{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T20:46:50Z","timestamp":1791233210329,"version":"4.1.0"},"reference-count":26,"publisher":"BMJ","issue":"6","funder":[{"name":"Kobren Family Chair for Patient Safety and Quality"},{"name":"Harvard College Research Program"},{"name":"Harvard University Summer Undergraduate Research in Global Health"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2019,3,14]]},"published-print":{"date-parts":[[2019,6]]},"abstract":"<jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>Many low-income and middle-income countries (LMICs) struggle to provide the health services investment required for life-saving congenital heart disease (CHD) surgery. We explored associations between risk-adjusted CHD surgical mortality from 17 LMICs and global development indices to identify patterns that might inform investment strategies.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Retrospective analysis: country-specific standardised mortality ratios were graphed against global development indices reflective of wealth and healthcare investment. Spearman correlation coefficients were calculated.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting and participants<\/jats:title>\n                    <jats:p>The International Quality Improvement Collaborative (IQIC) keeps a volunteer registry of outcomes of CHD surgery programmes in low-resource settings. Inclusion in the IQIC is voluntary enrolment by hospital sites. Patients in the registry underwent congenital heart surgery. Sites that actively participated in IQIC in 2013, 2014 or 2015 and passed a 10% data audit were asked for permission to share data for this study. 31 sites in 17 countries are included.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Outcome measures<\/jats:title>\n                    <jats:p>In-hospital mortality: standardised mortality ratios were calculated. Risk adjustment for in-hospital mortality uses the Risk Adjustment for Congenital Heart Surgery method, a model including surgical risk category, age group, prematurity, presence of a major non-cardiac structural anomaly and multiple congenital heart procedures during admission.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The IQIC registry includes 24\u2009917 congenital heart surgeries performed in children&lt;18 years of age. The overall in-hospital mortality rate was 5.0%. Country-level congenital heart surgery standardised mortality ratios were negatively correlated with gross domestic product (GDP) per capita (r=\u22120.34, p=0.18), and health expenditure per capita (r=\u22120.23, p=0.37) and positively correlated with under-five mortality (r=0.60, p=0.01) and undernourishment (r=0.39, p=0.17). Countries with lower development had wider variation in mortality. GDP per capita is a driver of the association between some other measures and mortality.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Results display a moderate relationship among wealth, healthcare investment and malnutrition, with significant variation, including superior results in many countries with low GDP per capita. These findings provide context and optimism for investment in CHD procedures in low-resource settings.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2018-028307","type":"journal-article","created":{"date-parts":[[2019,6,22]],"date-time":"2019-06-22T13:39:19Z","timestamp":1561210759000},"page":"e028307","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":42,"title":["Linking world bank development indicators and outcomes of congenital heart surgery in low-income and middle-income countries: retrospective analysis of quality improvement data"],"prefix":"10.1136","volume":"9","author":[{"given":"Sarah","family":"Rahman","sequence":"first","affiliation":[{"name":"Case Western Reserve University School of Medicine, Cleveland, OH, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bistra","family":"Zheleva","sequence":"additional","affiliation":[{"name":"Children\u2019s HeartLink, Minneapolis, Minnesota, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"K M","family":"Cherian","sequence":"additional","affiliation":[{"name":"Frontier Lifeline Hospital and Dr. KM Cherian Foundation, Mogappair, Tamil Nadu, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jan T","family":"Christenson","sequence":"additional","affiliation":[{"name":"Global Forum on Humanitarian Medicine in Cardiology and Cardiac Surgery, University Hospital of Geneva, Geneva, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kaitlin E","family":"Doherty","sequence":"additional","affiliation":[{"name":"Center for Applied Pediatric Quality Analytics, Boston Children\u2019s Hospital, Boston, MA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David","family":"de Ferranti","sequence":"additional","affiliation":[{"name":"Results for Development Institute, Washington, District of Columbia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kimberlee","family":"Gauvreau","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Boston Children\u2019s Hospital, Boston, MA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Patricia A","family":"Hickey","sequence":"additional","affiliation":[{"name":"Department of Nursing\/Patient Services, Boston Children\u2019s Hospital, Boston, MA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Raman Krishna","family":"Kumar","sequence":"additional","affiliation":[{"name":"Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jennifer K","family":"Kupiec","sequence":"additional","affiliation":[{"name":"Center for Applied Pediatric Quality Analytics, Boston Children\u2019s Hospital, Boston, MA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"William M","family":"Novick","sequence":"additional","affiliation":[{"name":"University of Tennessee Health Science Center-Global Surgery Institute and William Novick Global Cardiac Alliance, Memphis, Tennessee, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nestor F","family":"Sandoval","sequence":"additional","affiliation":[{"name":"Fundacion Cardioinfantil-Instituto de Cardiologia, Universidad del Rosario, Bogota, Colombia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kathy J","family":"Jenkins","sequence":"additional","affiliation":[{"name":"Center for Applied Pediatric Quality Analytics, Boston Children\u2019s Hospital, Boston, MA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2019,6,22]]},"reference":[{"key":"2025121515244489000_9.6.e028307.1","unstructured":"United Nations Sustainable Development. Sustainable\u00a0development goals - United Nations. https:\/\/www.un.org\/sustainabledevelopment\/sustainable-development-goals\/ (cited 2018 May 21)."},{"key":"2025121515244489000_9.6.e028307.2","doi-asserted-by":"crossref","first-page":"3027","DOI":"10.1016\/S0140-6736(16)31593-8","article-title":"Global, regional, and national causes of under-5 mortality in 2000\u201315: an updated systematic analysis with implications for the Sustainable Development Goals","volume":"388","author":"Liu","year":"2016","journal-title":"The Lancet"},{"key":"2025121515244489000_9.6.e028307.3","unstructured":"Children\u2019s HeartLink. A Case for the Invisible Child: Childhood Heart Disease and the Global Health Agenda. 2015 https:\/\/childrensheartlink.org\/wp-content\/uploads\/2017\/06\/The-Invisible-Child-Brief-1.pdf"},{"key":"2025121515244489000_9.6.e028307.4","doi-asserted-by":"publisher","DOI":"10.1016\/j.surg.2013.10.008"},{"key":"2025121515244489000_9.6.e028307.5","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(12)60990-8"},{"key":"2025121515244489000_9.6.e028307.6","doi-asserted-by":"crossref","first-page":"10","DOI":"10.1053\/j.sempedsurg.2015.09.003","article-title":"Financing pediatric surgery in low-, and middle-income countries","volume":"25","author":"Hsiung","year":"2016","journal-title":"Semin Pediatr Surg"},{"key":"2025121515244489000_9.6.e028307.7","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2014-0356"},{"key":"2025121515244489000_9.6.e028307.8","unstructured":"World Bank. World Development Indicators. 2014 http:\/\/datatopics.worldbank.org\/world-development-indicators\/"},{"key":"2025121515244489000_9.6.e028307.9","doi-asserted-by":"publisher","DOI":"10.1053\/j.pcsu.2004.02.009"},{"key":"2025121515244489000_9.6.e028307.10","doi-asserted-by":"publisher","DOI":"10.1067\/mtc.2002.119064"},{"key":"2025121515244489000_9.6.e028307.11","doi-asserted-by":"crossref","first-page":"84","DOI":"10.1016\/j.socscimed.2015.11.044","article-title":"Subjective socioeconomic status and health in cross-national comparison","volume":"149","author":"Pr\u00e4g","year":"2016","journal-title":"Soc Sci Med"},{"key":"2025121515244489000_9.6.e028307.12","doi-asserted-by":"publisher","DOI":"10.1016\/j.jbi.2008.08.010"},{"key":"2025121515244489000_9.6.e028307.13","doi-asserted-by":"publisher","DOI":"10.1007\/s12245-009-0106-y"},{"key":"2025121515244489000_9.6.e028307.14","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1186\/s12914-015-0066-7","article-title":"Comprehensive peace agreement implementation and reduction in neonatal, infant and under-5 mortality rates in post-armed conflict states, 1989-2012","volume":"15","author":"Joshi","year":"2015","journal-title":"BMC Int Health Hum Rights"},{"key":"2025121515244489000_9.6.e028307.15","unstructured":"Li H , Feng H , Wang J , et al . Relationships among gross domestic product per capita, government health expenditure per capita and infant mortality rate in China. Biomed Res 2017;28."},{"key":"2025121515244489000_9.6.e028307.16","doi-asserted-by":"crossref","first-page":"S22","DOI":"10.1017\/S104795111700258X","article-title":"Management of undernutrition and failure to thrive in children with congenital heart disease in low- and middle-income countries","volume":"27","author":"Argent","year":"2017","journal-title":"Cardiol Young"},{"key":"2025121515244489000_9.6.e028307.17","doi-asserted-by":"crossref","first-page":"24","DOI":"10.4067\/S0370-41062018000100024","article-title":"Nutritional recovery after cardiac surgery in children with congenital heart disease","volume":"89","author":"Oyarz\u00fan","year":"2018","journal-title":"Rev Chil Pediatr"},{"key":"2025121515244489000_9.6.e028307.18","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2009-0141"},{"key":"2025121515244489000_9.6.e028307.19","unstructured":"UNICEF DATA. Under-Five Mortality [Internet]. \/\/data.unicef.org\/topic\/child-survival\/under-five-mortality\/"},{"key":"2025121515244489000_9.6.e028307.20","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0165480","article-title":"Economic Analysis of Children\u2019s Surgical Care in Low- and Middle-Income Countries: A Systematic Review and Analysis","volume":"11","author":"Saxton","year":"2016","journal-title":"PLoS One"},{"key":"2025121515244489000_9.6.e028307.21","unstructured":"Disease control priorities. In: Debas HT , Donkor P , Gawande A , Jamison DT , Kruk ME , Mock CN , et al . eds. Essential surgery. 421. Third edition. Washington, DC: World Bank, 2015."},{"key":"2025121515244489000_9.6.e028307.22","doi-asserted-by":"crossref","first-page":"e1196","DOI":"10.1016\/S2214-109X(18)30386-3","article-title":"High-quality health systems in the sustainable development goals era: time for a revolution","volume":"6","author":"Kruk","year":"2018","journal-title":"Lancet Glob Health"},{"key":"2025121515244489000_9.6.e028307.23","unstructured":"Children\u2019s HeartLink. Finding the Invisible Child: Childhood Heart Disease and the Global Health Agenda. 2015 https:\/\/childrensheartlink.org\/wp-content\/uploads\/2017\/06\/The-Invisible-Child-Brief-2.pdf"},{"key":"2025121515244489000_9.6.e028307.24","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1000200","article-title":"Increasing access to surgical services in sub-saharan Africa: priorities for national and international agencies recommended by the bellagio essential surgery group","volume":"6","author":"Luboga","year":"2009","journal-title":"PLoS Med"},{"key":"2025121515244489000_9.6.e028307.25","doi-asserted-by":"publisher","DOI":"10.1016\/S1010-7940(03)00444-5"},{"key":"2025121515244489000_9.6.e028307.26","doi-asserted-by":"crossref","first-page":"430","DOI":"10.1016\/S2352-4642(18)30100-7","article-title":"Effect of family socioeconomic status on the prognosis of complex congenital heart disease in children: an observational cohort study from China","volume":"2","author":"Xiang","year":"2018","journal-title":"Lancet Child Adolesc Health"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2018-028307","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,15]],"date-time":"2025-12-15T23:24:57Z","timestamp":1765841097000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2018-028307"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019,6]]},"references-count":26,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2019,6,22]]},"published-print":{"date-parts":[[2019,6]]}},"alternative-id":["10.1136\/bmjopen-2018-028307"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2018-028307","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2019,6]]}}}