Benchmarking the quality of care of infants with low-risk gastroschisis using a novel risk stratification index

Background. The nationwide mortality of neonates with gastroschisis was compared to determine whether significant variations in outcome occurred at the hospital level. Methods. Utilizing a previously developed risk-stratification index, low-risk neonates with gastroschisis were identified by a score of <= 2. Only hospitals that had a record of treating >25 low-risk neonates were included in the analysis. Hospital performance in treating infants with gastroschisis was categorized into moderate and extreme outliers. Results. A total of 4,344 neonates with gastroschisis were identified at 506 individual hospitals. Low-risk neonates had an overall mortality of 2.9% compared with high-risk neonates whose overall mortality was 24.4%. Forty hospitals treated >25 low-risk neonates in the years studied for a total of 1,775 low-risk patients. The mean, in-hospital mortality of this cohort was 3.1% (range, 0-14.3). Eight hospitals were moderate outliers with mortality rates between 3.8% and 8.0%. Two hospitals were extreme outliers with mortality rates of 8.6% and 14.3%. Conclusion. A substantial variation exists in the mortality of neonates with low-risk gastroschisis across hospitals. Further improvements in survival may, thus, depend on targeting quality improvement initiatives to standardization of operative approaches as well improvements in nonoperative factors such as neonatal intensive care unit practices, nurse-to-patient ratios, and levels of intensivist staffing. (Surgery 2010;147:766-71.)