{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,15]],"date-time":"2026-10-15T06:51:26Z","timestamp":1792047086340,"version":"4.4.0"},"reference-count":32,"publisher":"American Academy of Pediatrics (AAP)","issue":"2","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2002,2,1]]},"abstract":"<jats:p>Objective. The association between high case volumes and better patient outcomes has been demonstrated for many surgical procedures and medical treatments, including surgery for children with congenital heart disease. To simulate the effects of regionalization of pediatric cardiac surgery, we assessed the impact of reducing the number of pediatric cardiac centers on surgical mortality and patient\u2019s travel distance.<\/jats:p>\n               <jats:p>Methods. This study used abstracted statewide hospital discharge data from California from 1995 to 1997. Case volume and in-hospital mortality for pediatric cardiac surgeries at each hospital were calculated. All hospitals that performed \u226510 pediatric cardiac surgeries in 1995 to 1997 were included in the analysis. To simulate regionalization, we \u201cclosed\u201d the hospital with the lowest case volume and redistributed patients from this hospital to the nearest remaining hospitals. The number of in-hospital deaths was then recalculated using the original mortality rate of each remaining hospital multiplied by its new case volume. A multivariate logistic regression was conducted to determine the odds ratios of mortality of various types of surgery compared with closure of ventricular septal defect. This result was used for adjusting for the case-mix of the hospitals. Regionalization simulation analysis was repeated, and the number of deaths was recalculated using this adjustment of hospital case-mix. We also examined the increase in travel distance of patients to the hospitals as a result of the regionalization simulation.<\/jats:p>\n               <jats:p>Results. In California, 6592 children underwent cardiac surgeries in 1995 to 1997 with 352 in-hospital deaths (overall mortality rate: 5.34%). A quadratic regression model demonstrated that a high surgical volume was associated with a low mortality rate. We found demarcations between low- and medium-volume hospitals at 70 cases per year and medium- and high-volume hospitals at 170 cases per year. With adjustment for hospital case-mix, we found that 41 deaths could be avoided when all patients from low-volume hospitals were referred, and 83 deaths could be avoided when all patients from low- and medium-volume hospitals were referred to high-volume hospitals (overall mortality rate decreased to 4.08%). The average travel distance for pediatric cardiac surgery was 45.4 miles, which increased by 12.7 miles when all surgeries were referred to high-volume hospitals. When only the 733 high-risk patients were referred from low- and medium-volume hospitals to high-volume hospitals, 49 deaths could be avoided, yielding an overall mortality rate of 4.60%.<\/jats:p>\n               <jats:p>Conclusions. Theoretical regionalization of pediatric cardiac surgery is associated with a reduction in surgical mortality from 5.34% to 4.08% when all cases were referred to high-volume hospitals, or decrease to 4.60% when high-risk cases were referred. Although regionalization is associated with an important decrease in the number of deaths, it also increases the travel distance for patients. Additional studies on the costs and benefits of regionalization are needed to determine the best strategies to improve outcomes for children who undergo cardiac surgery.<\/jats:p>","DOI":"10.1542\/peds.109.2.173","type":"journal-article","created":{"date-parts":[[2004,8,14]],"date-time":"2004-08-14T00:17:55Z","timestamp":1092442675000},"page":"173-181","source":"Crossref","is-referenced-by-count":144,"title":["Can Regionalization Decrease the Number of Deaths for Children Who Undergo Cardiac Surgery? A Theoretical Analysis"],"prefix":"10.1542","volume":"109","author":[{"given":"Ruey-Kang R.","family":"Chang","sequence":"first","affiliation":[{"name":"Division of Cardiology, Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas S.","family":"Klitzner","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Department of Pediatrics, UCLA School of Medicine, Los Angeles, California"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"417","published-online":{"date-parts":[[2002,2,1]]},"reference":[{"key":"2021121006172165900_R1","unstructured":"Ginzburg E. Regionalization & Health Policy. US Department of Health Education and Welfare. Washington, DC: US Government Printing Office;1977. DHEW Publ. No. [HRA]77\u2013623"},{"key":"2021121006172165900_R2","doi-asserted-by":"crossref","unstructured":"Luft HS. Regionalization of medical care. Am J Public Health.1985;75:125\u2013126","DOI":"10.2105\/AJPH.75.2.125"},{"key":"2021121006172165900_R3","doi-asserted-by":"crossref","unstructured":"Merkatz IR, Johnson K. Regionalization of perinatal care for the United States. Clin Perinatol.1976;3:271\u2013276","DOI":"10.1016\/S0095-5108(18)31235-1"},{"key":"2021121006172165900_R4","unstructured":"Rudolph CS, Borker SR. Regionalization. Issues in Intensive Care for High Risk Newborns and Their Families. New York, NY: Praeger Publishers;1987"},{"key":"2021121006172165900_R5","doi-asserted-by":"crossref","unstructured":"Luft HS, Bunker JP, Enthoven AC. Should operations be regionalized? The empirical relation between surgical volume and mortality. N Engl J Med.1979;301:1364\u20131369","DOI":"10.1056\/NEJM197912203012503"},{"key":"2021121006172165900_R6","doi-asserted-by":"crossref","unstructured":"Hannan EL, O\u2019Donnell JF, Kilburn H Jr, Bernard HR, Yazici A. Investigation of the relationship between volume and mortality for surgical procedures performed in New York State hospitals. JAMA.1989;262:503\u2013510","DOI":"10.1001\/jama.262.4.503"},{"key":"2021121006172165900_R7","doi-asserted-by":"crossref","unstructured":"Phibbs CS, Bronstein JM, Buxton E, Phibbs RH. The effects of patient volume and level of care at the hospital of birth on neonatal mortality. JAMA.1996;276:1054\u20131059","DOI":"10.1001\/jama.276.13.1054"},{"key":"2021121006172165900_R8","doi-asserted-by":"crossref","unstructured":"Stone VE, Seage GR III, Hertz T, Epstein AM. The relation between hospital experience and mortality for patients with AIDS. JAMA.1992;268:2655\u20132661","DOI":"10.1001\/jama.268.19.2655"},{"key":"2021121006172165900_R9","doi-asserted-by":"crossref","unstructured":"Bennett CL, Garfinkle JB, Greenfield S, et al. The relation between hospital experience and in-hospital mortality for patients with AIDS-related PCP. JAMA.1989;261:2975\u20132979","DOI":"10.1001\/jama.261.20.2975"},{"key":"2021121006172165900_R10","doi-asserted-by":"crossref","unstructured":"Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of hospital volume on operative mortality for major cancer surgery. JAMA.1998;280:1747\u20131751","DOI":"10.1001\/jama.280.20.1747"},{"key":"2021121006172165900_R11","doi-asserted-by":"crossref","unstructured":"Cebul RD, Snow RJ, Pine R, Hertzer NR, Norris DG. Indications, outcomes, and provider volumes for carotid endarterectomy. JAMA.1998;279:1282\u20131287","DOI":"10.1001\/jama.279.16.1282"},{"key":"2021121006172165900_R12","doi-asserted-by":"crossref","unstructured":"Kimmel SE, Berlin JA, Laskey WK. The relationship between coronary angioplasty procedure volume and major complications. JAMA.1995;274:1137\u20131142","DOI":"10.1001\/jama.274.14.1137"},{"key":"2021121006172165900_R13","doi-asserted-by":"crossref","unstructured":"Hannan EL, Racz M, Ryan TJ, et al. Coronary angioplasty volume-outcome relationships for hospitals and cardiologists. JAMA.1997;277:892\u2013898","DOI":"10.1001\/jama.277.11.892"},{"key":"2021121006172165900_R14","doi-asserted-by":"crossref","unstructured":"Hughes RG, Hunt SS, Luft HS. Effects of surgeon volume and hospital volume on quality of care in hospitals. Med Care.1987;25:489\u2013503","DOI":"10.1097\/00005650-198706000-00004"},{"key":"2021121006172165900_R15","unstructured":"Luft HS, Garnick DW, Mark DH, McPhee SJ. Hospital Volume, Physician Volume, and Patient Outcomes. Assessing the Evidence. Ann Arbor, MI: Health Administration Press Perspectives;1990"},{"key":"2021121006172165900_R16","doi-asserted-by":"crossref","unstructured":"Dudley RA, Johansen KL, Brand R, Rennie DJ, Milstein A. Selective referral to high-volume hospitals: estimating potentially avoidable deaths. JAMA.2000;283:1159\u20131166","DOI":"10.1001\/jama.283.9.1159"},{"key":"2021121006172165900_R17","doi-asserted-by":"crossref","unstructured":"Jenkins KJ, Newburger JW, Lock JE, et al. In-hospital mortality for surgical repair of congenital heart defects: preliminary observations of variation by hospital caseload. Pediatrics.1995;95:323\u2013330","DOI":"10.1542\/peds.95.3.323"},{"key":"2021121006172165900_R18","doi-asserted-by":"crossref","unstructured":"Hannan EL, Racz M, Kavey RE, Quaegebeur JM, Williams R. Pediatric cardiac surgery: the effect of hospital and surgeon volume on in-hospital mortality. Pediatrics.1998;101:963\u2013969","DOI":"10.1542\/peds.101.6.963"},{"key":"2021121006172165900_R19","doi-asserted-by":"crossref","unstructured":"Chernew M, Haywood R, Scanlon D. Managed care and open-heart surgery facilities in California. Health Aff (Milwood).1996;15:191\u2013201","DOI":"10.1377\/hlthaff.15.1.191"},{"key":"2021121006172165900_R20","doi-asserted-by":"crossref","unstructured":"Calmes D, Leake BD, Carlisle DM. Adverse asthma outcomes among children hospitalized with asthma in California. Pediatrics.1998;101:845\u2013850","DOI":"10.1542\/peds.101.5.845"},{"key":"2021121006172165900_R21","doi-asserted-by":"crossref","unstructured":"Chang R-KR, Chen AY, Klitzner TS. Factors associated with age at operation for children with congenital heart disease. Pediatrics.2000;105:1073\u20131081","DOI":"10.1542\/peds.105.5.1073"},{"key":"2021121006172165900_R22","doi-asserted-by":"crossref","unstructured":"Erickson LC, Wise PH, Cook EF, Beiser A, Newburger JW. The impact of managed care insurance on use of lower-mortality hospitals by children undergoing cardiac surgery in California. Pediatrics.2000;105:1271\u20131278","DOI":"10.1542\/peds.105.6.1271"},{"key":"2021121006172165900_R23","doi-asserted-by":"crossref","unstructured":"McGregor M, Pelletier G. Planning of specialized health facilities: size vs. cost and effectiveness in heart surgery. N Engl J Med.1978;299:179\u2013181","DOI":"10.1056\/NEJM197807272990405"},{"key":"2021121006172165900_R24","unstructured":"US Department of Health, Education, and Welfare. Health planning: national guidelines. Fed Reg.1978;43:1304\u20131350"},{"key":"2021121006172165900_R25","unstructured":"Scannel JG, Brown GE, Buckley MJ. Report of the Inter-Society Commission for the Heart Disease Resources: optimal resources for cardiac surgery: guideline for program planning and evaluation. Circulation.1975;53:A1\u2013A37"},{"key":"2021121006172165900_R26","doi-asserted-by":"crossref","unstructured":"Gordon TA, Burleyson GP, Tielsch JM, Cameron JL. The effects of regionalization on cost and outcome for one general high-risk surgical procedure. Ann Surg.1995;221:43\u201349","DOI":"10.1097\/00000658-199501000-00005"},{"key":"2021121006172165900_R27","doi-asserted-by":"crossref","unstructured":"Hamilton SM, Letourneau S, Pekeles E, Voaklander D, Johnston DW. The impact of regionalization on a surgery program in the Canadian health care system. Arch Surg.1997;132:605\u2013609","DOI":"10.1001\/archsurg.1997.01430300047010"},{"key":"2021121006172165900_R28","doi-asserted-by":"crossref","unstructured":"Finlayson SR, Birkmeyer JD, Tosteson AN, Nease RF Jr. Patient preferences for location of care: implications for regionalization. Med Care.1999;37:204\u2013209","DOI":"10.1097\/00005650-199902000-00010"},{"key":"2021121006172165900_R29","doi-asserted-by":"crossref","unstructured":"Lundstrom NR, Berggren H, Bjorkhem, Jogi P, Sunnegardh J. Centralization of pediatric heart surgery in Sweden. Pediatr Cardiol.2000;21:353:357","DOI":"10.1007\/s002460010079"},{"key":"2021121006172165900_R30","doi-asserted-by":"crossref","unstructured":"Corn RF. Quality control of hospital discharge data. Med Care.1980;18:416\u2013426","DOI":"10.1097\/00005650-198004000-00006"},{"key":"2021121006172165900_R31","doi-asserted-by":"crossref","unstructured":"Demlo LK, Campbell PM. Improving hospital discharge data: lesson from the national hospital discharge survey. Med Care.1981;19:1030\u20131040","DOI":"10.1097\/00005650-198110000-00005"},{"key":"2021121006172165900_R32","doi-asserted-by":"crossref","unstructured":"Romano PS, Zach A, Luft HS, Rainwater J, Remy LL, Campa D. The California Hospital Outcomes Project: using administrative data to compare hospital performance. Jt Comm J Qual Improv.1995;21:668\u2013682","DOI":"10.1016\/S1070-3241(16)30195-X"}],"container-title":["Pediatrics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/publications.aap.org\/pediatrics\/article-pdf\/109\/2\/173\/1113675\/pe0202000173.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/publications.aap.org\/pediatrics\/article-pdf\/109\/2\/173\/1113675\/pe0202000173.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,12,10]],"date-time":"2021-12-10T14:14:25Z","timestamp":1639145665000},"score":1,"resource":{"primary":{"URL":"https:\/\/publications.aap.org\/pediatrics\/article\/109\/2\/173\/64013\/Can-Regionalization-Decrease-the-Number-of-Deaths"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2002,2,1]]},"references-count":32,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2002,2,1]]},"published-print":{"date-parts":[[2002,2,1]]}},"URL":"https:\/\/doi.org\/10.1542\/peds.109.2.173","relation":{},"ISSN":["0031-4005","1098-4275"],"issn-type":[{"value":"0031-4005","type":"print"},{"value":"1098-4275","type":"electronic"}],"subject":[],"published":{"date-parts":[[2002,2,1]]}}}