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O'Byrne ML, Wilensky R, Glatz AC. Incorporating economic analysis in interventional cardiology research. Catheter Cardiovasc Interv 2023; 101:122-130. [PMID: 36480805 DOI: 10.1002/ccd.30506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 11/08/2022] [Accepted: 11/19/2022] [Indexed: 12/13/2022]
Abstract
Evaluative research in interventional cardiology has focused on clinical and technical outcomes. Inclusion of economic data can enhance evaluative research by quantifying the relative economic burden incurred by different therapies. When combined with clinical outcomes, cost data can provide a measure of value (e.g., marginal cost-effectiveness). In some select situations, cost data can also be used as surrogates for complexity of care and morbidity. In this narrative review, we aim to provide a framework for the application of cost data in clinical trials and observational research, detailing how to incorporate this kind of data into interventional cardiology research.
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Affiliation(s)
- Michael L O'Byrne
- Department of Pediatrics, Division of Cardiology and Clinical Futures, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute For Healthcare Economics, The University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert Wilensky
- Center for Cardiovascular Outcomes, Quality, and Evaluative Research, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Internal Medicine, Division of Cardiology, The Hospital of The University of Pennsylvania, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew C Glatz
- Department of Pediatrics, Division of Cardiology, Washington University School of Medicine, and St. Louis Children's Hospital, St. Louis, Missouri, USA
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O'Byrne ML, McHugh KE, Huang J, Song L, Griffis H, Anderson BR, Bucholz EM, Chanani NK, Elhoff JJ, Handler SS, Jacobs JP, Li JS, Lewis AB, McCrindle BW, Pinto NM, Sassalos P, Spar DS, Pasquali SK, Glatz AC. Cumulative In-Hospital Costs Associated With Single-Ventricle Palliation. JACC. ADVANCES 2022; 1:100029. [PMID: 38939312 PMCID: PMC11198056 DOI: 10.1016/j.jacadv.2022.100029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/20/2022] [Accepted: 04/22/2022] [Indexed: 06/29/2024]
Abstract
Background In the SVR (Single Ventricle Reconstruction) Trial, 1-year survival in recipients of right ventricle to pulmonary artery shunts (RVPAS) was superior to that in those receiving modified Blalock-Taussig-Thomas shunts (MBTTS), but not in subsequent follow-up. Cost analysis is an expedient means of evaluating value and morbidity. Objectives The purpose of this study was to evaluate differences in cumulative hospital costs between RVPAS and MBTTS. Methods Clinical data from SVR and costs from Pediatric Health Information Systems database were combined. Cumulative hospital costs and cost-per-day-alive were compared serially at 1, 3, and 5 years between RVPAS and MBTTS. Potential associations between patient-level factors and cost were explored with multivariable models. Results In total, 303 participants (55% of the SVR cohort) from 9 of 15 sites were studied (48% MBTTS). Observed total costs at 1 year were lower for MBTTS ($701,260 ± 442,081) than those for RVPAS ($804,062 ± 615,068), a difference that was not statistically significant (P = 0.10). Total costs were also not significantly different at 3 and 5 years (P = 0.21 and 0.32). Similarly, cost-per-day-alive did not differ significantly for either group at 1, 3, and 5 years (all P > 0.05). In analyses of transplant-free survivors, total costs and cost-per-day-alive were higher for RVPAS at 1 year (P = 0.05 for both) but not at 3 and 5 years (P > 0.05 for all). In multivariable models, aortic atresia and prematurity were associated with increased cost-per-day-alive across follow-up (P < 0.05). Conclusions Total costs do not differ significantly between MBTTS and RVPAS. The magnitude of longitudinal costs underscores the importance of efforts to improve outcomes in this vulnerable population.
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Affiliation(s)
- Michael L. O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics and Cardiovascular Outcomes, Quality, and Evaluative Research Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kimberly E. McHugh
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jing Huang
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lihai Song
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Heather Griffis
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Brett R. Anderson
- Division of Cardiology, New York-Presbyterian Morgan-Stanley Children’s Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Emily M. Bucholz
- Department of Cardiology, Children’s Hospital Boston and Harvard University Medical School, Boston, Massachusetts, USA
| | - Nikhil K. Chanani
- Children’s Healthcare of Atlanta, Sibley Heart Center and Emory University School of Medicine, Atlanta, Georgia, USA
| | - Justin J. Elhoff
- Sections of Critical Care and Cardiology, Texas Children’s Hospital and Baylor College of Medicine, Houston, Texas, USA
| | | | - Jeffery P. Jacobs
- Division of Cardiothoracic Surgery, Departments of Surgery and Pediatrics, Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Jennifer S. Li
- Division of Pediatric Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Alan B. Lewis
- Division of Cardiology, Department of Pediatrics, Children’s Hospital of Los Angeles, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Brian W. McCrindle
- Department of Pediatrics, Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nelangi M. Pinto
- Division of Cardiology, Primary Children’s Hospital and University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Peter Sassalos
- Division of Pediatric Cardiothoracic Surgery, C.S. Mott Children’s Hospital and University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - David S. Spar
- The Heart Institute, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - Sara K. Pasquali
- Division of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Andrew C. Glatz
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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3
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O'Byrne ML, Faerber JA, Katcoff H, Huang J, Edelson JB, Finkelstein DM, Lemley BA, Janson CM, Avitabile CM, Glatz AC, Goldberg DJ. Prevalent pharmacotherapy of US Fontan survivors: A study utilizing data from the MarketScan Commercial and Medicaid claims databases. Am Heart J 2022; 243:158-166. [PMID: 34582777 PMCID: PMC8819625 DOI: 10.1016/j.ahj.2021.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/23/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Survivors of Fontan palliation are at life-long risk of thrombosis, arrhythmia, and circulatory failure. To our knowledge, no studies have evaluated current United States pharmaceutical prescription practice in this population. METHODS A retrospective observational study evaluating the prevalent use of prescription medications in children and adolescents with hypoplastic left heart syndrome or tricuspid atresia after Fontan completion (identified using ICD9/10 codes) was performed using data contained in the MarketScan Commercial and Medicaid databases for the years 2013 through 2018. Cardiac pharmaceuticals were divided by class. Anticoagulant agents other than platelet inhibitors, which are not uniformly a prescription medication, were also studied. Associations between increasing age and the likelihood of a filled prescription for each class of drug were evaluated. Annualized retail costs of pharmaceutical regimens were calculated. RESULTS A cohort of 4,056 subjects (median age 12 years [interquartile range: 8-16], 61% male, 60% commercial insurance) was identified. Of the cohort, 50% received no prescription medications. Angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB) (38%), diuretics (15%), and mineralocorticoid receptor antagonists (8%) were prescribed with the highest frequency. Pulmonary vasodilators were received by 6% of subjects. Older age was associated with increased likelihood of filled prescriptions for anticoagulants (P = .008), antiarrhythmic agents, digoxin, ACEi/ARB, and beta blockers (each P < .0001), but also lower likelihood of filled prescriptions for pulmonary vasodilators, conventional diuretics (both P < .0001), and mineralocorticoid receptor antagonists (P = .02). CONCLUSIONS Pharmaceuticals typically used to treat heart failure and pulmonary hypertension are the most commonly prescribed medications following Fontan palliation. While the likelihood of treatment with a particular class of medication is associated with the age of the patient, determining the optimal regimen for individual patients and the population at large is an important knowledge gap for future research.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Pediatric Clinical Effectiveness at The Children's Hospital of Philadelphia, Philadelphia, PA; Leonard Davis Institute and Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA.
| | - Jennifer A Faerber
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Hannah Katcoff
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jing Huang
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jonathan B Edelson
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute and Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA
| | - David M Finkelstein
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Bethan A Lemley
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Christopher M Janson
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Catherine M Avitabile
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Andrew C Glatz
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Pediatric Clinical Effectiveness at The Children's Hospital of Philadelphia, Philadelphia, PA
| | - David J Goldberg
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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O'Byrne ML, Kennedy KF, Steven JM, Hill KD, Chamberlain RC, Millenson ME, Smith CL, Dori Y, Gillespie MJ, Rome JJ, Glatz AC. Outcomes of Operator-Directed Sedation and Anesthesiologist Care in the Pediatric/Congenital Catheterization Laboratory: A Study Utilizing Data From the IMPACT Registry. JACC Cardiovasc Interv 2021; 14:401-413. [PMID: 33602437 DOI: 10.1016/j.jcin.2020.10.054] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/15/2020] [Accepted: 10/13/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objective of this study was to assess contemporary use of operator directed sedation (ODS) and anesthesiologist care (AC) in the pediatric/congenital cardiac catheterization laboratory (PCCL), specifically evaluating whether the use of operator-directed sedation was associated with increased risk of major adverse events. BACKGROUND The safety of ODS relative to AC during PCCL procedures has been questioned. METHODS A multicenter, retrospective cohort study was performed studying procedures habitually performed with ODS or AC at IMPACT (Improving Adult and Congenital Treatment) registry hospitals using ODS for ≥5% of cases. The risks for major adverse events (MAE) for ODS and AC cases were compared, adjusted for case mix. Current recommendations were evaluated by comparing the ratio of observed to expected MAE for cases in which ODS was inappropriate (inconsistent with those guidelines) with those for similar risk AC cases, as well as those in which ODS or AC was appropriate. RESULTS Of the hospitals submitting data to IMPACT, 28 of 101 met inclusion criteria. Of the 7,042 cases performed using ODS at these centers, 88% would be inappropriate. Use of ODS was associated with lower likelihood of MAE both in observed results (p < 0.0001) and after adjusting for case-mix (odds ratio: 0.81; p = 0.006). Use of AC was also associated with longer adjusted fluoroscopy and procedure times (p < 0.0001 for both). The observed/expected ratio for ODS cases with high pre-procedural risk (inappropriate for ODS) was significantly lower than that for AC cases with comparable pre-procedural risk. Across a range of pre-procedural risks, there was no stratum in which risk for MAE was lower for AC than ODS. CONCLUSIONS Across a range of hospitals, ODS was used safely and with improved efficiency. Clinical judgment better identified cases in which ODS could be used than pre-procedural risk score. This should inform future guidelines for the use of ODS and AC in the catheterization laboratory.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Kevin F Kennedy
- Mid America Heart Institute St. Luke's Health System, Kansas City, Missouri, USA
| | - James M Steven
- Department of Anesthesia and Critical Care, The Children's Hospital of Philadelphia and Department of Anesthesia Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kevin D Hill
- Department of Pediatrics, Division of Pediatric Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Reid C Chamberlain
- Department of Pediatrics, Division of Pediatric Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Marisa E Millenson
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christopher L Smith
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yoav Dori
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew J Gillespie
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jonathan J Rome
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew C Glatz
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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O’Byrne ML, Song L, Huang J, Goldberg D, Gardner MM, Ravishankar C, Rome JJ, Glatz AC. Trends in Discharge Prescription of Digoxin After Norwood Operation: An Analysis of Data from the Pediatric Health Information System (PHIS) Database. Pediatr Cardiol 2021; 42:793-803. [PMID: 33528619 PMCID: PMC8113119 DOI: 10.1007/s00246-021-02543-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
Quality improvement efforts have focused on reducing interstage mortality for infants with hypoplastic left heart syndrome (HLHS). In 1/2016, two publications reported that use of digoxin was associated with reduced interstage mortality. The degree to which these findings have affected real world practice has not been evaluated. The discharge medications of neonates with HLHS undergoing Norwood operation between 1/2007 and 12/2018 at Pediatric Health Information Systems Database hospitals were studied. Mixed effects models were calculated to evaluate the hypothesis that the likelihood of digoxin prescription increased after 1/2016, adjusting for measurable confounders with furosemide and aspirin prescription measured as falsification tests. Interhospital practice variation was measured using the median odds ratio. Over the study period, 6091 subjects from 45 hospitals were included. After adjusting for measurable covariates, discharge after 1/2016 was associated with increased odds of receiving digoxin (OR 3.9, p < 0.001). No association was seen between date of discharge and furosemide (p = 0.26) or aspirin (p = 0.12). Prior to 1/2016, the likelihood of receiving digoxin was decreasing (OR 0.9 per year, p < 0.001), while after 1/2016 the rate has increased (OR 1.4 per year, p < 0.001). However, there remains significant interhospital variation in the likelihood of receiving digoxin even after adjusting for known confounders (median odds ratio = 3.5, p < 0.0001). Following publication of studies describing an association between digoxin and improved interstage survival, the likelihood of receiving digoxin at discharge increased without similar changes for furosemide or aspirin. Despite concerted efforts to standardize interstage care, interhospital variation in pharmacotherapy in this vulnerable population persists.
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Affiliation(s)
- Michael L O’Byrne
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA,Center For Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA,Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Lihai Song
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Jing Huang
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA,Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, The Children’s Hospital of Philadelphia, Philadelphia, PA,Department of Biostatistics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - David Goldberg
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Monique M Gardner
- Division of Cardiac Critical Care, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Chitra Ravishankar
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jonathan J Rome
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Andrew C Glatz
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA,Center For Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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O'Byrne ML, Glatz AC, Faerber JA, Seshadri R, Millenson ME, Mi L, Shinohara RT, Dori Y, Gillespie MJ, Rome JJ, Kawut SM, Groeneveld PW. Interhospital Variation in the Costs of Pediatric/Congenital Cardiac Catheterization Laboratory Procedures: Analysis of Data From the Pediatric Health Information Systems Database. J Am Heart Assoc 2020; 8:e011543. [PMID: 31023121 PMCID: PMC6512131 DOI: 10.1161/jaha.118.011543] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Cardiac catheterization is an important but costly component of health care for young patients with cardiac disease. Measurement of variation in their cost between hospitals and identification of the reasons for this variation may help reduce cost without compromising quality. Methods and Results Using data from Pediatric Health Information Systems Database from January 2007 to December 2015, the costs of 9 procedures were measured. Mixed‐effects multivariable models were used to generate case‐mix–adjusted estimates of each hospital's cost for each procedure and measure interhospital variation. Procedures (n=35 637) from 43 hospitals were studied. Median costs varied from $8249 (diagnostic catheterization after orthotopic heart transplantation) to $38 909 (transcatheter pulmonary valve replacement). There was marked variation in the cost of procedures between hospitals with 3.5‐ to 8.9‐fold differences in the case‐mix–adjusted cost between the most and least expensive hospitals. No significant correlation was found between hospitals’ procedure‐specific mortality rates and costs. Higher procedure volume was not associated with lower cost except for diagnostic procedures in heart transplant patients and pulmonary artery angioplasty. At the hospital level, the proportion of cases that were outliers (>95th percentile) was significantly associated with rank in terms of cost (Spearman's ρ ranging from 0.37 to 0.89, P<0.01). Conclusions Large‐magnitude hospital variation in cost was not explained by case‐mix or volume. Further research is necessary to determine the degree to which variation in cost is the result of differences in the efficiency of the delivery of healthcare services and the rate of catastrophic adverse outcomes and resultant protracted and expensive hospitalizations.
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Affiliation(s)
- Michael L O'Byrne
- 1 Division of Cardiology Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,2 Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia Philadelphia PA.,3 Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA
| | - Andrew C Glatz
- 1 Division of Cardiology Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,2 Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia Philadelphia PA
| | - Jennifer A Faerber
- 2 Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia Philadelphia PA
| | - Roopa Seshadri
- 2 Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia Philadelphia PA
| | - Marisa E Millenson
- 2 Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia Philadelphia PA
| | - Lanyu Mi
- 2 Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia Philadelphia PA
| | - Russell T Shinohara
- 4 Department of Biostatistics Center for Clinical Epidemiology and Biostatistics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Yoav Dori
- 1 Division of Cardiology Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Matthew J Gillespie
- 1 Division of Cardiology Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Jonathan J Rome
- 1 Division of Cardiology Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Steven M Kawut
- 5 Division of Pulmonology and Critical Care Department of Medicine Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Peter W Groeneveld
- 3 Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA.,6 Division of General Internal Medicine Department of Medicine Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,7 Corporal Michael J. Crescenz VA Medical Center Philadelphia PA
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7
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O'Byrne ML, DeCost G, Katcoff H, Savla JJ, Chang J, Goldmuntz E, Groeneveld PW, Rossano JW, Faerber JA, Mercer-Rosa L. Resource Utilization in the First 2 Years Following Operative Correction for Tetralogy of Fallot: Study Using Data From the Optum's De-Identified Clinformatics Data Mart Insurance Claims Database. J Am Heart Assoc 2020; 9:e016581. [PMID: 32691679 PMCID: PMC7792257 DOI: 10.1161/jaha.120.016581] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Despite excellent operative survival, correction of tetralogy of Fallot frequently is accompanied by residual lesions that may affect health beyond the incident hospitalization. Measuring resource utilization, specifically cost and length of stay, provides an integrated measure of morbidity not appreciable in traditional outcomes. Methods and Results We conducted a retrospective cohort study, using de‐identified commercial insurance claims data, of 269 children who underwent operative correction of tetralogy of Fallot from January 2004 to September 2015 with ≥2 years of continuous follow‐up (1) to describe resource utilization for the incident hospitalization and subsequent 2 years, (2) to determine whether prolonged length of stay (>7 days) in the incident hospitalization was associated with increased subsequent resource utilization, and (3) to explore whether there was regional variation in resource utilization with both direct comparisons and multivariable models adjusting for known covariates. Subjects with prolonged incident hospitalization length of stay demonstrated greater resource utilization (total cost as well as counts of outpatient visits, hospitalizations, and catheterizations) after hospital discharge (P<0.0001 for each), though the number of subsequent operative and transcatheter interventions were not significantly different. Regional differences were observed in the cost of incident hospitalization as well as subsequent hospitalizations, outpatient visits, and the costs associated with each. Conclusions This study is the first to report short‐ and medium‐term resource utilization following tetralogy of Fallot operative correction. It also demonstrates that prolonged length of stay in the initial hospitalization is associated with increased subsequent resource utilization. This should motivate research to determine whether these differences are because of modifiable factors.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA.,Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA
| | - Grace DeCost
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Hannah Katcoff
- Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA
| | - Jill J Savla
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Joyce Chang
- Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA.,Division of Rheumatology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Elizabeth Goldmuntz
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Peter W Groeneveld
- Division of General Internal Medicine Department of Medicine Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,Corporal Michael J. Crescenz VA Medical Center Philadelphia PA
| | - Joseph W Rossano
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA
| | - Jennifer A Faerber
- Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA
| | - Laura Mercer-Rosa
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
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O'Byrne ML, Faerber JA, Katcoff H, Frank DB, Davidson A, Giglia TM, Avitabile CM. Variation in the use of pulmonary vasodilators in children and adolescents with pulmonary hypertension: a study using data from the MarketScan® insurance claims database. Pulm Circ 2020; 10:2045894020933083. [PMID: 35154663 PMCID: PMC8826280 DOI: 10.1177/2045894020933083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 05/13/2020] [Indexed: 12/15/2022] Open
Abstract
Despite progress in pharmacotherapy in pediatric pulmonary hypertension, real-world
patterns of directed pulmonary hypertension therapy have not been studied in the current
era. A retrospective observational study of children (≤18 years) with pulmonary
hypertension was performed using data from the MarketScan® Commercial and Medicaid claims
databases. Associations between etiology of pulmonary hypertension and pharmaceutical
regimen were evaluated, as were the associations between subject social and geographic
characteristics (insurance-type, race, and/or census region) and regimen. Annualized costs
of single- and multi-class regimens were calculated. In total, 873 subjects were studied,
of which 94% received phosphodiesterase-5 inhibitors, 31% endothelin receptor antagonist,
9% prostacyclin analogs, and 7% calcium channel blockers. Monotherapy was used in 72% of
subjects. Phosphodiesterase-5 inhibitors monotherapy was the most common regimen (93%).
Subjects with idiopathic pulmonary hypertension, congenital heart disease, and
unclassified pulmonary hypertension receive more than one agent and were more likely to
receive both endothelin receptor antagonist and prostacyclin analogs than other forms of
pulmonary hypertension. Compared to recipients of public insurance, subjects with
commercial insurance were more likely to receive more intense therapy
(p = 0.003), which was confirmed in multivariable analysis (OR: 1.4,
p = 0.03). Receipt of commercial insurance was also associated with
increased annual costs across all subjects (p < 0.001) and for the
most common specific regimens. The majority of children with pulmonary hypertension
receive phosphodiesterase monotherapy, followed by phosphodiesterase–endothelin receptor
antagonist two drug regimens, and finally the addition of prostacyclin analogs for
three-drug therapy. However, even after adjustment for measurable confounders, commercial
insurance was associated with higher intensity care and higher costs (even within specific
classes of pulmonary vasodilators). The effect of these associations on clinical outcome
cannot be discerned from the current data set, but patterns of treatment deserve further
attention.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia, PA, USA
| | - Jennifer A Faerber
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Hannah Katcoff
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - David B Frank
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alex Davidson
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Therese M Giglia
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Catherine M Avitabile
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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9
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O'Byrne ML, Millenson ME, Grady CB, Huang J, Bamat NA, Munson DA, Song L, Dori Y, Gillespie MJ, Rome JJ, Glatz AC. Trends in transcatheter and operative closure of patent ductus arteriosus in neonatal intensive care units: Analysis of data from the Pediatric Health Information Systems Database. Am Heart J 2019; 217:121-130. [PMID: 31654942 PMCID: PMC6861695 DOI: 10.1016/j.ahj.2019.08.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 08/09/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND The risks and benefits of pharmacologic treatment and operative closure of patent ductus arteriosus (O-PDA) in premature infants remain controversial. Recent series have demonstrated the feasibility of transcatheter PDA closure (TC-PDA) in increasingly small infants. The effect of this change on practice has not been evaluated. METHODS A multicenter observational study of infants treated in neonatal intensive care units in hospitals contributing data to the Pediatric Health Information Systems Database from January 2007 to December 2017 was performed to study trends in the propensities for (1) mechanical closure of PDA and (2) TC-PDA versus O-PDA, as well as interhospital variation in practice. RESULTS A total of 6,214 subjects at 44 hospitals were studied (5% TC-PDA). Subject median gestational age was 25 weeks (interquartile range: 24-27 weeks). Median age at closure was 24 days (interquartile range: 14-36 days). The proportion of all neonatal intensive care unit patients undergoing either O-PDA or TC-PDA decreased (3.1% in 2007 and 0.7% in 2017, P < .001), whereas the proportion in which TC-PDA was used increased significantly (0.1% in 2007 to 29.0% in 2017). Case-mix-adjusted multivariable models similarly demonstrated increasing propensity to pursue TC-PDA (odds ratio [OR] 1.66 per year, P < .001) with acceleration of the trend after 2014 (OR 2.46 per year, P < .001) as well as significant practice variation (P < .001, median OR 4.6) across the study period. CONCLUSIONS In the face of decreasing closure of PDA, the use of TC-PDA increased dramatically with significant practice variability. This demonstrates that there is equipoise for potential clinical trials.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA; Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia, PA.
| | - Marisa E Millenson
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Connor B Grady
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jing Huang
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Nicolas A Bamat
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA; Division of Neonatology, INS; Philadelphia, Philadelphia, PA
| | - David A Munson
- Division of Neonatology, INS; Philadelphia, Philadelphia, PA
| | - Lihai Song
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Yoav Dori
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Matthew J Gillespie
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jonathan J Rome
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Andrew C Glatz
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA
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10
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O'Byrne ML, Glatz AC, Song L, Griffis HM, Millenson ME, Gillespie MJ, Dori Y, DeWitt AG, Mascio CE, Rome JJ. Association Between Variation in Preoperative Care Before Arterial Switch Operation and Outcomes in Patients With Transposition of the Great Arteries. Circulation 2019; 138:2119-2129. [PMID: 30474422 DOI: 10.1161/circulationaha.118.036145] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The arterial switch operation (ASO) is the gold standard operative correction of neonates with transposition of the great arteries and intact ventricular septum, with excellent operative survival. The associations between patient and surgeon characteristics and outcomes are well understood, but the associations between variation in preoperative care and outcomes are less well studied. METHODS A multicenter retrospective cohort study of infants undergoing neonatal ASO between January 2010 and September 2015 at hospitals contributing data to the Pediatric Health Information Systems database was performed. The association between preoperative care (timing of ASO, preoperative use of balloon atrial septostomy, prostaglandin infusion, mechanical ventilation, and vasoactive agents) and operative outcomes (mortality, length of stay, and cost) was studied with multivariable mixed-effects models. RESULTS Over the study period, 2159 neonates at 40 hospitals were evaluated. Perioperative mortality was 2.8%. Between hospitals, the use of adjuvant therapies and timing of ASO varied broadly. At the subject level, older age at ASO was associated with higher mortality risk (age >6 days: odds ratio, 1.90; 95% CI, 1.11-3.26; P=0.02), cost, and length of stay. Receipt of a balloon atrial septostomy was associated with lower mortality risk (odds ratio, 0.32; 95% CI, 0.17-0.59; P<0.001), cost, and length of stay. Later hospital median age at ASO was associated with higher odds of mortality (odds ratio, 1.15 per day; 95% CI, 1.02-1.29; P=0.03), longer length of stay ( P<0.004), and higher cost ( P<0.001). Other hospital factors were not independently associated with the outcomes of interest. CONCLUSIONS There was significant variation in preoperative care between hospitals. Some potentially modifiable aspects of perioperative care (timing of ASO and septostomy) were significantly associated with mortality, length of stay, and cost. Further research on the perioperative care of neonates is necessary to determine whether modifying practice on the basis of the observed associations translates into improved outcomes.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology (M.L.O., A.C.G., M.J.G., Y.D., J.J.R.), The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania.,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, PA (M.L.O., A.C.G., L.S., H.M.G., M.E.M.).,Leonard Davis Institute University of Pennsylvania, Philadelphia (M.L.O.).,Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania, Philadelphia (M.L.O.)
| | - Andrew C Glatz
- Division of Cardiology (M.L.O., A.C.G., M.J.G., Y.D., J.J.R.), The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania.,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, PA (M.L.O., A.C.G., L.S., H.M.G., M.E.M.)
| | - Lihai Song
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, PA (M.L.O., A.C.G., L.S., H.M.G., M.E.M.)
| | - Heather M Griffis
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, PA (M.L.O., A.C.G., L.S., H.M.G., M.E.M.)
| | - Marisa E Millenson
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, PA (M.L.O., A.C.G., L.S., H.M.G., M.E.M.)
| | - Matthew J Gillespie
- Division of Cardiology (M.L.O., A.C.G., M.J.G., Y.D., J.J.R.), The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania
| | - Yoav Dori
- Division of Cardiology (M.L.O., A.C.G., M.J.G., Y.D., J.J.R.), The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania
| | - Aaron G DeWitt
- Division of Cardiac Critical Care Medicine (A.G.D.), The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania
| | - Christopher E Mascio
- Division of Cardiothoracic Surgery (C.E.M.), The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania
| | - Jonathan J Rome
- Division of Cardiology (M.L.O., A.C.G., M.J.G., Y.D., J.J.R.), The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania
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11
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Operator-Directed Procedural Sedation in the Congenital Cardiac Catheterization Laboratory. JACC Cardiovasc Interv 2019; 12:835-843. [PMID: 30981573 DOI: 10.1016/j.jcin.2019.01.224] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 12/04/2018] [Accepted: 01/03/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate the association between the method of procedural sedation and outcomes for congenital cardiac catheterization procedures. BACKGROUND The safety of operator-directed sedation (ODS) in the pediatric/congenital cardiac catheterization laboratory has been questioned. To our knowledge, the relative safety of ODS versus general anesthesia (GA) in these cases has not to date been critically evaluated. METHODS A single-center retrospective cohort study was performed to compare the relative safety, cost, and times of catheterization procedures performed with ODS and those performed with GA from a cardiac anesthesiologist. The risk of adverse outcomes was compared using propensity-score-adjusted models. Using the same propensity score, procedure times and relative charges were also compared. RESULTS Over the study period, 4,424 procedures in 2,547 patients were studied. Of these, 27% of cases were performed with ODS. ODS procedures were 70% diagnostic procedures, 17% device closure of patent ductus arteriosus, 5% balloon pulmonary valvuloplasty, and 3% pulmonary artery angioplasty. The risk of adverse event in adjusted models for ODS cases was significantly lower than in GA cases (odds ratio: 0.66; 95% confidence interval: 0.45 to 0.95; p = 0.03). Total room time and case time were also significantly shorter (p < 0.001). Professional (charge ratio: 0.88; p < 0.001) and hospital (charge ratio: 0.84; p < 0.001) charges for ODS cases were also lower than those for GA cases. CONCLUSIONS This study demonstrates that clinical judgment can identify subjects in whom ODS is not associated with increased risk of adverse events. The use of ODS was associated with reduced case times and charges. In combination, these findings suggest that the selective use of ODS can allow for greater efficiency and higher value care without sacrificing safety.
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12
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Goldstein BH, O’Byrne ML, Petit CJ, Qureshi AM, Dai D, Griffis HM, France A, Kelleman MS, McCracken CE, Mascio CE, Shashidharan S, Ligon RA, Whiteside W, Wallen WJ, Agrawal H, Aggarwal V, Glatz AC. Differences in Cost of Care by Palliation Strategy for Infants With Ductal-Dependent Pulmonary Blood Flow. Circ Cardiovasc Interv 2019; 12:e007232. [PMID: 30998390 PMCID: PMC6546294 DOI: 10.1161/circinterventions.118.007232] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In infants with ductal-dependent pulmonary blood flow, initial palliation with patent ductus arteriosus (PDA) stent or modified Blalock-Taussig (BT) shunt have comparable mortality but discrepant length of stay, procedural complication rates and reintervention burdens, which may influence cost. The relative economic impact of these palliation strategies is unknown. METHODS AND RESULTS Retrospective study of infants with ductal-dependent pulmonary blood flow palliated with PDA stent (n=104) or BT shunt (n=251) from 2008 to 2015 at 4 centers of the Congenital Catheterization Research Collaborative. Inflation-adjusted inpatient hospital costs were calculated for first year of life using Pediatric Health Information System data. Costs derived from outpatient catheterizations not in Pediatric Health Information System were imputed. Costs were compared using propensity score-adjusted multivariable models, to account for baseline differences between groups. After propensity score adjustment, first year of life costs were significantly lower in PDA stent ($215 825 [190 644-244 333]) than BT shunt ($249 855 [230 693-270 609]) patients ( P=0.05). After addition of imputed costs, first year of life costs were not significantly different between PDA stent ($226 403 [200 274-255 941]) and BT shunt ($252 072 [232 955-272 759]) groups ( P=0.15). Patient characteristics associated with higher costs included: younger gestational age, genetic syndrome, noncardiac diagnoses, procedural complications, extracorporeal membrane oxygenation, duration of ventilation, intensive care unit and hospital length of stay and reintervention ( P≤0.02 for all). CONCLUSIONS In this first multicenter comparative cost study of PDA stent or BT shunt as palliation for infants with ductal-dependent pulmonary blood flow, adjusted for baseline differences, PDA stent was associated with lower to equivalent costs over the first year of life. Combined with previous evidence suggesting clinical noninferiority, these findings suggest that PDA stent provides competitive health care value.
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Affiliation(s)
| | - Michael L. O’Byrne
- The Cardiac Center at the Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine
| | | | - Athar M. Qureshi
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children’s Hospital, Baylor College of Medicine
| | - Dingwei Dai
- The Cardiac Center at the Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine
| | - Heather M. Griffis
- The Cardiac Center at the Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine
| | - Ashton France
- The Heart Institute, Cincinnati Children’s Hospital Medical Center
| | | | | | - Christopher E. Mascio
- The Cardiac Center at the Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine
| | - Subi Shashidharan
- Children’s Healthcare of Atlanta, Emory University School of Medicine
| | - R. Allen Ligon
- Children’s Healthcare of Atlanta, Emory University School of Medicine
| | - Wendy Whiteside
- The Heart Institute, Cincinnati Children’s Hospital Medical Center
| | - W. Jack Wallen
- The Heart Institute, Cincinnati Children’s Hospital Medical Center
| | - Hitesh Agrawal
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children’s Hospital, Baylor College of Medicine
| | - Varun Aggarwal
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children’s Hospital, Baylor College of Medicine
| | - Andrew C. Glatz
- The Cardiac Center at the Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine
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13
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O'Byrne ML, Kennedy KF, Rome JJ, Glatz AC. Variation in practice patterns in device closure of atrial septal defects and patent ductus arteriosus: An analysis of data from the IMproving Pediatric and Adult Congenital Treatment (IMPACT) registry. Am Heart J 2018; 196:119-130. [PMID: 29421004 DOI: 10.1016/j.ahj.2017.10.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 10/24/2017] [Indexed: 11/16/2022]
Abstract
Practice variation is a potentially important measure of healthcare quality. The IMPACT registry provides a representative national sample with which to study practice variation in trans-catheter interventions for congenital heart disease. METHODS We studied cases for closure of atrial septal defect (ASD) and patent ductus arteriosus (PDA) in IMPACT between January 1, 2011, and September 30, 2015, using hierarchical multivariate models studying (1) the distribution of indications for closure and (2) in patients whose indication for closure was left (LVVO) or right ventricular volume overload (RVVO), the factors influencing probability of closure of a small defect (either in size or in terms of the magnitude of shunt). RESULTS Over the study period, 5233 PDA and 4459 ASD cases were performed at 77 hospitals. The indications for ASD closure were RVVO in 84% and stroke prevention in 13%. Indications for PDA closure were LVVO in 57%, endocarditis prevention in 36%, and pulmonary hypertension in 7%. There was statistically significant variability in indications between hospitals for PDA and ASD procedures (median rate ratio (MRR): 1.3 and 1.1; both P<.001). The proportion of cases for volume overload with a Qp:Qs <1.5:1 decreased with increasing PDA and ASD procedural volume (P=.04 and 0.05). For ASD, the proportion was higher at hospitals with a larger proportion of adult cases (P=.0007). There was significant variation in practice in the risk of closing PDA <2 mm for LVVO (MRR: 1.4, P<.001). CONCLUSION There is measurable variation in transcatheter closure of PDA and ASD. Further research is necessary to study whether this affects outcomes or resource utilization.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology, Children's National Health System and Department of Pediatrics, George Washington University School of Health Sciences, Washington, DC, USA.
| | - Kevin F Kennedy
- Mid America Heart Institute St. Luke's Health System, Kansas City, MO, USA
| | - Jonathan J Rome
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew C Glatz
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Center for Pediatric Clinical Effectiveness, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
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14
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O’Byrne ML, Glatz AC, Gillespie MJ. Transcatheter device closure of atrial septal defects: more to think about than just closing the hole. Curr Opin Cardiol 2018; 33:108-116. [PMID: 29076870 PMCID: PMC6112166 DOI: 10.1097/hco.0000000000000476] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To review current controversies in the transcatheter device closure of ostium secundum atrial septal defects (ASD). RECENT FINDINGS Transcatheter device closure of ASD (TC-ASD) has well established efficacy and safety. For most individual patients with suitable anatomy, TC-ASD is the preferred method for treating ASD. The availability of large multicenter data sets has made it possible to study practice patterns at a range of hospitals across the United States. These studies have revealed differences in practice that were not previously appreciated. Interpretation of the indications for TC-ASD, specifically the definition of right ventricular volume overload varies between hospitals. In response to concern about device erosion, an increasing proportion of patients are being referred for operative ASD closure. Over the last decade, the average age at which ASD closure occurs has decreased. These trends demonstrate previously underappreciated differences in opinion between cardiologists across the country and suggest that further research is necessary to address knowledge gaps limiting consistency of practice. SUMMARY As TC-ASD and congenital interventional cardiology mature as a field, studies of real-world practice provide increasingly valuable information about aspects of care in which there are disagreements about best practices and in which further research is necessary.
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Affiliation(s)
- Michael L O’Byrne
- Division of Cardiology The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania Philadelphia, Philadelphia PA
- Center for Pediatric Clinical Effectiveness and Cardiac Center Research Core, The Children’s Hospital of Philadelphia, Philadelphia PA
- Leonard Davis Institute, University of Pennsylvania, Philadelphia PA
| | - Andrew C Glatz
- Division of Cardiology The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania Philadelphia, Philadelphia PA
- Center for Pediatric Clinical Effectiveness and Cardiac Center Research Core, The Children’s Hospital of Philadelphia, Philadelphia PA
| | - Matthew J Gillespie
- Division of Cardiology The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania Philadelphia, Philadelphia PA
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