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Background: Quality improvement efforts have focused on reducing interstage mortality for infants with hypoplastic left heart syndrome (HLHS). In 2016 two publications reported that digoxin use was associated with reduced interstage mortality. The degree to which these findings have affected real world practice has not been evaluated. Methods: A multicenter retrospective cohort study of rates of digoxin prescription at discharge was performed of neonates with HLHS surviving to discharge without transplant from 1/2006-12/2018 at PHIS hospitals. A difference in difference analysis was performed using mixed effects models to adjust for measurable covariates (known arrhythmia, prematurity, renal insufficiency, etc.) with the hypothesis that the likelihood of digoxin prescription increased after 1/2016. Inter-hospital practice variation was measured, calculating the median odds ratio (MOR). Likelihood of furosemide and aspirin prescriptions were studied as falsification tests. Results: Over the study period 6091 subjects from 35 hospitals were included. Likelihood of receiving digoxin, furosemide, and aspirin are depicted (Figure). After adjusting for measurable covariates, discharge after 1/2016 was associated with increased odds of receiving digoxin (OR: 3.9, p Conclusion: The use of digoxin increased after publication of data about potential benefit in the interstage period. However, despite concerted quality improvement efforts, there is persistent large magnitude inter-hospital variation in practice.

Background: The arterial switch operation (ASO) is the gold standard operative correction of neonates with transposition of the great arteries and intact ventricular septum, with excellent operative survival. The associations between patient and surgeon characteristics and outcomes are well understood, but the associations between variation in preoperative care and outcomes are less well studied. Methods: A multicenter retrospective cohort study of infants undergoing neonatal ASO between January 2010 and September 2015 at hospitals contributing data to the Pediatric Health Information Systems database was performed. The association between preoperative care (timing of ASO, preoperative use of balloon atrial septostomy, prostaglandin infusion, mechanical ventilation, and vasoactive agents) and operative outcomes (mortality, length of stay, and cost) was studied with multivariable mixed-effects models. Results: Over the study period, 2159 neonates at 40 hospitals were evaluated. Perioperative mortality was 2.8%. Between hospitals, the use of adjuvant therapies and timing of ASO varied broadly. At the subject level, older age at ASO was associated with higher mortality risk (age >6 days: odds ratio, 1.90; 95% CI, 1.11–3.26; P =0.02), cost, and length of stay. Receipt of a balloon atrial septostomy was associated with lower mortality risk (odds ratio, 0.32; 95% CI, 0.17–0.59; P P =0.03), longer length of stay ( P P Conclusions: There was significant variation in preoperative care between hospitals. Some potentially modifiable aspects of perioperative care (timing of ASO and septostomy) were significantly associated with mortality, length of stay, and cost. Further research on the perioperative care of neonates is necessary to determine whether modifying practice on the basis of the observed associations translates into improved outcomes.

BACKGROUND: The arterial switch operation (ASO) is the gold standard operative correction of neonates with transposition of the great arteries and intact ventricular septum, with excellent operative survival. The associations between patient and surgeon characteristics and outcomes are well understood, but the associations between variation in preoperative care and outcomes are less well studied. METHODS: A multicenter retrospective cohort study of infants undergoing neonatal ASO between 1/2010 and 9/2015 at hospitals contributing data to the Pediatric Health Information Systems Database was performed. The association between preoperative care (timing of ASO, preoperative use of balloon atrial septostomy, prostaglandin infusion, mechanical ventilation, and vasoactive agents) and operative outcomes (mortality, length of stay, and cost) was studied using multivariable mixed effects models. RESULTS: Over the study period, 2,159 neonates at 40 hospitals were evaluated. Perioperative mortality was 2.8%. Between hospitals, the use of adjuvant therapies and timing of arterial switch operation varied broadly. At the subject-level, older age at ASO was associated with higher mortality risk (age >6 days OR: 1.90, 95% CI: 1.11–3.26, p=0.02), cost, and length of stay. Receipt of a balloon atrial septostomy was associated with lower mortality risk (OR: 0.32, 95% CI: 0.17–0.59, p