purpose of CAPSNet and its process of case ascertainment and data abstraction have been described previously [11]. Briefly, on-site trained research assistants abstract data from maternal and infant charts using a

Results

One hundred twenty-one CDH cases were entered into the database from the 13 contributing CAPSNet sites (Table 1). Of the 121 cases in the database, 98 survived to hospital discharge for an actual survival rate of 81% across all centers.

The median number of cases per site was 6. Six centers were identified as having greater than 6 CDH patient admissions (range, 7-36; n = 97 patients), entered in the database during the 31-month study period, and these hospitals were classified as HVC. The

Discussion

Multiple studies have been published on survival rates for infants with CDH demonstrating significant variability among centers [1], [2], [3], [4], [5], [6], [7], [8], [9], [10]. Improvements in preoperative stabilization, including the establishment of physiologic goal-directed ventilatory and cardiovascular treatment algorithms that address pulmonary hypoplasia and pulmonary hypertension while minimizing iatrogenic injury, have allowed some tertiary pediatric centers to report survival rates

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  • Cited by (0)

    Presented at the 40th Annual CAPS Meeting, August 21-24, 2008, Toronto, Ontario, Canada.

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