Discharge Barriers and Length of Stay Following Congenital Heart Surgery: A Mixed-Methods Approach.

BACKGROUND

This study aimed to identify granular discharge barriers after congenital heart surgery and compare the contributions of discharge barriers versus clinical factors to postoperative length of stay (LOS) variation among infants with severe congenital heart defects.

METHODS

This was a retrospective cohort study of patients who underwent initial cardiac surgery at ≤12 months, from 2015 to 2021, at a high-volume congenital heart defect surgical center. The outcome was postoperative LOS. The exposure was discharge barrier category, a 7-level categorical variable determined a priori using a mixed-methods approach. Covariates included surgical/anatomic complexity, postoperative complications, sociodemographics, and comorbidities. Associations between discharge barrier categories and postoperative LOS were estimated with log-linear models. A Shorrocks-Shapley decomposition estimated each covariate's contribution to outcome variation.

RESULTS

A total of 752 infants met the inclusion criteria; 24.3% experienced a discharge barrier. The most common discharge barrier category was medical equipment delivery or prior authorization delays (52/752, 6.9%). Median postoperative LOS for those without and with barriers was 8 (interquartile range, 5-15) and 26 (interquartile range, 14-52) days, respectively (P<0.001). In a multivariable analysis, 4 of the 6 barrier categories were associated with higher postoperative LOS when compared with patients without barriers (31%-242%, P=0.000-0.030). Surgical complexity and discharge barriers accounted for similar amounts of variation in postoperative LOS (22.2% [95% CI, 17.3%-26.8%] and 21.2% [95% CI, 14.9%-27.0%], respectively).

CONCLUSIONS

Discharge barriers are as influential as surgical and anatomic complexity in explaining variation in postoperative LOS among infants undergoing congenital heart surgery. Future research and clinical efforts to mitigate modifiable discharge barriers may yield improvements in postoperative LOS.