2018 John H. Gibbon, Jr., Lecture

Early Hospital Mortality: A Misleading Metric for Quality Assurance in the New Era of Hybrid

Early Hospital Mortality: A Misleading Metric for Quality Assurance | Clinical Congress

Richard Andrew Jonas MBBS, FACS, FRACS

It was truly a great honor to present the Gibbon Lecture in 2018. My goal was to focus attention on what I saw then and now—three years later—as one of the greatest threats to 50 years of progress towards widespread acceptance of the advantages of early repair of congenital heart anomalies. What I did not foresee at the time was the dramatic impact the COVID-19 pandemic would have in changing the priorities of hospitals and surgeons. The principal database used by surgeons throughout North America has produced almost no outcomes data for most of the pandemic. Data collection from many countries by the World Database managed by Dr. Jim Kirklin and his team at University of Alabama–Birmingham (UAB) for the World Society for Pediatric and Congenital Heart Surgery has also been seriously impacted by the worldwide impact of the pandemic.

The program notes from 2018 summarized the thesis of my lecture well:\

The problem, Dr. Jonas said, is that pediatric databases used widely in the United States and Europe focus on early hospital mortality as a quality marker for the treatment of congenital heart repairs as initially developed for adult cardiac surgery. Although the highest-risk pediatric patients are more likely to survive an initial palliative procedure, they have an important risk of death before the later repair which is not captured by the early mortality metric. With early primary repair the early mortality metric captures every death suggesting a higher mortality with this approach even though there is actually significantly improved one-year and longer survival.

“The current incentive is pressuring hospitals away from early primary repair, which is important to the child, the family and society,” he said. “We need a congenital heart defect database that includes all patients who arrive in a hospital with a diagnosis. Survival at least one year out is how congenital heart care should be judged. Avoiding early primary repair is a retrograde step for our specialty.”