Working in Teams: Data and Communication

Objective: The pathway to become a congenital heart surgeon(CHS) is challenging and unpredictable. Previous voluntary manpower surveys have shed partial light on this problem but have not included all trainees. We believe this arduous journey merits more attention.
Methods: To examine the real-life challenges of recent participants in American Council of Graduate Medical Education accredited CHS training programs, we conducted phone interviews with graduates of all 11 approved programs from 2020-2022. This IRB approved survey focused on issues including preparation, length of training, debt burden and employment. Results are presented in n(%) and median(range).
Results: All 22(100%) graduates during the study period were interviewed and were predominantly male(77%), white(64%), married(86%) and have children(77%). (Table) Age at fellowship completion was 37(range: 33-45) years. Individuals were highly accomplished in college and medical school with the majority honors graduates and 33% having additional advanced degrees. Number of peer reviewed manuscripts at completion of training was 20 (range: 5-100). Pathways to fellowship included traditional general surgery with adult cardiac(43%), abbreviated general surgery("4+3", 19%) and integrated-6(38%). For CHS fellowship preparation, 1(5%) underwent visual acuity testing and 0 participated in formal leadership training. Time spent on any pediatric related rotation prior to CHS fellowship was 3(range: 1-7) months. Three(14%) participated in formal pediatric echocardiography or catheterization rotations. Nine(43%) participated in a formal cardiac morphology course. Neonatal cases actually performed as primary surgeon during fellowship was 8(range: 2-25). Debt burden at completion was $179,000(range $0-$550,000). Maximal financial compensation during training before and during CHS fellowship were $65,000(range: $50,000-$100,000) and $80,000(range: $65,000-$165,000) respectively. All are employed - 5(22.7%) as instructors, 13(59.1%) as assistant or associate professors, and 2(9.1%) private practice. Median salary in first job is $450,000(range: $80,000-$700,000). Nine(40.9%) had any financial savings at fellowship completion.
Conclusion: While graduates of CHS fellowships find jobs, individuals are old and compensation is highly variable. Aptitude screening and pediatric focused preparation are minimal. Debt burden is onerous. Further attention to refining training paradigms and compensation are justified. 

Objective: Ideal reporting of outcomes in congenital heart surgery requires accommodating multiple stakeholders: surgeons, cardiologists, parents, and hospital leadership. The report must be easily understandable and compare homogeneous groups of patients. We sought to develop a system of reporting that can meet these needs.

Methods: For this proof-of-concept project, we selected 19 commonly performed procedures ranging in complexity from the Norwood procedure to repair of atrial septal defects (ASD). To ensure the homogeneity of data and the creation of standard risk cohorts for each of the 19 procedures, we developed strict inclusion and exclusion criteria that encompassed diagnosis, procedure performed, prior interventions, and combination procedures. Preoperative, procedural, and postoperative data were collected for consecutive eligible patients from 8 centers between 1/1/2016 to 12/31/2021. Unadjusted mortality rates (mortality at hospital discharge or within 30 days if discharged home within 30 days) for each of the 19 procedures were analyzed in aggregate and stratified by each center.

Results: A total of 7979 patients were included from 8 centers with the number of cases for each procedure ranging from 75 for tetralogy of Fallot repair after prior palliation to 1104 for ventricular septal defect repairs (Figure). In aggregate, the unadjusted mortality ranged from 0% for ASD repair to 25.3% for Hybrid Stage I. There was significant heterogeneity in case volumes and unadjusted mortality for the different procedural categories across sites (e.g., ASO/VSD n=7 to 42, mortality 0% to 7%; Hybrid n=1 to 41, mortality 0% to 43%).

Conclusion: Reporting of institutional case volumes and outcomes, albeit unadjusted, within homogenous procedural categories will enable centers to benchmark their outcomes, better understand trends in mortality, and provides direction for improvement. Such analyses, when made public, will provide parents with information on a wide variety of specific operations. Including volumes of common operations will allow them to better understand each institution's experience with each operation. Future analysis will include adjustment for preoperative and patient-specific factors, which may allow for the development of prediction tools for outcomes that can aid counseling and setting of expectations not only for parents but also for the entire care team. 

Objective: Given the dearth of clinical prediction rules for mortality at one year following discharge from congenital heart surgery (CHS), we sought to develop a novel risk prediction model that accounts for clinical, anatomic, echocardiographic, and socioeconomic factors.
Methods: This was a single-center, retrospective review of consecutive patients who underwent CHS (the index operation) from 01/2011-01/2021 with known survival status at one year following discharge from the index hospitalization. The primary outcome was post-discharge mortality at one year. Variables of interest included age, prematurity, non-cardiac anomalies or syndromes, the Childhood Opportunity Index (COI, a US Census tract-based, nationally-normed composite metric of contemporary child neighborhood opportunity comprising 29 indicators across education, health/environment, and socioeconomic domains), STAT mortality category, major adverse postoperative complications (e.g., prolonged mechanical ventilation, renal failure, etc.), and the Residual Lesion Score (RLS, a quality improvement metric that assesses residual lesion severity at discharge based on echocardiographic criteria and pre-discharge unplanned reinterventions). Logistic regression models were used to develop a weighted risk score for the primary outcome. The final prediction model was internally validated using a bootstrapping resampling approach to estimate the optimism-corrected C-statistic based on 500 samples.
Results: Of 10,412 consecutive patients who were discharged following CHS, 8,827 (84.8%) met entry criteria. The median age was 1.9 (IQR 0.3-8.1) years. There were 195 (2.2%) deaths at one year post-discharge. Uni- and multivariable logistic regression models of the primary outcome are shown in Table 1. A weighted risk score was formulated based on the variables in the final risk prediction model (Table 1), which included all aforementioned factors of interest (this model had a C-statistic of 0.82, 95% CI 0.80-0.85). The median risk score was 7 (IQR 5-9) points. Patients were categorized as low (score 0-5), medium (score 6-10), high (score 11-15), or very high (score 16-20) risk for 1-year mortality. The predicted probability of mortality was 0.3 ± 0.1%, 1.5 ± 0.9%, 8.0 ± 4.3%, and 34.5 ± 8.2% for low, medium, high, and very high risk patients, respectively.
Conclusions: A risk prediction model of 1-year mortality may guide prognostication and follow-up of high-risk patients following discharge from CHS.