Regional Variation after Cardiac Surgery in Adults with Congenital Heart Disease in the US

Introduction: We describe regional variation in perioperative care among adults with congenital heart disease (ACHD) undergoing cardiac surgery in the United States. Methods: Analysis using the 2016-2020 Nationwide Inpatient Sample, including admissions of ≥18 years old patients with congenital heart ICD-10 diagnosis codes and cardiac surgical procedure codes. Outcomes included hospitalization costs, length of stay, high-resource utilization (HRU), and in-hospital mortality. Adjusted multilevel regressions estimated observed-to-expected (O/E) ratios and risk-standardized (RS) outcomes. Results: Among 83,800 admissions, the median age was 59 years (IQR 48-67) and the most common diagnosis was congenital aortic insufficiency (AI) with 58.7% (n=49,149). Elective admissions represented 76.5% (n=64,115) admissions; valve replacements were coded in 68.1% (n=57,065) admissions, followed by CABG (22.0%, n=18,420). Regional distribution was 21% West, 20% Northeast, 27% Midwest, and 31% South. Midwest had a higher proportion of valve repairs whereas Northeast had a higher valve replacement procedure. RS-HRU rate raged from 14.8% (95% CI 13.0-16.7) in the Midwest to 20.4% (18.5-22.3) in the South. RS-costs varied from $49,303 (95% CI 47,944-50,665) in the Northeast to $59,899 (95% CI 58,432-61,355) in the West. In-hospital mortality did not significantly differ by region. Sensitivity analysis excluding congenital AI admissions showed increased resource utilization and mortality. Conclusion: Substantial regional variation exists in ACHD resource utilization. Future studies will focus on specific procedure types and hospital characteristics to uncover potential region-specific strategies to optimize ACHD care as healthcare moves toward value-based models aligned with regional demands.