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Ann Thorac Surg 2007;84:1-2
© 2007 The Society of Thoracic Surgeons
a The Children’s Hospital, University of Colorado, Denver, Colorado
b St. Christopher’s Hospital for Children, Philadelphia, Pennsylvania
c The Congenital Heart Institute of Florida, University of South Florida, St. Petersburg, Florida
d Children’s Memorial Hospital, Northwestern University, Chicago, Illinois
* Address correspondence to Dr Lacour-Gayet, Denver Children’s Hospital, University of Colorado, 1056 E 19th Ave, Denver, CO 80218 (Email: lacour-gayet.francois{at}tchden.org).
Today the evaluation of quality of care in congenital heart surgery is essentially based on operative mortality, which stands at 4% to 5%, ignoring the potential operative morbidity occurring in the discharged patients (95%). In this volume of The Annals of Thoracic Surgery, Benavidez and colleagues [1] address the important and controversial issue of morbidity evaluation in congenital heart surgery. Clearly a system of identifying, classifying, and quantifying complications associated with surgery for congenital heart disease is an essential ingredient of outcome assessment, performance evaluation, and quality improvement. In their investigation of the potential relationship between complications and mortality, Benavidez and his associates [1] have chosen to start by using data from the Kids’ Inpatient Database (KID) 2000. As a result, their analysis suffers from all of the limitations of a data set characterized by the "vagaries" and errors that have been shown to occur when administrative data based upon ICD9 and CPT9 codes is entered by nonclinicians. Despite its high volume, the KID database remains a nonvalidated administrative database. The data are usually not entered by physicians or nurses, but are essentially entered by administrative staff in charge of financial coding.
The poor accuracy of the ICD9 and CPT9 coding for congenital heart disease and surgery has led The Society of Thoracic Surgeons along with the European Association for Cardio-Thoracic Surgery (EACTS) to establish their own "International Nomenclature for Congenital Heart Surgery" to study quality of care in the year 2000. Benavidez and colleagues [1] state that the methodology used in this article was "created by a multidisciplinary group including physicians, nurses, statisticians, a medical technologist, and [an] epidemiologist that identified ICD9 CM codes indicative of complication." A key feature of this analysis is the manner in which complications are defined. We must consider the possibility that the use of ICD9 complication codes in the setting of surgery for congenital heart disease may lead to analyses that are at best difficult to interpret, and at worst may be inaccurate and misleading. The publication from the "National Quality Forum Consensus Report on Standardizing a Patient Safety Taxonomy" articulates the problem well: "The problem is not that there is no existing taxonomy for patient safety, but that there are so many" [2].
The listing of ICD9 coding for complications provided in the article is extremely limited and vague. The official ICD 997.1 cardiac complication code, the most frequent complication in the article, is questionable, as follows: cardiac arrest during or resulting from a procedure, cardiac insufficiency during or resulting from a procedure, cardiorespiratory failure during or resulting from a procedure, and heart failure during or resulting from a procedure. Any surgical patient who is ventilated and who is receiving inotropic support can be coded 997.1. Thus coders are likely to fail miserably in differentiating a "complicated" postoperative course from one that is not. Another frequent ICD9 code 997.3, is, by its definition, exclusively attributable to Mendelson’s aspiration syndrome. It is surprising that this rare complication is seen in 14% of patients. The code "iatrogenic hypotension" is too vague to be applied to surgical patients. Of equal concern is the omission of frequent and severe complications not listed or not considered at all in the study, including the following: permanent atrioventricular block, unplanned reoperation during the same admission, prolonged ventilation, prolonged pleural effusion, chylothorax, neurologic complications (ie, phrenic nerve palsy, convulsions, brain hemorrhage, stroke), necrotizing enterocolitis, and acute renal insufficiency.
Importantly, The Society of Thoracic Surgeons has recently created a "Quality Score in Adult Cardiac Surgery" that includes mortality and morbidity measurements [3]. It represents a significant step towards transparency of quality of care in our specialty. It is noticeable that the evaluation of morbidity in this new quality score is based on complications and not adverse events. Adverse "actions" from healthcare providers are unfortunately a reality. To date, there is no agreement to define the nature of these adverse events, whether preventable or not, or negligent or not. There is however a growing consensus in the evaluation of complications, which can occur with or without an adverse event. Complications may be considered minor when they are associated with no permanent disability or when they result in only a modest consumption of resources or prolonged length of hospital stay. Complications may be considered major when resulting in death, permanent disability, or a significant increase in length of hospital stay. It is the latter that is included in The Society of Thoracic Surgeons’ quality score. It is our belief that while we wait for a consensus on the nature of an adverse event, the morbidity measurement should be based on observed negative outcomes (ie, major complications).
Benavidez and colleagues [1] set out to examine potential relationships between "reported complications" and other risk factors for mortality during congenital heart surgery admissions. What comes out is a tautology (ie, patients with complication diagnosis codes have a higher mortality than those who do not). The most prevalent complication diagnosis code is "cardiac complication due to or resulting from a surgical procedure." When isn’t death after a cardiac procedure associated with a "cardiac complication"? The authors lend great credence to their previously published finding (already challenged or contradicted in other reports from clinical databases) of a positive correlation between large institutional case volume and low mortality, but they found that complication diagnoses were "more commonly reported" at centers with larger case volumes. This stands in contradistinction to their principle finding that complication diagnoses are associated with higher mortality. Explaining this on the basis of "better reporting" from some institutions is tantamount to discounting the accuracy and reliability of the data.
The authors are commended for their initiative and effort expended to explore the importance of complications after surgery for congenital heart disease and their relation with mortality, and for bringing this subject to the attention of the readers of The Annals of Thoracic Surgery in a timely fashion. But they themselves have pointed to the important and inescapable fact that answers will only come from prospective investigation using consensus-derived definitions of complications and validated data. Their statement that "the complication method used in this study not only has a low sensitivity but was not specifically designed to identify complications during congenital heart surgery admissions," speaks importantly to the need for consensus-derived, clinically relevant definitions of complications as an element of a "quality score" for surgery for congenital heart disease.
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