Variation in Adjusted Mortality for Medical Admissions to Pediatric Cardiac ICUs

Objectives: Pediatric cardiac ICUs should be adept at treating both critical medical and surgical conditions for patients with cardiac disease. There are no case-mix adjusted quality metrics specific to medical cardiac ICU admissions. We aimed to measure case-mix adjusted cardiac ICU medical mortality rates and assess variation across cardiac ICUs in the Pediatric Cardiac Critical Care Consortium. Design: Observational analysis. Setting: Pediatric Cardiac Critical Care Consortium clinical registry. Patients: All cardiac ICU admissions that did not include cardiac surgery. Interventions: None. Measurements and Main Results: The primary endpoint was cardiac ICU mortality. Based on multivariable logistic regression accounting for clustering, we created a case-mix adjusted model using variables present at cardiac ICU admission. Bootstrap resampling (1,000 samples) was used for model validation. We calculated a standardized mortality ratio for each cardiac ICU based on observed-to-expected mortality from the fitted model. A cardiac ICU was considered a statistically significant outlier if the 95% CI around the standardized mortality ratio did not cross 1. Of 11,042 consecutive medical admissions from 25 cardiac ICUs (August 2014 to May 2017), the observed mortality rate was 4.3% (n = 479). Final model covariates included age, underweight, prior surgery, time of and reason for cardiac ICU admission, high-risk medical diagnosis or comorbidity, mechanical ventilation or extracorporeal membrane oxygenation at admission, and pupillary reflex. The C-statistic for the validated model was 0.87, and it was well calibrated. Expected mortality ranged from 2.6% to 8.3%, reflecting important case-mix variation. Standardized mortality ratios ranged from 0.5 to 1.7 across cardiac ICUs. Three cardiac ICUs were outliers; two had lower-than-expected (standardized mortality ratio 1) mortality. Conclusions: We measured case-mix adjusted mortality for cardiac ICU patients with critical medical conditions, and provide the first report of variation in this quality metric within this patient population across Pediatric Cardiac Critical Care Consortium cardiac ICUs. This metric will be used by Pediatric Cardiac Critical Care Consortium cardiac ICUs to assess and improve outcomes by identifying high-performing (low-mortality) centers and engaging in collaborative learning. Lauren Retzloff is now Lauren Bush. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (https://ift.tt/2gIrZ5Y). Supported, in part, by funding from the University of Michigan Congenital Heart Center, CHAMPS for Mott, and the Michigan Institute for Clinical & Health Research (National Institutes of Health/NCATS UL1TR002240). Dr. Gaies received support for article research from the National Institutes of Health/National Heart, Lung, and Blood Institute (K08HL116639). Dr. Costello disclosed that he has served on Pediatric Cardiac Critical Care Consortium’s Executive Committee for the last 5–6 year (unpaid, volunteer position). Ms. Zhang disclosed work for hire. Dr. Pasquali receives support from the Janette Ferrantino Professorship. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: mgaies@med.umich.edu ©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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