While failure to rescue (FTR) is increasingly recognized as a quality metric, studies in congenital cardiac operations remain sparse. Within a national cohort of children undergoing heart surgery, we characterized the presence of center-level variation in FTR and hypothesized a strong association with mortality but not complications.
All children undergoing congenital cardiac operations were identified in the 2013-2019 Nationwide Readmissions Database. FTR was defined as in-hospital death after cardiac arrest, ventricular tachycardia/fibrillation, prolonged mechanical ventilation, pneumonia, stroke, venous thromboembolism or sepsis, among other complications. Hierarchical models were used to generate hospital-specific, risk-adjusted rates of mortality, complications and FTR. Centers in the highest decile of FTR were identified and compared to others.
Of an estimated 74,070 patients, 1.9% died before discharge, 43.0% developed at least one perioperative complication and 4.1% experienced FTR. Following multi-level modeling, decreasing age, non-elective admission and increasing operative complexity were associated with greater odds of FTR. Variations in overall mortality and FTR exhibited a strong, positive relationship (r=0.97), while mortality and complications had a negligible association (r=-0.02). Compared to others, patients at centers with high rates of FTR had similar distributions of age, sex, chronic conditions and operative complexity.
In the present study, center-level variations in mortality were more strongly explained by differences in FTR than complications. Our findings suggest the utility of FTR as a quality metric for congenital heart surgery, although further study is needed to develop a widely accepted definition and appropriate risk-adjustment models.

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