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Treating Center Volume and Congenital Diaphragmatic Hernia Outcomes in California

  • Apfeld, Jordan C.1, 2
  • Kastenberg, Zachary J.1, 3
  • Gibbons, Alexander T.2
  • Carmichael, Suzan L.4, 5
  • Lee, Henry C.5, 6
  • Sylvester, Karl G.1, 3, 4, 5
  • 1 Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
  • 2 Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH
  • 3 Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford, CA
  • 4 Center for Fetal and Maternal Health, Lucile Packard Children’s Hospital, Stanford, CA
  • 5 Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
  • 6 California Perinatal Quality Care Collaborative (CPQCC), Stanford University, Stanford, CA
Published Article
The Journal of pediatrics
Publication Date
May 14, 2020
DOI: 10.1016/j.jpeds.2020.03.028
PMID: 32418817
PMCID: PMC7546600
PubMed Central


Objective To examined outcomes for infants born with congenital diaphragmatic hernias (CDH), according to specific treatment center volume indicators. Study design A population-based retrospective cohort study was conducted involving neonatal intensive care units in California. Multivariable analysis was used to examine the outcomes of infants with CDH including mortality, total days on ventilation, and respiratory support at discharge. Significant covariables of interest included treatment center surgical and overall neonatal intensive care unit volumes. Results There were 728 infants in the overall CDH cohort, and 541 infants (74%) in the lower risk subcohort according to a severity-weighted congenital malformation score and never requiring extracorporeal membrane oxygenation. The overall cohort mortality was 28.3% (n = 206), and 19.8% (n = 107) for the subcohort. For the lower risk subcohort, the adjusted odds of mortality were significantly lower at treatment centers with higher CDH repair volume (OR, 0.41; 95% CI, 0.23–0.75; P = .003), ventilator days were significantly lower at centers with higher thoracic surgery volume (OR, 0.56; 9 5% CI, 0.33–0.95; P = .03), and respiratory support at discharge trended lower at centers with higher neonatal intensive care unit admission volumes (OR, 0.51; 9 5% CI, 0.26–1.02; P = .06). Conclusions Overall and surgery-specific institutional experience significantly contribute to optimized outcomes for infants with CDH. These data and follow-on studies may help inform the ongoing debate over the optimal care setting and relevant quality indicators for newborn infants with major surgical anomalies.

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