{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T08:57:45Z","timestamp":1790845065904,"version":"4.1.0"},"reference-count":33,"publisher":"BMJ","issue":"9","license":[{"start":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T00:00:00Z","timestamp":1789516800000},"content-version":"unspecified","delay-in-days":15,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2026,9,3]]},"published-print":{"date-parts":[[2026,9]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>The objective of this study was to evaluate factors associated with in-hospital periprocedural mortality and length of stay (LOS) among patients treated through a publicly funded programme such as Pakistan\u2019s Chief Minister\u2019s Congenital Heart Surgery Program (CMCHSP), including impact of socioeconomic factors.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Study design<\/jats:title>\n                    <jats:p>Retrospective cohort study using the CMCHSP registry.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>Patients undergoing congenital cardiac interventions between January 2024 and August 2025, across multiple public and private hospitals in Punjab, Pakistan.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Primary outcomes were in-hospital periprocedural mortality and hospital LOS. Procedural complexity was classified using the Risk Adjustment for Congenital Heart Surgery (RACHS) system. Socioeconomic status was assessed using Proxy Means Test scores. Multivariable logistic and linear regression models were used to evaluate risk-adjusted associations with mortality and LOS, accounting for clustering at the patient level.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>A total of 5431 patients underwent 5744 procedures, of which 55.3% were surgical and 44.7% catheter-based. The cohort was predominantly paediatric (87.1%) and had a median age of 6.0 years. Mortality increased significantly with procedural complexity, ranging from 1.46% in RACHS category 1 to 30.23% in category 4 (p&lt;0.001). On multivariable analysis, each increase in RACHS category was associated with higher odds of mortality (adjusted OR 2.08, 95%\u2009CI 1.57 to 2.76). Urgent procedures were also associated with increased mortality (aOR 1.68, p=0.046). Socioeconomic status was not independently associated with mortality. Higher procedural complexity, treatment in public hospitals and greater distance-to-care were associated with prolonged LOS.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>In this large, programme-based cohort, outcomes were influenced by procedural complexity and clinical factors rather than socioeconomic status once access to care was achieved. These findings suggest that publicly financed congenital heart disease programmes can deliver equitable short-term outcomes, though system-level barriers continue to influence resource utilisation.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2026-125110","type":"journal-article","created":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T14:55:35Z","timestamp":1789570535000},"page":"e125110","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Outcomes of congenital heart disease procedures in Pakistan: a retrospective cohort study using a publicly funded congenital heart surgery programme registry"],"prefix":"10.1136","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5377-784X","authenticated-orcid":false,"given":"Mahim","family":"Malik","sequence":"first","affiliation":[{"name":"Congenital Cardiac Surgery, Rawalpindi Institute of Cardiology, Rawalpindi, Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Asad Saulat","family":"Fatimi","sequence":"additional","affiliation":[{"name":"The Aga Khan University, Karachi, Sindh, Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Salman","family":"Shah","sequence":"additional","affiliation":[{"name":"University of Child Health Sciences, Lahore, Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Muhammad Asim","family":"Khan","sequence":"additional","affiliation":[{"name":"University of Child Health Sciences, Lahore, Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Faiz","family":"Rasool","sequence":"additional","affiliation":[{"name":"University of Child Health Sciences, Lahore, Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tariq","family":"Waqar","sequence":"additional","affiliation":[{"name":"Chaudhry Pervaiz Elahi Institute of Cardiology Multan, Multan, Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Usman","family":"Riaz","sequence":"additional","affiliation":[{"name":"Chaudhry Pervaiz Elahi Institute of Cardiology Multan, Multan, Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zaigham Rasool","family":"Khalid","sequence":"additional","affiliation":[{"name":"Department of Surgery, Faisalabad Institute of Cardiology, Faisalabad, Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Syed Najam","family":"Hyder","sequence":"additional","affiliation":[{"name":"University of Child Health Sciences, Lahore, Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sheikh Abdul","family":"Malik","sequence":"additional","affiliation":[{"name":"Department of Surgery, Rawalpindi Institute of Cardiology, Rawalpindi, Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Muhammad","family":"Younas","sequence":"additional","affiliation":[{"name":"Chaudhry Pervaiz Elahi Institute of Cardiology Multan, Multan, Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abdul Razzaq","family":"Mughal","sequence":"additional","affiliation":[{"name":"Department of Surgery, Faisalabad Institute of Cardiology, Faisalabad, Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Asif Ur","family":"Rehman","sequence":"additional","affiliation":[{"name":"Punjab Institute of Cardiology, Lahore, Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Farqad","family":"Alamgir","sequence":"additional","affiliation":[{"name":"Punjab Institute of Cardiology, Lahore, Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adnan","family":"Khan","sequence":"additional","affiliation":[{"name":"Sharif Medical City, Lahore, Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1941-0240","authenticated-orcid":false,"given":"Masood","family":"Sadiq","sequence":"additional","affiliation":[{"name":"University of Child Health Sciences, Lahore, Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,9,16]]},"reference":[{"key":"2026100101100762000_16.9.e125110.1","doi-asserted-by":"crossref","first-page":"812","DOI":"10.1007\/s12055-024-01787-6","article-title":"Surgery for congenital heart disease in Pakistan-the challenges and solutions","volume":"41","author":"Malik","year":"2025","journal-title":"Indian J Thorac Cardiovasc Surg"},{"key":"2026100101100762000_16.9.e125110.2","doi-asserted-by":"crossref","first-page":"184","DOI":"10.1177\/21501351231213627","article-title":"Hospital Resources and Practice Patterns for Congenital Cardiac Surgery in Pakistan: A Nationwide Status Report","volume":"15","author":"Malik","year":"2024","journal-title":"World J Pediatr Congenit Heart Surg"},{"key":"2026100101100762000_16.9.e125110.3","doi-asserted-by":"crossref","first-page":"i1","DOI":"10.1093\/eurheartjsupp\/suaf091","article-title":"Who will be our adult congenital heart disease patient tomorrow?","volume":"28","author":"Sarubbi","year":"2026","journal-title":"Eur Heart J Suppl"},{"key":"2026100101100762000_16.9.e125110.4","doi-asserted-by":"publisher","DOI":"10.1634\/theoncologist.2019-0057"},{"key":"2026100101100762000_16.9.e125110.5","doi-asserted-by":"crossref","first-page":"704","DOI":"10.1007\/s12055-024-01771-0","article-title":"Late presentation of congenital heart diseases in low- and middle-income countries: impact on outcomes","volume":"41","author":"Das","year":"2025","journal-title":"Indian J Thorac Cardiovasc Surg"},{"key":"2026100101100762000_16.9.e125110.6","unstructured":"Chief minister\u2019s children heart surgery program. 2025. Available: https:\/\/statehealth.com.pk\/Heart-Surgery"},{"key":"2026100101100762000_16.9.e125110.7","doi-asserted-by":"publisher","DOI":"10.1017\/S1047951108002904"},{"key":"2026100101100762000_16.9.e125110.8","doi-asserted-by":"crossref","first-page":"21501351261450531","DOI":"10.1177\/21501351261450531","article-title":"Mortality and Risk Factors in Pediatric Cardiac Surgery for Congenital Heart Disease in Mexico","volume":"25 2026","author":"Leyva-L\u00f3pez","year":"2026","journal-title":"World J Pediatr Congenit Heart Surg"},{"key":"2026100101100762000_16.9.e125110.9","doi-asserted-by":"crossref","first-page":"206","DOI":"10.1055\/s-0043-1761155","article-title":"Social Determinants of Health and Impact in Perioperative Space","volume":"36","author":"Devin","year":"2023","journal-title":"Clin Colon Rectal Surg"},{"key":"2026100101100762000_16.9.e125110.10","doi-asserted-by":"publisher","DOI":"10.1101\/2021.01.06.20248468"},{"key":"2026100101100762000_16.9.e125110.11","unstructured":"Pakistan bureau of statistics government of Pakistan national health accounts 2021-2022. 2022. Available: https:\/\/www.pbs.gov.pk\/wp-content\/uploads\/2020\/07\/NHA-Pakistan-2021-22-1.pdf"},{"key":"2026100101100762000_16.9.e125110.12","unstructured":"World bank group out-of-pocket expenditure (% of current health expenditure) - Pakistan. 2026. Available: https:\/\/data.worldbank.org\/indicator\/SH.XPD.OOPC.CH.ZS?locations=PK"},{"key":"2026100101100762000_16.9.e125110.13","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.39335.541782.AD"},{"key":"2026100101100762000_16.9.e125110.14","unstructured":"Affairs UNOftCoH . Pakistan - subnational edge-matched administrative boundaries. n.d. Available: https:\/\/data.humdata.org\/dataset\/cod-em-pak"},{"key":"2026100101100762000_16.9.e125110.15","doi-asserted-by":"crossref","unstructured":"Stout KK , Daniels CJ , Aboulhosn JA , et al . 2018 AHA\/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology\/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019;139. doi:10.1161\/CIR.0000000000000603","DOI":"10.1161\/CIR.0000000000000683"},{"key":"2026100101100762000_16.9.e125110.16","doi-asserted-by":"crossref","first-page":"327","DOI":"10.1007\/978-1-4471-6587-3_26","article-title":"Risk Adjustment for Congenital Heart Surgery -1 (RACHS-1) for Evaluation of Mortality in Children Undergoing Cardiac Surgery","volume":"2015","author":"Thiagarajan","year":"2015","journal-title":"Pediatric and Congenital Cardiac Care"},{"key":"2026100101100762000_16.9.e125110.17","unstructured":"National socio-economic registry (NSER). n.d. Available: https:\/\/www.pass.gov.pk\/Detail\/NzAwYTI3NjAtOTNjYS00ZmU0LTk5OGEtYzBkYjA1NTdlZGQ1"},{"key":"2026100101100762000_16.9.e125110.18","doi-asserted-by":"crossref","DOI":"10.3389\/fpubh.2025.1714957","article-title":"Determinants of hospitalization expenditure for pediatric congenital heart disease: a single-center study from Xinjiang, China","volume":"13","author":"Jiangabieke","year":"2025","journal-title":"Front Public Health"},{"key":"2026100101100762000_16.9.e125110.19","first-page":"219","article-title":"Epidemiology of congenital heart disease in Brazil","volume":"30","author":"Pinto J\u00fanior","year":"2015","journal-title":"Rev Bras Cir Cardiovasc"},{"key":"2026100101100762000_16.9.e125110.20","doi-asserted-by":"crossref","DOI":"10.1161\/JAHA.124.037291","article-title":"Burden of Congenital Heart Anomalies in North Africa and the Middle East, 1990 to 2021: A Systematic Analysis for the Global Burden of Disease Study 2021","volume":"14","author":"Soleimani","year":"2025","journal-title":"J Am Heart Assoc"},{"key":"2026100101100762000_16.9.e125110.21","doi-asserted-by":"publisher","DOI":"10.1111\/chd.12220"},{"key":"2026100101100762000_16.9.e125110.22","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijcard.2009.11.006"},{"key":"2026100101100762000_16.9.e125110.23","doi-asserted-by":"crossref","first-page":"1","DOI":"10.4103\/apc.apc_67_24","article-title":"Pediatric cardiac procedures in India: Who bears the cost?","volume":"17","author":"Faisal","year":"2024","journal-title":"Ann Pediatr Cardiol"},{"key":"2026100101100762000_16.9.e125110.24","doi-asserted-by":"crossref","DOI":"10.1542\/peds.2025-070739G","article-title":"A Population-Based Approach to Congenital Heart Disease in Kerala, India","volume":"156","author":"Nair","year":"2025","journal-title":"Pediatrics"},{"key":"2026100101100762000_16.9.e125110.25","doi-asserted-by":"crossref","first-page":"e316","DOI":"10.1016\/S2214-109X(15)70115-4","article-title":"Global access to surgical care: a modelling study","volume":"3","author":"Alkire","year":"2015","journal-title":"Lancet Glob Health"},{"key":"2026100101100762000_16.9.e125110.26","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMsa0903048"},{"key":"2026100101100762000_16.9.e125110.27","doi-asserted-by":"crossref","first-page":"1033","DOI":"10.1097\/PCC.0000000000002807","article-title":"Socioeconomic Disadvantage and Distance to Pediatric Critical Care*","volume":"22","author":"Brown","year":"2021","journal-title":"Pediatric Critical Care Medicine"},{"key":"2026100101100762000_16.9.e125110.28","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2023-078884","article-title":"Factors associated with poor outcomes after congenital heart surgery in low-resource setting in Pakistan: insight from the IQIC Registry \u2013 a descriptive analysis","volume":"13","author":"Furnaz","year":"2023","journal-title":"BMJ Open"},{"key":"2026100101100762000_16.9.e125110.29","doi-asserted-by":"publisher","DOI":"10.1016\/J.JACC.2021.11.036"},{"key":"2026100101100762000_16.9.e125110.30","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1007\/s00246-023-03351-2","article-title":"Enhancing Quality of Congenital Heart Care Within Resource-Limited Settings","volume":"46","author":"Mohsin","year":"2025","journal-title":"Pediatr Cardiol"},{"key":"2026100101100762000_16.9.e125110.31","doi-asserted-by":"publisher","DOI":"10.1016\/j.cjcpc.2023.10.001"},{"key":"2026100101100762000_16.9.e125110.32","doi-asserted-by":"crossref","first-page":"57","DOI":"10.1002\/pd.6481","article-title":"Patient-reported barriers to prenatal diagnosis of congenital heart defects: A mixed-methods study","volume":"44","author":"Woo","year":"2024","journal-title":"Prenat Diagn"},{"key":"2026100101100762000_16.9.e125110.33","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2023-012049","article-title":"Recommendations for developing effective and safe paediatric and congenital heart disease services in low-income and middle-income countries: a public health framework","volume":"8","author":"Hasan","year":"2023","journal-title":"BMJ Glob Health"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2026-125110","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T08:11:17Z","timestamp":1790842277000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2026-125110"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9]]},"references-count":33,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2026,9,16]]},"published-print":{"date-parts":[[2026,9]]}},"alternative-id":["10.1136\/bmjopen-2026-125110"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2026-125110","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9]]}}}