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J Thorac Cardiovasc Surg 2002;124:97-104
© 2002 The American Association for Thoracic Surgery

Surgery for Congenital Heart Disease (CHD)

Center-specific differences in mortality: Preliminary analyses using the Risk Adjustment in Congenital Heart Surgery (RACHS-1) method

From the Department of Cardiology, Children's Hospital, Boston, Mass.

This work was supported by National Institutes of Health/National Heart, Lung, and Blood Institute grant K08HL2936-01 (Dr Jenkins) and by the Kobren Fund (Dr Gauvreau).

Received for publication March 15, 2001. Revisions requested Aug 17, 2001; revisions received Nov 2, 2001. Accepted for publication Dec 14, 2001. Address for reprints: Kathy J. Jenkins, MD, MPH, Children's Hospital, Department of Cardiology, 300 Longwood Ave, Boston, MA 02115 (E-mail: jenkins{at}cardio.tch.harvard.edu).

Objective: We sought to explore the usefulness of the Risk Adjustment in Congenital Heart Surgery method (designated RACHS-1) of adjusting for case-mix differences when comparing institutional mortality after surgery for congenital heart disease.
Methods: By using 1996 hospital discharge data from 6 states, centers performing at least 100 operations for congenital heart disease (patient age <18 years) were identified. Using the RACHS-1 method, procedures were grouped into 6 risk categories, and institutions were ranked in order of increasing mortality rate. A graphic display of ranks by risk category identified patterns of performance. Incorporating age, prematurity, and presence of a major noncardiac structural anomaly into multivariate models allowed computation of an overall risk-adjusted rank for each institution on the basis of its standardized mortality ratio.
Results: Among 109 centers performing 7177 operations for congenital heart disease, 22 performed at least 100 cases (72.3% of total operations). Unadjusted mortality rates ranged from 2.5% to 11.4%. A total of 4318 cases could be placed into 1 of the 6 risk categories. Few deaths occurred in risk category 1, and few institutions performed procedures in risk categories 5 and 6, making institutional comparisons in these categories uninformative. Considering mortality rates in categories 2 through 4, institutions displayed either relatively consistent ranks, a threshold increase in mortality as higher-risk procedures were performed, or a threshold decrease in mortality. Standardized mortality ratios indicated which institutions performed better or worse than expected on the basis of their case mix.
Conclusions: The RACHS-1 method can be used to judge relative institutional performance, either by evaluating within-risk-category differences or by comparisons of observed and expected mortality rates.

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