Higher Programmatic Volume in Neonatal Heart Surgery Is Associated With Lower Early Mortality Andrzej Kansy, MD, PhD, Christine zu Eulenburg, PhD, Georgios.

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Higher Programmatic Volume in Neonatal Heart Surgery Is Associated With Lower Early Mortality Andrzej Kansy, MD, PhD, Christine zu Eulenburg, PhD, Georgios Sarris, MD, PhD, Jeffrey P. Jacobs, MD, PhD, Jose Fragata, MD, PhD, Zdzislaw Tobota, MD, Tjark Ebels, MD, PhD, Bohdan Maruszewski, MD, PhD The Annals of Thoracic Surgery Volume 105, Issue 5, Pages 1436-1440 (May 2018) DOI: 10.1016/j.athoracsur.2017.11.028 Copyright © 2018 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Operative mortality by center volume. Scattergram of all 722 individual center-years of 90 participating centers. The number of operations per center-year is depicted on the horizontal axis (N). Operative mortality is defined as the number of deaths per center-year (p) divided by N and is depicted as p/N on the vertical axis. The data points arrange themselves in curved shapes owing to the discrete nature of the number of deaths (p: 1, 2, 3, etc.) per center-year. The curves are solutions for different values of p as indicated in the top left secondary horizontal axis. The lowest curve is actually a straight line coinciding with the horizontal (X) axis and indicates 0 deaths per center-year. The red curve defines the average operative mortality per center volume, calculated through logarithmic regression. (vs. = versus.) The Annals of Thoracic Surgery 2018 105, 1436-1440DOI: (10.1016/j.athoracsur.2017.11.028) Copyright © 2018 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Odds ratio for mortality per 5-operation change per center-year. Depicted are odds ratios for mortality per 5-operation increase of center-year volume, derived by multivariate analysis on the vertical axis. Displayed are the estimate (black) and the 95% confidence interval bounds (red). A value less than 1.0 represents a risk decrease with increasing number of operations, and a value greater than 1.0 means a risk increase with increasing number of operations. When the odds ratio becomes larger than 1, at a center-year volume larger than 60, the confidence interval bounds become wider, while the number of patients included drop below 11,000 and p values approach 1. On the horizontal axis are depicted groups of neonatal operations per center-year where the lower limit for inclusion increases from left to right. Group 0 comprises all 26,598 operations from 722 center-years included in the multivariate analysis. The next group marked as >20 includes all 24,032 operations performed in center-years of more than 20 operations, and so on. Thus, all data points indicate the results of repeated analyses including patients from centers with >20, >40, >50, >55, >60, >65, >80, and >100 patients per center-year. The secondary vertical axis on the right indicates the number of operations included. The Annals of Thoracic Surgery 2018 105, 1436-1440DOI: (10.1016/j.athoracsur.2017.11.028) Copyright © 2018 The Society of Thoracic Surgeons Terms and Conditions