Adults or big kids: what is the ideal clinical environment for management of grown-up patients with congenital heart disease?

Background: Initiatives to develop Adult Congenital Centers for management of grown-up congenital heart disease (GUCH) patients (aged >/=18 years) have widened without evidence identifying the ideal clinical environment. To elucidate the optimum care paradigm, we investigated whether mortality for patients with GUCH was influenced by the type of hospital where they had surgery, children's specialty hospital (CH) versus general hospital (GH), and by the clinical focus of the surgeon, congenital heart surgery (CHS) or noncongenital (adult acquired) heart surgery (NCHS).

Methods: In the Nationwide Inpatient Sample 1988-2003, we identified index procedures in patients 18 or more years of age within 12 congenital cardiac disease diagnostic groups. The CHS surgeons were defined as those whose annual practice volume consisted of more than 75% pediatric cardiac operations. Four clinical environment combinations were constructed: CH plus CHS, CH plus NCHS, GH plus CHS, and GH plus NCHS. Years were grouped into quartiles to identify trends in management over time.

Results: In all, 29,070 operations occurred at GH and 10,971 occurred at CH. Unadjusted in-hospital mortality was lowest in the CH plus CHS environment (1.14%), and highest for in the GH plus CHS environment (9.93%; p < 0.001). After risk adjustment for patient factors, the CH plus CHS environment remained optimum, whereas the other three environments increased the risk of in-hospital death (GH plus NCHS: odds ratio 2.4 [95% confidence interval: 0.9 to 6.2]; CH plus NCHS: odds ratio 2.4 [95% confidence interval: 0.9 to 6.5]; GH plus CHS: odds ratio 9.1 [95% confidence interval: 3.0 to 27.6]). Over the study period, there was a dramatic rise in the number of GUCH patients treated in GH plus NCHS and CH plus NCHS, suggesting that the shift in clinical environment was provider specific rather than hospital-type specific.

Conclusions: Case mix varies with the clinical environment, with more complex procedures performed at GH plus CHS. The optimal environment for complex GUCH surgery involved CHS operating within CH. Initiatives to develop adult congenital centers dedicated to the care of GUCH patients are warranted, and should include congenital heart surgeons operating in a setting mimicking children's hospitals.