Pediatric inpatient hospital resource use for congenital heart defects

Health Care Resource Utilization Among Children With Congenital Heart Disease: A Population-Based Study

BACKGROUND

Data regarding health care resource utilization (HRU) in early childhood among children with congenital heart disease (CHD) are scarce. Therefore, we sought to describe the extent of HRU incurred among children with CHD in the first 5 years of life.

METHODS

This population-based retrospective cohort study included all children born between January 2005 and March 2014 in Alberta, Canada. We linked inpatient, outpatient, practitioner claims, and drug dispensing databases with vital statistics (birth and death registries).

RESULTS

In the first year of life, the cumulative hospitalization rate per 100 children was 335 (95% confidence interval: 312-360) for single ventricle (SV) children, 200 (194-206) for moderate-complex CHD, and 152 (149-156) for simple CHD vs 109 (108-109) among children without CHD (P < 0.001). The ambulatory-care visit rate per 100 children was 4871 (4780-4963) for SV, 2278 (2258-2299) for moderate-complex, and 1416 (1405-1426) for simple CHD vs 246 (246-247) for children without CHD (P < 0.001). The rates of physician claims and drug dispensing also demonstrated similar patterns. The median total hospitalization length of stay during the first year of life was 54 days (interquartile range: 26-95) in SV, 15 (4-39) in moderate-complex, and 6 (2-26) in simple CHD compared with 2 (1-3) among children without CHD (P < 0.001). These differences remained throughout the first 5 years of life, with children with CHD having consistently higher hospitalization rates and emergency department visit rates in every year of age compared with children without CHD.

CONCLUSIONS

Cumulative HRU is high among children with CHD in the first 5 years of life and increases with increasing CHD severity. Improving survival of SV lesions will require increasing resource allocation to this group.

Tissue engineered vascular grafts for pediatric cardiac surgery

New technologies and science have contributed to improved surgical outcomes in patients with congenital cardiovascular diseases. However, current materials display shortcomings, such as risk of infection and lack of growth capacity when applied to the pediatric patient population. Tissue engineering has the potential to address these limitations as the ideal tissue engineered vascular graft (TEVG) would be durable, biocompatible, nonthrombogenic, and ultimately remodel into native tissue. The traditional TEVG paradigm consists of a scaffold, cell source, and the integration of the scaffold and cells via seeding. The subsequent remodeling process is driven by cellular adhesion and proliferation, as well as, biochemical and mechanical signaling. Clinical trials have displayed encouraging results, but graft stenosis is observed as a frequent complication. Recent investigations have suggested that a host's immune response plays a vital role in neotissue formation. Current and future studies will focus on modulating host immunity as a means of reducing the incidence of stenosis.

Toward a patient-specific tissue engineered vascular graft

Integrating three-dimensional printing with the creation of tissue-engineered vascular grafts could provide a readily available, patient-specific, autologous tissue source that could significantly improve outcomes in newborns with congenital heart disease. Here, we present the recent case of a candidate for our tissue-engineered vascular graft clinical trial deemed ineligible due to complex anatomical requirements and consider the application of three-dimensional printing technologies for a patient-specific graft. We 3D-printed a closed-disposable seeding device and validated that it performed equivalently to the traditional open seeding technique using ovine bone marrow–derived mononuclear cells. Next, our candidate’s preoperative imaging was reviewed to propose a patient-specific graft. A seeding apparatus was then designed to accommodate the custom graft and 3D-printed on a commodity fused deposition modeler. This exploratory feasibility study represents an important proof of concept advancing progress toward a rationally designed patient-specific tissue-engineered vascular graft for clinical application.

Functional polymorphisms of the neuropilin 1 gene are associated with the risk of tetralogy of Fallot in a Chinese Han population

Tetralogy of Fallot (TOF) is one of the most severe forms of cyanotic congenital heart disease (CHD) and is also the most common. Previous genome-wide association study (GWAS) and replication studies have suggested that a polymorphism in the neuropilin 1 (NRP1) gene is significantly associated with the risk of TOF. To further confirm the association between the NRP1 polymorphism and the risk of TOF and to identify additional positive functional single-nucleotide polymorphisms (SNPs) for TOF risk, we systematically screened for functional polymorphisms throughout the regulatory and coding regions of the NRP1 gene. A total of 11 functional SNPs in 747 Chinese Han individuals, including 314 TOF patients and 433 healthy controls, were genotyped using the MassARRAY system and GeneScan. The results revealed that the allelic and genotypic frequencies of the NRP1 polymorphism rs2228638 were strongly associated with the risk of TOF (p = 0.002 and 0.001, respectively). To increase the robustness of rs2228638 as a TOF risk SNP, we conducted a meta-analysis that combined published studies and our current case-control study. The meta-analysis showed that the T allele of the NRP1 polymorphism rs2228638 was significantly associated with an increased risk of TOF in the combined population, which included European and Chinese Han individuals [combined p < 0.00001, odds ratio (OR) = 1.53, 95% confidence interval (95% CI) = 1.35-1.73]. In addition, the association analysis suggested for the first time that there is a strong association between the allele distribution of rs10080 and susceptibility to TOF (p = 0.001). Our data provide further evidence of the association between NRP1 polymorphisms and TOF risk, and suggest that rs2228638 may be an excellent marker for TOF risk in European and Chinese Han populations.

Cost Variation Across Centers for the Norwood Operation

BACKGROUND

The Norwood operation is associated with high health care utilization, and prior studies reported substantial variability in Norwood costs across centers. However, specific factors driving this cost variation are unclear. We assessed center variability in Norwood costs and underlying mechanisms in a multicenter cohort.

METHODS

Clinical data from the Pediatric Heart Network Single Ventricle Reconstruction trial were linked with cost data from the Children's Hospital Association Inpatient Essentials database. Center variation was assessed by modeling Norwood costs adjusted for baseline patient characteristics, and the relationship with complications, length of stay (LOS), and specific cost categories was examined. Patients undergoing transplantation or stage 2 palliation during the Norwood admission were excluded.

RESULTS

Nine centers (332 patients) were included. Adjusted mean cost/case varied 4.6-fold across centers (range: $50,559 to $230,851, p < 0.001). In addition, variation was found across centers in the adjusted mean number of complications/case (2.6-fold variation) and adjusted mean LOS/case (1.9-fold variation). Differences in complications explained 63% of the cost variation across centers. After accounting for complications, differences in LOS explained 66% of the remaining cost variation. Seven specific complications were found to occur more frequently at high-cost centers: pleural effusion, seizures, wound infection, thrombus, liver dysfunction, sepsis, necrotizing enterocolitis (all p < 0.001). With regard to types of cost, room and board/supplies and laboratory costs were the primary drivers of cost variation across centers.

CONCLUSIONS

This study identified several factors associated with center variation in Norwood costs, which may be targeted in subsequent initiatives aimed at both improving quality of care and reducing costs.

Effect of Glucose on 3D Cardiac Microtissues Derived from Human Induced Pluripotent Stem Cells

Maternal hyperglycemia is a risk factor for fetal cardiac anomalies. This study aimed to assess the effect of high glucose on human induced pluripotent stem cell-derived cardiomyocyte self-assembly into 3D microtissues and their calcium handling. Stem cells were differentiated to beating cardiomyocytes using established protocols. On the final day of the differentiation process, cells were treated with control media, 12 mM glucose, or 12 mM mannitol (an osmolality control). Once beating, the cardiac cells were dissociated with trypsin, collected, mixed with collagen, and plated into custom-made silicone micro molds in order to generate 3D cardiac microtissues. A time-lapse microscope took pictures every 4 h to quantify the kinetics of cellular self-assembly of 3D cardiac tissues. Fiber widths were recorded at 4-h intervals and plotted over time to assess cardiomyocyte 3D fiber self-assembly. Microtissue calcium flux was recorded with optical mapping by pacing microtissues at 0.5 and 1.0 Hz. Exposure to high glucose impaired the ability of cardiomyocytes to self-assemble into compact microtissues, but not their ability to spontaneously contract. Glucose-exposed cardiomyocytes took longer to self-assemble and finished as thicker fibers. When cardiac microtissues were paced at 0.5 and 1.0 Hz, those exposed to high glucose had altered calcium handling with shorter calcium transient durations, but larger amplitudes of the calcium transient when compared to controls. Additional studies are needed to elucidate a potential mechanism for these findings. This model provides a novel method to assess the effects of exposures on the cardiomyocytes' intrinsic abilities for organogenesis in 3D.

Tissue-engineered vascular grafts for congenital cardiac disease: Clinical experience and current status

Congenital heart disease is a leading cause of death in the newborn period, and man-made grafts currently used for reconstruction are associated with multiple complications. Tissue engineering can provide an alternative source of vascular tissue in congenital cardiac surgery. Clinical trials have been successful overall, but the most frequent complication is graft stenosis. Recent studies in animal models have indicated the important role of the recipient׳s immune response in neotissue formation, and that modulating the immune response can reduce the incidence of stenosis.

Factors Associated with Readmission of Patients with Congenital Heart Disease in a Swiss University Hospital

Congenital heart defects (CHD) lead to extensive use of healthcare resources. Still, there is little information available regarding readmission rates or associated factors. We sought to evaluate readmission rates and their determinants among patients with CHD hospitalized in a Swiss university hospital. We conducted a retrospective study using data from all non-adult (<18 years) patients hospitalized between 2002 and 2014 at the University Hospital of Lausanne with an International Classification of Diseases version 10 code Q20-Q25. Overall, 996 patients (460 girls, 332 undergoing surgery, mean age 2.7 years) were assessed, 96 of whom (9.6%) were readmitted within 30 days after discharge. Among the 96 readmissions, 83 (86.5%) were related to the CHD. Median time to readmission was 10 days (interquartile range 6-20) and median length of readmission was 12 days (interquartile range 6-20). After multivariate adjustment, foreign nationality, greater distance to hospital and length of index hospitalization <14 days predisposed to readmission. Patients who underwent surgery were less likely to be readmitted (8.7%). We conclude that readmissions were frequent, almost 1 in 10 patients, and associated with several socio-clinical factors. Providing patients who live far from hospital with specialized care closer to home may help reduce the rate of readmission.

Healthcare Data Analytics for Parkinson's Disease Patients: A Study of Hospital Cost and Utilization in the United States

Parkinson's Disease (PD), a prevalent problem, especially for the aged populations, is a progressive but non-fatal nervous system disorder. PD patients have special motor as well as non-motor symptoms over time. There are several limitations in the study of PD such as unavailability of data, proper diagnosis and treatment methods. These limitations significantly reduce the quality of PD patient life quality, either directly or indirectly. PD also imposes great financial burdens to PD patients and their family. This project aims to analyze the most common reasons for PD patient hospitalization, review complications that occur during inpatient stays, and measure the costs associated with PD patient characteristics. Using the HCUP NIS data, comprehensive data analysis has been performed. The results are customized visualized using Tableau and other software systems. The preliminary findings sheds light into how to improve the life quality of PD patients.

Intravascular Ultrasound Characterization of a Tissue-Engineered Vascular Graft in an Ovine Model

Patients who undergo implantation of a tissue-engineered vascular graft (TEVG) for congenital cardiac anomalies are monitored with echocardiography, followed by magnetic resonance imaging or angiography when indicated. While these methods provide data regarding the lumen, minimal information regarding neotissue formation is obtained. Intravascular ultrasound (IVUS) has previously been used in a variety of conditions to evaluate the vessel wall. The purpose of this study was to evaluate the utility of IVUS for evaluation of TEVGs in our ovine model. Eight sheep underwent implantation of TEVGs either unseeded or seeded with bone marrow-derived mononuclear cells. Angiography, IVUS, and histology were directly compared. Endothelium, tunica media, and graft were identifiable on IVUS and histology at multiple time points. There was strong agreement between IVUS and angiography for evaluation of luminal diameter. IVUS offers a valuable tool to evaluate the changes within TEVGs, and clinical translation of this application is warranted.

Proportion of selected congenital heart defects attributable to recognized risk factors

PURPOSE

To assess the contribution of multiple risk factors for two congenital heart defects-hypoplastic left heart syndrome (HLHS) and tetralogy of Fallot (TOF).

METHODS

We used data from the National Birth Defects Prevention Study (1997-2011) to estimate average adjusted population attributable fractions for several recognized risk factors, including maternal prepregnancy overweight-obesity, pregestational diabetes, age, and infant sex.

RESULTS

There were 594 cases of isolated simple HLHS, 971 cases of isolated simple TOF, and 11,829 controls in the analysis. Overall, 57.0% of HLHS cases and 37.0% of TOF cases were estimated to be attributable to risk factors included in our model. Among modifiable HLHS risk factors, maternal prepregnancy overweight-obesity accounted for the largest proportion of cases (6.5%). Among modifiable TOF risk factors, maternal prepregnancy overweight-obesity and maternal age of 35 years or older accounted for the largest proportions of cases (8.3% and 4.3%, respectively).

CONCLUSIONS

Approximately half of HLHS cases and one-third of TOF cases were estimated to be attributable to risk factors included in our models. Interventions targeting factors that can be modified may help reduce the risk of HLHS and TOF development. Additional research into the etiology of HLHS and TOF may reveal other modifiable risk factors that might contribute to primary prevention efforts.

Maternal Chlamydia Infection During Pregnancy and Risk of Cyanotic Congenital Heart Defects in the Offspring

OBJECTIVES

Genital Chlamydia is a common bacterial sexually-transmitted infection among reproductive aged women, particularly younger populations. Cyanotic congenital heart defects (CCHDs) constitute about one quarter of all cardiac malformations at birth, and are associated with high rate of morbidity and mortality. Epidemiological research on the association between maternal Chlamydia during pregnancy and CCHDs in the offspring is lacking.

METHODS

Using data from the 2012 United States birth certificates, we examined the association between CCHDs and prenatal exposure to Chlamydia among live singleton births with CCHDs (n = 2487) and unaffected singleton births (n = 3,334,424). We estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) using unconditional logistic regression analysis for all CCHDs combined, and isolated CCHDs (without other major congenital malformations).

RESULTS

Overall 1.7% of case and 1.7% of control women reported having Chlamydia during their pregnancies. After controlling for potential confounders, we found a weak positive association between maternal Chlamydia during pregnancy and all CCHDs combined (aOR = 1.39; 95% CI 1.02-1.90). The positive association persisted for isolated CCHD cases, but with marginal significance (aOR = 1.34; 95% CI 0.96-1.74). Subgroup analyses for younger women showed an increased risk for CCHDs; however, the associations were not statistically significant.

CONCLUSIONS

Maternal exposure to Chlamydia during pregnancy was weakly associated with a higher risk of CCHDs in the offspring. The finding should be interpreted with caution due to limitations of birth certificate data. Future studies using more robust data sources are warranted to further study the association between maternal Chlamydia during pregnancy and CCHDs in the offspring.

Resource Utilization for Noncardiac Admissions in Pediatric Patients With Single Ventricle Disease

Patients with single ventricle (SV) congenital heart disease (CHD) incur high hospital costs during staged surgical palliation. Health care resource utilization for noncardiac admissions in patients with SV has not been reported. This study sought to compare costs and outcomes for common noncardiac hospital admissions between patients with SV and patients without CHD. Hospital discharge data from the University Health System Consortium from January 2011 to December 2013 was queried for patients aged ≤18 years with International Classification of Diseases, Ninth Revision (ICD-9) codes for SV lesions: hypoplastic left heart syndrome (746.7), tricuspid atresia (746.1), or common ventricle (745.3). Primary diagnosis, direct cost, length of stay (LOS), intensive care unit admission rate and mortality data were obtained. The 10 most common noncardiac admission diagnoses were compared between patients with SV and patients without CHD using t test and Fisher's exact test. Total direct cost, LOS, and intensive care unit admission rate were higher for patients with SV for all diagnoses with the exception of LOS for dehydration, which was not different between groups. Hospital mortality was significantly higher for patients with SV admitted for acute kidney injury, esophageal reflux, failure to thrive, respiratory syncytial virus bronchiolitis and pneumonia. In conclusion, our study demonstrates that patients with SV CHD admitted with noncardiac diagnoses have higher health care resource utilization compared to those without CHD. As long-term survival increases, it can be expected that this patient group will use a disproportionate amount of medical dollars. Further characterization of costs will be important so steps can be taken to reduce or prevent hospitalization in these patients.

A genome-wide association study of congenital cardiovascular left-sided lesions shows association with a locus on chromosome 20

Congenital heart defects involving left-sided lesions (LSLs) are relatively common birth defects with substantial morbidity and mortality. Previous studies have suggested a high heritability with a complex genetic architecture, such that only a few LSL loci have been identified. We performed a genome-wide case-control association study to address the role of common variants using a discovery cohort of 778 cases and 2756 controls. We identified a genome-wide significant association mapping to a 200 kb region on chromosome 20q11 [P= 1.72 × 10^-8 for rs3746446; imputed Single Nucleotide Polymorphism (SNP) rs6088703 P= 3.01 × 10^-9, odds ratio (OR)= 1.6 for both]. This result was supported by transmission disequilibrium analyses using a subset of 541 case families (lowest P in region= 4.51 × 10^-5, OR= 1.5). Replication in a cohort of 367 LSL cases and 5159 controls showed nominal association (P= 0.03 for rs3746446) resulting in P= 9.49 × 10^-9 for rs3746446 upon meta-analysis of the combined cohorts. In addition, a group of seven SNPs on chromosome 1q21.3 met threshold for suggestive association (lowest P= 9.35 × 10^-7 for rs12045807). Both regions include genes involved in cardiac development-MYH7B/miR499A on chromosome 20 and CTSK, CTSS and ARNT on chromosome 1. Genome-wide heritability analysis using case-control genotyped SNPs suggested that the mean heritability of LSLs attributable to common variants is moderately high ([Formula: see text] range= 0.26-0.34) and consistent with previous assertions. These results provide evidence for the role of common variation in LSLs, proffer new genes as potential biological candidates, and give further insight to the complex genetic architecture of congenital heart disease.

Population-based study of hospital costs for hospitalizations of infants, children, and adults with a congenital heart defect, Arkansas 2006 to 2011

BACKGROUND

Congenital heart defects (CHDs) are common birth defects and are associated with high hospital costs. The objectives of this study were to assess hospitalization costs, across the lifespan, of patients with CHDs in Arkansas.

METHODS

Data from the 2006 to 2011 Healthcare Cost and Utilization Project Arkansas State Inpatient Databases were used. We included hospitalizations of patients whose admission occurred between January 1, 2006, and December 31, 2011, and included a principal or secondary CHD ICD-9-CM diagnosis code (745.0-747.49, except 747.0 and 745.5 for preterm infants). Hospitalizations were excluded if they involved out-of-state residents, normal newborn births, or if missing data included age at admission, state of residence, or hospital charges. Children were defined as those < 18 years-old at time of admission.

RESULTS

Between 2006 and 2011, there were 2,242,484 inpatient hospitalizations in Arkansas. There were 9071 (0.4%) hospitalizations with a CHD, including 5,158 hospitalizations of children (2.2% of hospitalizations among children) and 3,913 hospitalizations of adults (0.2% of hospitalizations of adults). Hospital costs for these CHD hospitalizations totaled $355,543,696. The average annual cost of CHD hospitalizations in Arkansas was $59,257,283 during this time period. Infants accounted for 72% of all CHD-related hospital costs; total costs of CHD hospitalizations for children were almost five times those of hospitalization costs for adults with CHD.

CONCLUSION

Hospitalizations with CHDs account for a disproportionate share of hospital costs in Arkansas. Hospitalizations of children with CHD accounted for a higher proportion of total hospitalizations than did hospitalizations of adults with CHD.

Evaluating cost and resource use associated with pulse oximetry screening for critical congenital heart disease: Empiric estimates and sources of variation

BACKGROUND

Newborn screening for critical congenital heart disease (CCHD) using pulse oximetry is being implemented in the United States and internationally; however, few data are available on the associated in-hospital costs and use of resources.

METHODS

Time and motion study in well-baby nurseries at two large urban hospitals in Utah using different approaches to pulse oximetry screening. Two observers recorded the time for each screening step together with provider and equipment characteristics. Structured questionnaire provided additional information on labor and equipment costs.

RESULTS

Fifty-three CCHD screens were observed. At site A (n = 22), screening was mostly done by medical assistants (95%) using disposable probes (100%); at site B (n = 31), screening was mostly performed by certified nursing assistants (90%) using reusable probes (90%). Considering only first screens (n = 53), the median screen time was 8.6 min (range: 3.2-23.2), with no significant difference between sites. The overall cost ($ in 2014) of screening per baby was $24.52 at site A and $2.60 at site B. Nearly all the variation in cost (90%) was due to the cost of disposable probes; labor costs were similar between sites.

CONCLUSION

CCHD screening by means of pulse oximetry is reasonably fast for most babies, leading to relative small labor costs with little variation by provider type. The main driver of costs is equipment: in a high throughput setting, reusable probes are currently associated with considerable cost saving compared with disposable probes. As programs expand to universal screening, improved and cheaper technologies could lead to considerable economies of scale.

Factors associated with inpatient hospitalizations among patients aged 1 to 64 years with congenital heart defects, Arkansas 2006 to 2011

BACKGROUND

Individuals with congenital heart defects (CHDs) have high hospital resource use. We sought to identify factors associated with hospital costs and multiple hospitalizations among individuals with CHDs.

METHODS

Data from the 2006 to 2011 Healthcare Cost and Utilization Project Arkansas State Inpatient Databases were linked across encrypted patient identifiers to develop a cohort of Arkansas residents aged 1 to 64 years who were hospitalized at least once with a CHD during this time period. Infants were excluded because patient identifiers were missing for 18 to 52% each year. CHDs were identified using principal and secondary International Classification of Diseases, Ninth Revision, Clinical Modification diagnoses codes. All hospitalizations of individuals ever admitted with a CHD were included. Mean and median patient-level costs were estimated; the association of hospital costs and patient readmissions were examined with linear and logistic regression.

RESULTS

There were 1,185,868 inpatient hospitalizations of Arkansas residents aged 1 to 64 years between 2006 and 2011; these were accrued by 603,925 patients. Of those, 2542 patients (0.42%) had at least one hospitalization with a CHD diagnosis. Total costs for these 2542 patients were $126,999,837 and they accumulated 7898 hospitalizations. Factors associated with increased costs included patient age, CHD type, cardiac procedures, and comorbidities. Factors associated with hospital readmission within 1 year included age, CHD type, expected payer, and comorbidities.

CONCLUSION

Individuals with CHDs in Arkansas experience variation in hospital use and costs by patient characteristics. Future research should investigate factors associated with readmissions, cardiac procedures, and comorbidities, as these are strongly associated with hospital costs. Birth Defects Research (Part A) 103:589-596, 2015. © 2015 Wiley Periodicals, Inc.

Diagnostic Value of Transthoracic Echocardiography in Patients with Coarctation of Aorta: The Chinese Experience in 53 Patients Studied between 2008 and 2012 in One Major Medical Center

Although aortography is well known as the "gold standard" for the diagnosis of coarctation of aorta (CoA), the method is invasive, expensive and not readily accepted by some patients. Ultrasound diagnosis for CoA is non-invasive, inexpensive, readily accepted by every patient, and can be repeated as frequently as necessary. The purpose of this presentation is to evaluate the applicability of transthoracic echocardiography for the diagnosis of CoA. The echocardiographic appearances of 53 patients with CoA who had undergone surgery during a 5-year period from January 2008 to October 2012 were analyzed retrospectively, and the results were compared with findings at surgery. Fifty-three patients with CoA include six with isolated CoA and 47 of CoA associated with other cardiac anomalies. Of the 53 operated patients, 48 were correctly diagnosed preoperatively by echocardiography, while two were misdiagnosed as interrupted aortic arch and the diagnosis were missed in three other patients. Thus the diagnostic accuracy rate was 90.6%, and the misdiagnosis rate was 9.4%. Preoperative echocardiographic evaluation offers very satisfactory anatomic assessment in most patients with CoA. It makes preoperative angiography unnecessary. Thus transthoracic echocardiography should be the first-line method for the diagnosis of coarctation of the aorta.