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El-Amin A, Koehlmoos T, Yue D, Chen J, Cho NY, Benharash P, Franzini L. The Association of High-Quality Hospital Use on Health Care Outcomes for Pediatric Congenital Heart Defects in a Universal Health Care System. Mil Med 2024; 189:e2163-e2169. [PMID: 38364865 DOI: 10.1093/milmed/usae026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/18/2024] [Accepted: 01/29/2024] [Indexed: 02/18/2024] Open
Abstract
INTRODUCTION Congenital heart disease (CHD) has an incidence of 0.8% to 1.2% worldwide, making it the most common birth defect. Researchers have compared high-volume to low-volume hospitals and found significant hospital-level variation in major complications, health resource utilization, and mortality after CHD surgery. In addition, researchers found critical CHD patients at low-volume/non-teaching facilities to be associated with higher odds of inpatient mortality when compared to CHD patients at high-volume/teaching hospitals (odds ratio 1.76). We examined the effects of high-quality hospital (HQH) use on health care outcomes and health care costs in pediatric CHD care using an instrumental variable (IV) approach. MATERIALS AND METHODS Using nationwide representative claim data from the United States Military Health System from 2016 to 2020, TRICARE beneficiaries with a diagnosis of CHD were tabulated based on relevant ICD-10 (International Classification of Diseases, 10th revision) codes. We examined the relationships between annual readmissions, annual emergency room (ER) use, and mortality and HQH use. We applied both the naive linear probability model (LPM), controlling for the observed patient and hospital characteristics, and the two-stage least squares (2SLS) model, accounting for the unobserved confounding factors. The differential distance between the patient and the closest HQH at the index date and the patient and nearest non-HQH was used as the IV. This protocol was approved by the Institutional Review Board at the University of Maryland, College Park (Approval Number: 1576246-2). RESULTS The naive LPM indicated that HQH use was associated with a higher probability of annual readmissions (marginal effect, 18%; 95% CI, 0.12 to 0.23). The naive LPM indicated that HQH use was associated with a higher probability of mortality (marginal effect, 2.2%; 95% CI, 0.01 to 0.03). Using the differential distance of closest HQH and non-HQH, we identified a significant association between HQH use and annual ER use (marginal effect, -14%; 95% CI, -0.24 to -0.03). CONCLUSIONS After controlling for patient-level and facility-level covariates and adjusting for endogeneity, (1) HQH use did not increase the probability of more than one admission post 1-year CHD diagnosis, (2) HQH use lowered the probability of annual ER use post 1-year CHD diagnosis, and (3) HQH use did not increase the probability of mortality post 1-year CHD diagnosis. Patients who may have benefited from utilizing HQH for CHD care did not, alluding to potential barriers to access, such as health insurance restrictions or lack of patient awareness. Although we used hospital quality rating for congenital cardiac surgery as reported by the Society of Thoracic Surgeons, the contributing data span a 4-year period and may not reflect real-time changes in center performance. Since this study focused on inpatient care within the first-year post-initial CHD diagnosis, it may not reflect the full range of health system utilization. It is necessary for clinicians and patient advocacy groups to collaborate with policymakers to promote the development of an overarching HQH designation authority for CHD care. Such establishment will facilitate access to HQH for military beneficiary populations suffering from CHD.
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Affiliation(s)
- Amber El-Amin
- Center for Health Services Research, Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD 20742, USA
| | - Tracey Koehlmoos
- Center for Health Services Research, Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
| | - Dahai Yue
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD 20742, USA
| | - Jie Chen
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD 20742, USA
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA 90024, USA
| | - Nam Yong Cho
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA 90024, USA
- Department of Surgery, University of California, Los Angeles, CA 90024, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA 90024, USA
- Department of Surgery, University of California, Los Angeles, CA 90024, USA
| | - Luisa Franzini
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD 20742, USA
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El-Amin A, Koehlmoos T, Yue D, Chen J, Cho NY, Benharash P, Franzini L. High-Quality Hospital Status on Health Care Costs for Pediatric Congenital Heart Disease Care for U.S. Military Beneficiaries. Mil Med 2024:usae350. [PMID: 38970436 DOI: 10.1093/milmed/usae350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 06/05/2024] [Accepted: 06/25/2024] [Indexed: 07/08/2024] Open
Abstract
INTRODUCTION Congenital heart disease (CHD) is the most common and resource demanding birth defect managed in the United States, with approximately 40,000 children undergoing CHD surgery year. Researchers have compared high-volume to low-volume hospitals and found significant hospital-level variation in major complications, health resource utilization, and health care costs after CHD surgery. MATERIALS AND METHODS Using nationwide representative claim data from the United States Military Health System from 2016 to 2020, TRICARE beneficiaries diagnosed with CHD were tabulated based on ICD-10 codes (International Classification of Diseases, 10th revision). We examined the relationships between total costs and total hospitalizations costs post 1-year CHD diagnosis and presence or absence of High-Quality Hospital (HQH) designation. We applied both the naive generalized linear model (GLM) to control for the observed patient and hospital characteristics and the 2-stage least squares (2SLS) model to account for the unobserved confounding factors. This study was approved by University of Maryland, College Park Institutional Review Board (IRB) (Approval Number: 1576246-2). RESULTS A relationship between HQH designation and total CHD related costs was not seen across 2SLS model specifications (marginal effect; -$41,579; 95% CI, -$83,429 to $271). For patients diagnosed with a moderate-complex or single ventricle CHD, the association of HQH status was a statistically significant reduction in total costs (marginal effect; -$84,395; 95% CI, -$140,560 to -$28,229) and hospitalization costs (marginal effect; -$73,958; 95% CI, -$121,878 to -$26,039). CONCLUSIONS It is very imperative for clinicians and patient support advocates to urge policymakers to deliberate the establishment of a quality designation authority for CHD management. These efforts will not only help to identify and standardize quality care metrics but to improve long-term health, effectiveness, and equity in the management of CHD. Furthermore, these efforts can be used to navigate patients to proven HQH, thereby improving care and reducing associated treatment costs for CHD patients.
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Affiliation(s)
- Amber El-Amin
- Center for Health Services Research, Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD 20742, USA
| | - Tracey Koehlmoos
- Center for Health Services Research, Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
| | - Dahai Yue
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD 20742, USA
| | - Jie Chen
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD 20742, USA
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA 90024, USA
| | - Nam Yong Cho
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA 90024, USA
- Department of Surgery, University of California, Los Angeles, CA 90024, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA 90024, USA
- Department of Surgery, University of California, Los Angeles, CA 90024, USA
| | - Luisa Franzini
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD 20742, USA
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Dawson-Gore CC, Well A, Wallace S, Teisberg E, Born C, Carberry K, Gottlieb E, Holt DB, Fraser CD, Mery CM. Evaluating variation in pre-operative evaluation and planning for children undergoing atrial or ventricular septal defect repair. Cardiol Young 2024; 34:164-170. [PMID: 37309178 DOI: 10.1017/s1047951123001336] [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] [Indexed: 06/14/2023]
Abstract
BACKGROUND CHD care is resource-intensive. Unwarranted variation in care may increase cost and result in poorer health outcomes. We hypothesise that process variation exists within the pre-operative evaluation and planning process for children undergoing repair of atrial septal defect or ventricular septal defect and that substantial variation occurs in a small number of care points. METHODS From interviews with staff of an integrated congenital heart centre, an initial process map was constructed. A retrospective chart review of patients with isolated surgical atrial septal defect and ventricular septal defect repair from 7/1/2018 through 11/1/2020 informed revisions of the process map. The map was assessed for points of consistency and variability. RESULTS Thirty-two surgical atrial septal defect/ventricular septal defect repair patients were identified. Ten (31%) were reviewed by interventional cardiology before surgical review. Of these, 6(60%) had a failed catheter-based closure and 4 (40%) were deemed inappropriate for catheter-based closure. Thirty (94%) were reviewed in case conference, all attended surgical clinic, and none were admitted prior to surgery. The process map from interviews alone identified surgery rescheduling as a point of major variability; however, chart review revealed this was not as prominent a source of variability as pre-operative interventional cardiology review. CONCLUSIONS Significant variation in the pre-operative evaluation and planning process for surgical atrial septal defect/ventricular septal defect patients was identified. If such process variation is widespread through CHD care, it may contribute to variations in outcome and cost previously documented within CHD surgery. Future research will focus on determining whether the variation is warranted or unwarranted, associated health outcomes and cost variation attributed to these variations in care processes.
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Affiliation(s)
- Catherine C Dawson-Gore
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin / Dell Children's Medical Center, AustinTX, USA
- Department of Surgery School of Medicine, University of Colorado, Anschutz Medical Campus, AuroraCO, USA
| | - Andrew Well
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin / Dell Children's Medical Center, AustinTX, USA
- Department of Surgery and Perioperative Care, The University of Texas at Austin Dell Medical School, AustinTX, USA
- The Value Institute for Health and Care, The University of Texas at Austin Dell Medical School and McCombs School of Business, AustinTX, USA
| | - Scott Wallace
- The Value Institute for Health and Care, The University of Texas at Austin Dell Medical School and McCombs School of Business, AustinTX, USA
| | - Elizabeth Teisberg
- The Value Institute for Health and Care, The University of Texas at Austin Dell Medical School and McCombs School of Business, AustinTX, USA
| | | | - Kathleen Carberry
- The Value Institute for Health and Care, The University of Texas at Austin Dell Medical School and McCombs School of Business, AustinTX, USA
| | - Erin Gottlieb
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin / Dell Children's Medical Center, AustinTX, USA
- Department of Surgery and Perioperative Care, The University of Texas at Austin Dell Medical School, AustinTX, USA
| | - Dudley Byron Holt
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin / Dell Children's Medical Center, AustinTX, USA
- Department of Pediatrics, The University of Texas at Austin Dell Medical School, AustinTX, USA
| | - Charles D Fraser
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin / Dell Children's Medical Center, AustinTX, USA
- Department of Surgery and Perioperative Care, The University of Texas at Austin Dell Medical School, AustinTX, USA
| | - Carlos M Mery
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin / Dell Children's Medical Center, AustinTX, USA
- Department of Surgery and Perioperative Care, The University of Texas at Austin Dell Medical School, AustinTX, USA
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Mohiuddin TA, Raol N, Tey CS, Horný M, Zhang C, Sharp WG, Chanani N, Patzer RE. Quantifying the Healthcare Burden of Pediatric Feeding Disorder after Congenital Heart Surgery. J Pediatr 2023; 261:113593. [PMID: 37399917 DOI: 10.1016/j.jpeds.2023.113593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 05/27/2023] [Accepted: 06/26/2023] [Indexed: 07/05/2023]
Abstract
OBJECTIVE To determine the healthcare costs and use burden of pediatric feeding disorder after congenital heart surgery. STUDY DESIGN A retrospective, population-based cohort study using claims data (2009-2018) was performed. Participants include patients aged 0-18 years who had undergone congenital heart surgery and were included in the insurance database ≥1 year after surgery. The main exposure variable was the presence of a pediatric feeding disorder, defined as a need for a feeding tube at discharge or diagnosis of dysphagia or feeding-related difficulty within the study timeframe. Main outcomes include overall and feeding-related medical care use, defined as readmissions and outpatient use, and feeding-related cost of care within 1 year of surgery. RESULTS A total of 10 849 pediatric patients were identified, with 3347 (30.9%) presenting with pediatric feeding disorder within 1 year of surgery. Patients with pediatric feeding disorder spent a median of 12 days (IQR, 6-33 days) in the hospital, compared with 5 days (IQR, 3-8 days) in patients without (P < .001). Rate ratios for overall readmissions, feeding-related readmissions, feeding-related outpatient use, and cost of care over the first year after surgery were significantly increased at 2.9 (95% CI, 2.5-3.4), 5.1 (95% CI, 4.6-5.7), 7.7 (95% CI, 6.5-9.1), and 2.2 (95% CI, 2.0-2.3) among patients with pediatric feeding disorder as compared with those without. CONCLUSIONS Pediatric feeding disorder after congenital heart surgery is associated with a significant healthcare burden. Multidisciplinary care for and research on this health condition is needed to identify optimal management strategies to reduce this burden and improve outcomes.
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Affiliation(s)
- Tahmina A Mohiuddin
- Medical Scholars Program, Augusta University/University of Georgia Medical Partnership, Athens, GA
| | - Nikhila Raol
- Department of Otolaryngology, Emory School of Medicine, Atlanta, GA; Department of Pediatrics, Emory School of Medicine, Atlanta, GA; Childrens Healthcare of Atlanta, Atlanta, GA; Division of Pediatric Otolaryngology, Children's Healthcare of Atlanta, Atlanta, GA.
| | - Ching S Tey
- Department of Pediatrics, Emory School of Medicine, Atlanta, GA
| | - Michal Horný
- Department of Radiology and Imaging Sciences, Emory School of Medicine, Atlanta, GA; Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA
| | - Chao Zhang
- Department of Pediatrics, Emory School of Medicine, Atlanta, GA
| | - William G Sharp
- Department of Pediatrics, Emory School of Medicine, Atlanta, GA; Childrens Healthcare of Atlanta, Atlanta, GA; Children's Feeding Program, Children's Healthcare of Atlanta, Atlanta, GA
| | - Nikhil Chanani
- Department of Pediatrics, Emory School of Medicine, Atlanta, GA; Childrens Healthcare of Atlanta, Atlanta, GA; Sibley Heart Center, Alpharetta, GA; Division of Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, GA
| | - Rachel E Patzer
- Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA
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Dorobantu DM, Huang Q, Espuny Pujol F, Brown KL, Franklin RC, Pufulete M, Lawlor DA, Crowe S, Pagel C, Stoica SC. Hospital resource utilization in a national cohort of functionally single ventricle patients undergoing surgical treatment. JTCVS OPEN 2023; 14:441-461. [PMID: 37425480 PMCID: PMC10329026 DOI: 10.1016/j.xjon.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 02/22/2023] [Accepted: 03/27/2023] [Indexed: 07/11/2023]
Abstract
Objective The study objective was to provide a detailed overview of health resource use from birth to 18 years old for patients with functionally single ventricles and identify associated risk factors. Methods All patients with functionally single ventricles treated between 2000 and 2017 in England and Wales were linked to hospital and outpatient records using data from the Linking AUdit and National datasets in Congenital HEart Services project. Hospital stay was described in yearly age intervals, and associated risk factors were explored using quantile regression. Results A total of 3037 patients with functionally single ventricles were included, 1409 (46.3%) undergoing a Fontan procedure. During the first year of life, the median days spent in hospital was 60 (interquartile range, 37-102), mostly inpatient days, mirroring a mortality of 22.8%. This decreases to between 2 and 9 in-hospital days/year afterward. Between 2 and 18 years, most hospital days were outpatient, with a median of 1 to 5 days/year. Lower age at the first procedure, hypoplastic left heart syndrome/mitral atresia, unbalanced atrioventricular septal defect, preterm birth, congenital/acquired comorbidities, additional cardiac risk factors, and severity of illness markers were associated with fewer days at home and more intensive care unit days in the first year of life. Only markers of early severe illness were associated with fewer days at home in the first 6 months after the Fontan procedure. Conclusions Hospital resource use in functionally single ventricle cases is not uniform, decreasing 10-fold during adolescence compared with the first year of life. There are subsets of patients with worse outcomes during their first year of life or with persistently high hospital use throughout their childhood, which could be the target of future research.
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Affiliation(s)
- Dan-Mihai Dorobantu
- Children's Health and Exercise Research Centre, University of Exeter, Exeter, United Kingdom
- Population Health Sciences, University of Bristol, Bristol, United Kingdom
- University Hospitals Bristol and Weston National Health Service Foundation Trust, Bristol, United Kingdom
| | - Qi Huang
- Clinical Operational Research Unit, Department of Mathematics, University College London, London, United Kingdom
| | - Ferran Espuny Pujol
- Clinical Operational Research Unit, Department of Mathematics, University College London, London, United Kingdom
| | - Katherine L. Brown
- Cardiac and Critical Care Division, Great Ormond Street Hospital National Health Service Foundation Trust, London, United Kingdom
| | - Rodney C. Franklin
- Department of Paediatric Cardiology, Royal Brompton and Harefield National Health Service Foundation Trust, London, United Kingdom
| | - Maria Pufulete
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Deborah A. Lawlor
- Population Health Sciences, University of Bristol, Bristol, United Kingdom
- Medical Research Council Integrative Epidemiology Unit at the University of Bristol, Bristol, United Kingdom
- Bristol National Institute for Health Research Biomedical Research Centre, Bristol, United Kingdom
| | - Sonya Crowe
- Clinical Operational Research Unit, Department of Mathematics, University College London, London, United Kingdom
| | - Christina Pagel
- Clinical Operational Research Unit, Department of Mathematics, University College London, London, United Kingdom
| | - Serban C. Stoica
- University Hospitals Bristol and Weston National Health Service Foundation Trust, Bristol, United Kingdom
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Berry AE, Bearl DW. Rethinking status 1A criteria in pediatric cardiac transplantation: A case for the prioritization of patients with single ventricle anatomy supported by ventricular assist devices. Front Pediatr 2023; 11:1057903. [PMID: 36911016 PMCID: PMC9998663 DOI: 10.3389/fped.2023.1057903] [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: 10/10/2022] [Accepted: 01/31/2023] [Indexed: 03/14/2023] Open
Abstract
Over the past 2 years advancements in the techniques and technology of pediatric heart transplantation have exponentially increased. However, even as the number of pediatric donor hearts has grown, demand for this limited resource continues to far outpace supply. Thus, lifesaving support in the form of ventricular assist devices (VAD) has become increasingly utilized in bridging pediatric patients to cardiac transplant. In the current pediatric heart transplant listing criteria, adopted by the United Network for Organ Sharing (UNOS) in 2016, all pediatric patients with a VAD are granted 1A status and assigned top transplant priority regardless of their underlying pathology. However, should this be the case? We suggest that the presence of a VAD alone may not be sufficient for status 1A listing. In doing so, we specifically highlight the heightened acuity, resource utilization, risk profile, and diminished outcomes in patients with single ventricle physiology supported with VAD as compared to patients with structurally normal hearts who would both be listed under 1A status. Given this, from a distributive justice perspective, we further suggest that the lack of granularity in current pediatric cardiac transplant listing categories may inadvertently lead to an inequitable distribution of donor organs and hospital resources especially as it pertains to those with single ventricle anatomy on VAD support. We propose revisiting the current listing priorities in light of improved techniques, technology, and recent data to mitigate this phenomenon. By doing this, pediatric patients with single ventricle disease might be more equitably stratified while awaiting heart transplant.
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Affiliation(s)
- Anna E Berry
- Internal Medicine-Pediatrics Residency Program, Monroe Carell Jr. Children's Hospital and Vanderbilt University Hospital, Vanderbilt University Medical Center, Nashville, TN, United States
| | - David W Bearl
- Division of Pediatric Cardiology, Department of Pediatrics, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, TN, United States
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Respiratory viral infections are prevalent but uncomplicated in single ventricle CHD. Cardiol Young 2022; 33:557-563. [PMID: 35438065 DOI: 10.1017/s1047951122001287] [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] [Indexed: 11/07/2022]
Abstract
BACKGROUND Patients with single ventricle CHD have significant morbidity and healthcare utilisation throughout their lifetime, including non-cardiac hospital admissions. Respiratory viral infections are the main cause of hospitalisation in children, but few data exist for single ventricle patients. We sought to identify how respiratory viral infections impact patients with single ventricle CHD and potential differences between Glenn and Fontan circulation. METHODS We conducted a retrospective study of patients seen from 01/01/2011-12/31/2020. We identified patients with a history of single ventricle CHD and Glenn palliation, and a normoxic control group with isolated atrial septal defect requiring surgical closure. We compared viral-related clinical presentations, admissions, and admission characteristics. RESULTS A total of 312 patients were included (182 single ventricle, 130 atrial septal defect). Single ventricle patients were more likely than children with isolated atrial septal defect to be admitted with a respiratory virus (odds ratio 4.15 [2.30-7.46]), but there was no difference in mechanical ventilation or hospital length of stay (p = 0.4709). Single ventricle patients with Glenn circulation were more likely than those with Fontan circulation to present and be admitted (odds ratio 3.25 [1.62-6.52]), but there was no difference in ICU admission, mechanical ventilation, or hospital length of stay (p = 0.1516). CONCLUSIONS Respiratory viral infections are prevalent but uncomplicated in patients with single ventricle CHD. Viral-related presentations and admissions are more prevalent during the period of Glenn circulation compared to Fontan circulation; however, rate of mechanical ventilation and hospital length of stay are similar.
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John AS, Jackson JL, Moons P, Uzark K, Mackie AS, Timmins S, Lopez KN, Kovacs AH, Gurvitz M. Advances in Managing Transition to Adulthood for Adolescents With Congenital Heart Disease: A Practical Approach to Transition Program Design: A Scientific Statement From the American Heart Association. J Am Heart Assoc 2022; 11:e025278. [PMID: 35297271 PMCID: PMC9075425 DOI: 10.1161/jaha.122.025278] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
It is now expected that most individuals with congenital heart disease will survive to adulthood, including those with complex heart conditions. Maintaining lifelong medical care requires those with congenital heart disease to eventually transfer from pediatric to adult-oriented health care systems. Developing health care transition skills and gaining independence in managing one's own health care is imperative to this process and to ongoing medical and psychosocial success. This scientific statement reviews the recent evidence regarding transition and provides resources, components, and suggestions for development of congenital heart disease transition programs with the goals of improving patient knowledge, self-management, and self-efficacy skills to the level they are capable to eventually integrate smoothly into adult-oriented health care. Specifically, the scientific statement updates 3 sections relevant to transition programming. First, there is a review of specific factors to consider, including social determinants of health, psychosocial well-being, and neurocognitive status. The second section reviews costs of inadequate transition including the public health burden and the impairment in individual quality of life. Finally, the last section discusses considerations and suggestions for transition program design including communication platforms, a family-centered approach, and individual models. Although this scientific statement reviews recent literature surrounding transitions of care for individuals with congenital heart disease there remain significant knowledge gaps. As a field, we have yet to determine ideal timing and methods of transition, and barriers to transition and transfer remain, particularly for the underserved populations. The consequences of poor health care transition are great and garnering outcomes and information through organized, multifaceted, collaborative approaches to transition is critical to improving the lifelong care of individuals with congenital heart disease.
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Shi J, Chen N, Yu W, Liu R, Jin H, Yu Z, Luo L, Gu L, Yang R, Liu Q, Feng W, Wang Z. Status of Comorbid Congenital Anomalies and Their Influence on Resource Use in Pediatric Inpatients: A Serial Cross-Sectional Study in Shanghai, China. Front Public Health 2020; 8:580664. [PMID: 33194984 PMCID: PMC7661780 DOI: 10.3389/fpubh.2020.580664] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/05/2020] [Indexed: 11/13/2022] Open
Abstract
Objectives: The status of children with comorbid congenital anomalies (CAs) and their effects on related hospital resource utilization have been minimally investigated. We aimed to describe the congenital anomalies comorbidity status and their effects on hospital resource utilization (length of stay, cost) by pediatric patients. Setting: This study was conducted in five tertiary care children's hospitals in Shanghai, China. Participants: Data were obtained from the inpatients' electronic health records; diagnoses were recorded using International Classification of Disease, Ninth Revision codes. In total, 7,890 children were diagnosed with congenital anomalies (13.13%), which were either primary or secondary. Primary and secondary outcome measures: The dependent variables were length of stay and cost. The independent variables were demographic and clinical characteristics and CA status. Results: In total, 50.98% of the hospitalized patients had comorbid CA conditions. Medical+CA patients were associated with a longer LOS (β = 2.656, P < 0.001), and CA+medical patients were associated with higher costs (β = 7.222, P < 0.001). Cardiovascular, musculoskeletal, and genitourinary diseases were the top three comorbid diseases. The average LOS for the top three comorbid diseases was longest in the medical+CA group, followed by CA+medical group. Cardiovascular disease was the most frequent comorbidity (ranking 1 in the medical+CA group and 2 in the CA+medical group), and the cost of cardiovascular disease was highest in all groups. Conclusions: A high prevalence of comorbid CA conditions was observed among pediatric inpatients in the sampled tertiary hospitals in China. Strategic planning should be improved to guide resource utilization for complex comorbid CA care.
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Affiliation(s)
- Jianwei Shi
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai General Practice and Community Health Development Research Center, Shanghai, China
| | - Ning Chen
- School of Medicine, Tongji University, Shanghai, China
| | - Wenya Yu
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Rui Liu
- Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hua Jin
- Shanghai General Practice and Community Health Development Research Center, Shanghai, China
| | | | - Li Luo
- School of Public Health, Fudan University, Shanghai, China
| | - Li Gu
- Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Rong Yang
- Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Qian Liu
- School of Medicine, Tongji University, Shanghai, China
| | - Wei Feng
- Department of Psychological Medicine, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhaoxin Wang
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai General Practice and Community Health Development Research Center, Shanghai, China
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Ambrose SE, Ongkasuwan J, Dedhia K, Diercks GR, Anne S, Shashidharan S, Raol N. Analysis of Vocal Fold Motion Impairment in Neonates Undergoing Congenital Heart Surgery. JAMA Otolaryngol Head Neck Surg 2019; 144:406-412. [PMID: 29543970 DOI: 10.1001/jamaoto.2017.3459] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Vocal fold motion impairment (VFMI) is a known risk factor following congenital heart surgery (CHS). The impact of this diagnosis on utilization and outcomes is unknown. Objective To evaluate the cost, postprocedure length of stay (PPLOS), and outcomes for neonates with VFMI after CHS. Design, Setting, and Participants A cross-sectional analysis of the 2012 Kids' Inpatient Database (KID) of neonates who underwent CHS was carried out. The KID is an administrative data set of patients, aged 20 years or younger, and contains data on more than 10 million hospitalizations from 44 states. The KID is limited to inpatient hospitalization and contains discharge summary level of data. Patients were limited to those who were born during the hospitalization and those who were aged 28 days or younger at the time of admission for CHS. A weighted total of 4139 neonates who underwent CHS were identified, of which 3725 survived. The proportion of neonates diagnosed with VFMI was 264 (6.92%) of 3725. Exposures Congenital heart surgery. Main Outcomes and Measures Cost of inpatient hospital stay, postprocedure length of stay, odds of pneumonia, gastrostomy tube placement, and tracheostomy tube placement. Risk-adjusted generalized linear models examined differences in cost and PPLOS between neonates who underwent CHS and were diagnosed with VFMI and those who were not. Risk-adjusted logistic regression compared the odds of selected outcomes (gastrostomy, tracheostomy, pneumonia). Models were weighted to provide national estimates. Results Of 3725 neonates (aged 0-28 days), 2203 (59.1%) were male and 1517 (40.7%) were female. Neonates diagnosed with VFMI had significantly higher total cost by $34 000 (95% CI, 2200-65 000) and PPLOS by 9.1 days (95% CI, 4.6-13.7) compared with those who did not. When PPLOS was included as a covariate in the model for cost, presence of VFMI was no longer significant. There were no differences in odds of pneumonia, gastrostomy, or tracheostomy. Conclusions and Relevance Vocal fold motion impairment after CHS was associated with significant increases in cost owing to increased PPLOS. These findings provide a foundation to further investigate standardized screening for VFMI following CHS; early identification and treatment may decrease cost and PPLOS.
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Affiliation(s)
- Stephanie E Ambrose
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Julina Ongkasuwan
- Department of Otolaryngology-Head and Neck Surgery, Baylor College Of Medicine, Houston, Texas.,Department of Otolaryngology-Head and Neck Surgery, Texas Children's Hospital, Houston, Texas
| | - Kavita Dedhia
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Gillian R Diercks
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Brookline, Massachusetts.,Massachusetts Eye and Ear Infirmary, Boston
| | - Samantha Anne
- Department of Otolaryngology-Head and Neck Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Nikhila Raol
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, Georgia
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11
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Zielonka B, Snarr BS, Liu MY, Zhang X, Mascio CE, Fuller S, Gaynor JW, Spray TL, Rychik J. Resource Utilization for Prenatally Diagnosed Single-Ventricle Cardiac Defects: A Philadelphia Fetus-to-Fontan Cohort Study. J Am Heart Assoc 2019; 8:e011284. [PMID: 31140350 PMCID: PMC6585367 DOI: 10.1161/jaha.118.011284] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Healthcare resource utilization is substantial for single‐ventricle cardiac defects (SVCD), with effort commencing at time of fetal diagnosis through staged surgical palliation. We sought to characterize and identify variables that influence resource utilization for SVCD from fetal diagnosis through death, completed staged palliation, or cardiac transplant. Methods and Results Patients with a prenatal diagnosis of SVCD at our institution from 2004 to 2011 were screened. Patients delivered with intent to treat who received cardiac care exclusively at our institution were included. Primary end points included the total days hospitalized and the numbers of echocardiograms and cardiac catheterizations. Subanalysis was performed on survivors of completed staged palliation on the basis of Norwood operation, dominant ventricular morphology, and additional risk factors. Of 202 patients born with intent to treat, 136 patients survived to 6 months after completed staged palliation. The median number of days hospitalized per patient‐year was 25.1 days, and the median numbers of echocardiograms and catheterizations per patient‐year were 7.2 and 0.7, respectively. Mortality is associated with increased resource utilization. Survivors had a cumulative length of stay of 57 days and underwent a median of 21 echocardiograms and 2 catheterizations through staged palliation. Right‐ventricle–dominant lesions requiring Norwood operation are associated with increased resource utilization among survivors of staged palliation. Conclusions For fetuses with SVCD, those with dominant right‐ventricular morphology requiring Norwood operation demand increased resource utilization regardless of mortality. Our findings provide insight into care for SVCD, facilitate precise prenatal counseling, and provide information about the resources utilized to successfully manage SVCD.
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Affiliation(s)
- Benjamin Zielonka
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Brian S Snarr
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Michael Y Liu
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Xuemei Zhang
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Christopher E Mascio
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Stephanie Fuller
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - J William Gaynor
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Thomas L Spray
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Jack Rychik
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
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12
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Islam S, Kaul P, Tran DT, Mackie AS. Health Care Resource Utilization Among Children With Congenital Heart Disease: A Population-Based Study. Can J Cardiol 2018; 34:1289-1297. [PMID: 30205987 DOI: 10.1016/j.cjca.2018.06.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 06/26/2018] [Accepted: 06/26/2018] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Sunjidatul Islam
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Padma Kaul
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Dat T Tran
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew S Mackie
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada; Division of Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
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13
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Nandi D, Rossano JW, Wang Y, Jerrell JM. Risk Factors for Heart Failure and Its Costs Among Children with Complex Congenital Heart Disease in a Medicaid Cohort. Pediatr Cardiol 2017; 38:1672-1679. [PMID: 28852817 DOI: 10.1007/s00246-017-1712-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 08/09/2017] [Indexed: 01/05/2023]
Abstract
Little research attention has been paid to the occurrence of heart failure (HF) in children with complex congenital heart diseases (CHDs). Herein, we describe the prevalence, risk factors, and costs associated with HF in complex CHD. Patients aged ≤17 years and diagnosed with a complex CHD on multiple service visits over a 15-year period in the SC Medicaid dataset (1996-2010) were tracked and analyzed. The cohort included 2999 unduplicated patients; 51.0% were male; 34.4% were African American. HF was diagnosed in 7.6%. Single ventricle lesions, genetic syndromes, and ventricular arrhythmia were significantly associated with an increased likelihood of being diagnosed with HF, controlling for development of comorbid pulmonary hypertension. Patients with HF received significantly more subspecialty care, more surgeries, more hospitalizations, more total days of inpatient care, and more emergency department care than those without HF. Patients with significantly higher total care costs paid by Medicaid had HF, more cardiac surgeries, and more specialized mechanical or other support procedures, controlling for diagnosed single ventricle CHD, a genetic syndrome, and number of non-cardiac surgeries. Complex CHD patients with HF incur significantly higher care costs but require multifaceted, intensive supports for management of incident complications and comorbid conditions.
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Affiliation(s)
- Deipanjan Nandi
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
| | - Joseph W Rossano
- The Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Yinding Wang
- Department of Epidemiology and Biostatistics, University of South Carolina Arnold School of Public Health, Columbia, SC, USA
| | - Jeanette M Jerrell
- Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine, 15 Medical Park, Suite 301, Columbia, SC, 29203, USA.
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14
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Huang L, Schilling C, Dalziel KM, Xie S, Celermajer DS, McNeil JJ, Winlaw D, Hornung TS, Radford DJ, Grigg LE, Bullock A, Wheaton GR, Justo RN, Blake J, Bishop R, Du Plessis K, d'Udekem Y. Hospital Inpatient Costs for Single Ventricle Patients Surviving the Fontan Procedure. Am J Cardiol 2017; 120:467-472. [PMID: 28583678 DOI: 10.1016/j.amjcard.2017.04.049] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 04/26/2017] [Accepted: 04/26/2017] [Indexed: 01/08/2023]
Abstract
We estimated the inpatient resource use for a Fontan patient from birth to adulthood and explored factors that might induce cost differences (2014 US dollar). Inpatient costing records from 4 hospitals with greatest numbers of Fontan patients in Australia and New Zealand were linked with the Fontan registry database. Inpatient records between July 1995 and September 2014 for 420 Fontan patients were linked, and the most frequent primary diagnoses were hypoplastic left heart syndrome (20.7%), tricuspid atresia (19.7%), and double inlet left ventricle (17.1%). The mean hospital cost for a Fontan patient from birth to 18 years of age was estimated to be $390,601 (95% confidence interval [CI] $264,703 to $516,499), corresponding to 164 (95% CI 98 to 231) inpatient days. The cost incurred from birth through to Fontan completion (the staged procedures period) was $219,482 (95% CI $202,410 to $236,553) and the cost thereafter over 15 years was $146,820 (95% CI $44,409 to $249,231), corresponding to 82 (95% CI 72 to 92) and 65 (95% CI 18 to 112) inpatient days, respectively. Costs were higher in male and hypoplastic left heart syndrome patients in the staged procedures period (p <0.001). Having fenestration was associated with higher costs in the staged procedures period (p <0.001) and lower cost after Fontan over 15 years (p = 0.66). In conclusion, patients with single ventricle congenital heart disease continue to demand considerable inpatient resources after the staged procedures period. Over 40% of the pediatric hospital costs for Fontan patients were estimated to occur after the last planned surgery.
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15
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Affiliation(s)
- Richard J Czosek
- The Heart Institute, Cincinnati Children's Hospital Medical Center , Cincinnati, Ohio , USA
| | - Jeffery B Anderson
- The Heart Institute, Cincinnati Children's Hospital Medical Center , Cincinnati, Ohio , USA
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