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Prabhu NK, Moya-Mendez ME, Kang L, Medina CK, McCrary AW, Allareddy V, Overbey D, Turek JW. Textbook Outcome for Superior Cavopulmonary Connection: A Metric for Single Ventricle Heart Surgery. World J Pediatr Congenit Heart Surg 2024; 15:303-312. [PMID: 38263731 DOI: 10.1177/21501351231215261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
Background: To develop a more holistic measure of congenital heart center performance beyond mortality, we created a composite "textbook outcome" (TO) for the Glenn operation. We hypothesized that meeting TO would have a positive prognostic and financial impact. Methods: This was a single center retrospective study of patients undergoing superior cavopulmonary connection (bidirectional Glenn or Kawashima ± concomitant procedures) from 2005 to 2021. Textbook outcome was defined as freedom from operative mortality, reintervention, 30-day readmission, extracorporeal membrane oxygenation, major thrombotic complication, length of stay (LOS) >75th percentile (17d), and mechanical ventilation duration >75th percentile (2d). Multivariable logistic regression and Cox proportional hazards modeling were used. Results: Fifty-one percent (137/269) of patients met TO. Common reasons for TO failure were prolonged LOS (78/132, 59%) and ventilator duration (67/132, 51%). In multivariable analysis, higher weight [odds ratio, OR: 1.44 (95% confidence interval, CI: 1.15-1.84), P = .002] was a positive predictor of TO achievement while right ventricular dominance [OR 0.47 (0.27-0.81), P = .007] and higher preoperative pulmonary vascular resistance [OR 0.58 (0.40-0.82), P = .003] were negative predictors. After controlling for preoperative factors and excluding operative mortalities, TO achievement was independently associated with a decreased risk of death over long-term follow-up [hazard ratio: 0.50 (0.25-0.99), P = .049]. Textbook outcome achievement was also associated with lower direct cost of care [$137,626 (59,333-167,523) vs $262,299 (114,200-358,844), P < .0001]. Conclusion: Achievement of the Glenn TO is associated with long-term survival and lower costs and can be predicted by certain risk factors. As outcomes continue to improve within congenital heart surgery, operative mortality will become a less informative metric. Textbook outcome analysis may represent a more balanced measure of a successful outcome.
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Affiliation(s)
- Neel K Prabhu
- Congenital Heart Surgery Research and Training Laboratory, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mary E Moya-Mendez
- Congenital Heart Surgery Research and Training Laboratory, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Lillian Kang
- Congenital Heart Surgery Research and Training Laboratory, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Cathlyn K Medina
- Congenital Heart Surgery Research and Training Laboratory, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Andrew W McCrary
- Duke Children's Pediatric and Congenital Heart Center, Duke University Medical Center, Durham, NC, USA
| | - Veerajalandhar Allareddy
- Duke Children's Pediatric and Congenital Heart Center, Duke University Medical Center, Durham, NC, USA
| | - Douglas Overbey
- Congenital Heart Surgery Research and Training Laboratory, Department of Surgery, Duke University Medical Center, Durham, NC, USA
- Duke Children's Pediatric and Congenital Heart Center, Duke University Medical Center, Durham, NC, USA
| | - Joseph W Turek
- Congenital Heart Surgery Research and Training Laboratory, Department of Surgery, Duke University Medical Center, Durham, NC, USA
- Duke Children's Pediatric and Congenital Heart Center, Duke University Medical Center, Durham, NC, USA
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Foote HP, Thibault D, Gonzalez CD, Hill GD, Minich LL, Overbey DM, Tallent SL, Hill KD, McCrary AW. Center-level factors associated with shorter length of stay following stage 1 palliation: An analysis of the national pediatric cardiology quality improvement collaborative registry. Am Heart J 2023; 265:143-152. [PMID: 37572784 PMCID: PMC10729415 DOI: 10.1016/j.ahj.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/24/2023] [Accepted: 08/05/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND Stage 1 single ventricle palliation (S1P) has the longest length of stay (LOS) of all benchmark congenital heart operations. Center-level factors contributing to prolonged hospitalization are poorly defined. METHODS We analyzed data from infants status post S1P included in the National Pediatric Cardiology Quality Improvement Collaborative Phase II registry. Our primary outcome was patient-level LOS with days alive and out of hospital before stage 2 palliation (S2P) used as a balancing measure. We compared patient and center-level characteristics across quartiles for median center LOS, and used multivariable regression to calculate center-level factors associated with LOS after adjusting for case mix. RESULTS Of 2,510 infants (65 sites), 2037 (47 sites) met study criteria (61% male, 61% white, 72% hypoplastic left heart syndrome). There was wide intercenter variation in LOS (first quartile centers: median 28 days [IQR 19, 46]; fourth quartile: 62 days [35, 95], P < .001). Mortality prior to S2P did not differ across quartiles. Shorter LOS correlated with more pre-S2P days alive and out of hospital, after accounting for readmissions (correlation coefficient -0.48, P < .001). In multivariable analysis, increased use of Norwood with a right ventricle to pulmonary artery conduit (aOR 2.65 [1.1, 6.37]), shorter bypass time (aOR 0.99 per minute [0.98,1.0]), fewer additional cardiac operations (aOR 0.46 [0.22, 0.93]), and increased use of NG tubes rather than G tubes (aOR 7.03 [1.95, 25.42]) were all associated with shorter LOS centers. CONCLUSIONS Modifiable center-level practices may be targets to standardize practice and reduce overall LOS across centers.
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Affiliation(s)
- Henry P Foote
- Division of Pediatric Cardiology, Duke University Medical Center, Durham, NC
| | | | | | - Garick D Hill
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - L Luann Minich
- Department of Pediatrics, The University of Utah and Primary Children's Hospital, Salt Lake City, UT
| | - Douglas M Overbey
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, NC
| | - Sarah L Tallent
- Division of Pediatric Cardiology, Duke University Medical Center, Durham, NC
| | - Kevin D Hill
- Division of Pediatric Cardiology, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC.
| | - Andrew W McCrary
- Division of Pediatric Cardiology, Duke University Medical Center, Durham, NC
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O'Byrne ML, Song L, Huang J, Lemley B, Goldberg D, Gardner MM, Ravishankar C, Rome JJ, Glatz AC. Attributable mortality benefit of digoxin treatment in hypoplastic left heart syndrome after the Norwood operation: An instrumental variable-based analysis using data from the Pediatric Health Information Systems Database. Am Heart J 2023; 263:35-45. [PMID: 37169122 DOI: 10.1016/j.ahj.2023.05.005] [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: 02/11/2023] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Observational studies have demonstrated an association between the use of digoxin and reduced interstage mortality after Norwood operation for hypoplastic left heart syndrome (HLHS). Digoxin use has increased significantly but remains variable between different hospitals, independent of case-mix. Instrumental variable analyses have the potential to overcome unmeasured confounding, the major limitation of previous observational studies and to generate an estimate of the attributable benefit of treatment with digoxin. METHODS A cohort of neonates with HLHS born from January 1, 2007 to December 31, 2021 who underwent Norwood operation at Pediatric Health Information Systems Database hospitals and survived >14 days after operation were studied. Using hospital-specific, 6-month likelihood of administering digoxin as an instrumental variable, analyses adjusting for both unmeasured confounding (using the instrumental variable) and measured confounders with multivariable logistic regression were performed. RESULTS The study population included 5,148 subjects treated at 47 hospitals of which 63% were male and 46% non-Hispanic white. Of these, 44% (n = 2,184) were prescribed digoxin. Treatment with digoxin was associated with superior 1-year transplant-free survival in unadjusted analyses (85% vs 82%, P = .02). This survival benefit persisted in an instrumental-variable analysis (OR: 0.71, 95% CI: 0.54-0.94, P = .01), which can be converted to an absolute risk reduction of 5% (number needed to treat of 20). CONCLUSIONS In this observational study of patients with HLHS after Norwood using instrumental variable techniques, a significant benefit in 1-year transplant-free survival attributable to digoxin was demonstrated. In the absence of clinical trial data, this should encourage the use of digoxin in this vulnerable population.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center For Pediatric Clinical Effectiveness, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, Perelman School of Medicine, 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, Department of Pediatrics, Perelman School of Medicine, 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, University of Pennsylvania, Philadelphia, PA
| | - Bethan Lemley
- Division of Cardiology, Department of Pediatrics, Lurie Children's Hospital, Feinberg School of Medicine Northwestern University, Chicago, IL
| | - David Goldberg
- Division of Cardiology, The Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Monique M Gardner
- Division of Cardiac Critical Care, The Children's Hospital of Philadelphia, Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Chitra Ravishankar
- Division of Cardiology, The Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jonathan J Rome
- Division of Cardiology, The Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Andrew C Glatz
- Division of Cardiology St. Louis Children's Hospital and Department of Pediatrics Washington University Medical School, St. Louis, MO
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Prabhu NK, Nellis JR, Moya-Mendez M, Hoover A, Medina C, Meza JM, Allareddy V, Andersen ND, Turek JW. Textbook outcome for the Norwood operation-an informative quality metric in congenital heart surgery. JTCVS OPEN 2023; 15:394-405. [PMID: 37808016 PMCID: PMC10556845 DOI: 10.1016/j.xjon.2023.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/05/2023] [Accepted: 05/09/2023] [Indexed: 10/10/2023]
Abstract
Objectives To develop a more holistic measure of center performance than operative mortality, we created a composite "textbook outcome" for the Norwood operation using several postoperative end points. We hypothesized that achieving the textbook outcome would have a positive prognostic and financial impact. Methods This was a single-center retrospective study of primary Norwood operations from 2005 to 2021. Through interdisciplinary clinician consensus, textbook outcome was defined as freedom from operative mortality, open or catheter-based reintervention, 30-day readmission, extracorporeal membrane oxygenation, cardiac arrest, reintubation, length of stay >75%ile from Society of Thoracic Surgeons data report (66 days), and mechanical ventilation duration >75%ile (10 days). Multivariable logistic regression and Cox proportional hazards modeling were used to determine predictive factors for textbook outcome achievement and association of the outcome with long-term survival, respectively. Results Overall, 30% (58/196) of patients met the textbook outcome. Common reasons for failure to attain textbook outcome were prolonged ventilation (68/138, 49%) and reintubation (63/138, 46%). In multivariable analysis, greater weight (odds ratio [OR], 2.11; 95% confidence interval [CI], 1.17-3.95; P = .02) was associated with achieving the textbook outcome whereas preoperative shock (OR, 0.36; 95% CI, 0.13-0.87; P = .03) and longer bypass time (OR, 0.99; 95% CI, 0.98-1.00; P = .002) were negatively associated. Patients who met the outcome incurred fewer hospital costs ($152,430 [141,798-177,983] vs $269,070 [212,451-372,693], P < .001), and after adjusting for patient factors, achieving textbook outcome was independently associated with decreased risk of all-cause mortality (hazard ratio, 0.45; 95% CI, 0.22-0.89; P = .02). Conclusions Outcomes continue to improve within congenital heart surgery, making operative mortality a less-sensitive metric. The Norwood textbook outcome may represent a balanced measure of a successful episode of care.
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Affiliation(s)
- Neel K. Prabhu
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, NC
| | - Joseph R. Nellis
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, NC
| | - Mary Moya-Mendez
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, NC
| | - Anna Hoover
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, NC
| | - Cathlyn Medina
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, NC
| | - James M. Meza
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, NC
| | - Veerajalandhar Allareddy
- Duke Children's Pediatric and Congenital Heart Center, Durham, NC
- Division of Critical Care Medicine, Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Nicholas D. Andersen
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, NC
- Duke Children's Pediatric and Congenital Heart Center, Durham, NC
| | - Joseph W. Turek
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, NC
- Duke Children's Pediatric and Congenital Heart Center, Durham, NC
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Variation in hospital costs and resource utilisation after congenital heart surgery. Cardiol Young 2023; 33:420-431. [PMID: 35373722 DOI: 10.1017/s1047951122001019] [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: 11/05/2022]
Abstract
BACKGROUND Children undergoing cardiac surgery have overall improving survival, though they consume substantial resources. Nationwide inpatient cost estimates and costs at longitudinal follow-up are lacking. METHODS Retrospective cohort study of children <19 years of age admitted to Pediatric Health Information System administrative database with an International Classification of Diseases diagnosis code undergoing cardiac surgery. Patients were grouped into neonates (≤30 days of age), infants (31-365 days of age), and children (>1 year) at index procedure. Primary and secondary outcomes included hospital stay and hospital costs at index surgical admission and 1- and 5-year follow-up. RESULTS Of the 99,670 cohort patients, neonates comprised 27% and had the highest total hospital costs, though daily hospital costs were lower. Mortality declined (5.6% in 2004 versus 2.5% in 2015, p < 0.0001) while inpatient costs rose (5% increase/year, p < 0.0001). Neonates had greater index diagnosis complexity, greater inpatient costs, required the greatest ICU resources, pharmacotherapy, and respiratory therapy. We found no relationship between hospital surgical volume, mortality, and hospital costs. Neonates had higher cumulative hospital costs at 1- and 5-year follow-up compared to infants and children. CONCLUSIONS Inpatient hospital costs rose during the study period, driven primarily by longer stay. Neonates had greater complexity index diagnosis, required greater hospital resources, and have higher hospital costs at 1 and 5 years compared to older children. Surgical volume and in-hospital mortality were not associated with costs. Further analyses comprising merged clinical and administrative data are necessary to identify longer stay and cost drivers after paediatric cardiac surgery.
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Sengupta A, Gauvreau K, Kaza A, Hoganson D, Del Nido PJ, Nathan M. Timing of reintervention influences survival and resource utilization following first-stage palliation of single ventricle heart disease. J Thorac Cardiovasc Surg 2023; 165:436-446. [PMID: 35961880 DOI: 10.1016/j.jtcvs.2022.04.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/11/2022] [Accepted: 04/27/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Outcomes after first-stage palliation of single-ventricle heart disease are influenced by many factors, including the presence of residual lesions requiring reintervention. However, there is a dearth of information regarding the optimal timing of reintervention. We assessed if earlier reintervention would be favorably associated with in-hospital outcomes among patients requiring unplanned reinterventions after the Norwood operation. METHODS This was a single-center, retrospective review of all patients who underwent the Norwood procedure from January 1997 to November 2017 and required a predischarge unplanned surgical or transcatheter reintervention on 1 or more subcomponent areas repaired at the index operation. Outcomes of interest included in-hospital mortality or transplant, postoperative hospital length of stay, and inpatient cost. Associations between timing of reintervention and outcomes were assessed using logistic regression (mortality or transplant) or generalized linear models (postoperative hospital length of stay and cost), adjusting for baseline patient-related and procedural factors. RESULTS Of 500 patients who underwent the Norwood operation, 92 (18.4%) required an unplanned reintervention. Median time to reintervention was 12 days (interquartile range, 5-35 days). There were 31 (33.7%) deaths or transplants, median postoperative hospital length of stay was 49 days (interquartile range, 32-87 days), and median cost was $328,000 (interquartile range, $204,000-$464,000). On multivariable analysis, each 5-day increase in time to reintervention increased the odds of mortality or transplant by 20% (odds ratio, 1.2; 95% confidence interval, 1.1-1.3; P = .004). Longer time to reintervention was also significantly associated with greater postoperative hospital length of stay (P < .001) and higher cost (P < .001). CONCLUSIONS For patients requiring predischarge unplanned reinterventions after the Norwood operation, earlier reintervention is associated with improved in-hospital transplant-free survival and resource use.
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Affiliation(s)
- Aditya Sengupta
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Biostatistics, Harvard School of Public Health, Boston, Mass
| | - Aditya Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - David Hoganson
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass.
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Nathan M, Sengupta A. Cost Containment in the Single Ventricle Population. JACC. ADVANCES 2022; 1:100033. [PMID: 38939309 PMCID: PMC11198688 DOI: 10.1016/j.jacadv.2022.100033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Aditya Sengupta
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
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8
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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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Wald R, Mertens L. Hypoplastic Left Heart Syndrome Across the Lifespan: Clinical Considerations for Care of the Fetus, Child, and Adult. Can J Cardiol 2022; 38:930-945. [PMID: 35568266 DOI: 10.1016/j.cjca.2022.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 04/22/2022] [Accepted: 04/24/2022] [Indexed: 12/14/2022] Open
Abstract
Hypoplastic left heart syndrome (HLHS) is the most common anatomic lesion in children born with single ventricle physiology and is characterized by the presence of a dominant right ventricle and a hypoplastic left ventricle along with small left-sided heart structures. Diagnostic subgroups of HLHS reflect the extent of inflow and outflow obstruction at the aortic and mitral valves, specifically stenosis or atresia. If left unpalliated, HLHS is a uniformly fatal lesion in infancy. Following introduction of the Norwood operation, early survival has steadily improved over the past four decades, mirroring advances in operative and peri-operative management as well as reflecting refinements in patient surveillance and interstage clinical care. Notably, survival following staged palliation has increased from 0% to a 5-year survival of 60-65% for children in some centres. Despite the prevalence of HLHS in childhood with relatively favourable surgical outcomes in contemporary series, this cohort is only now reaching early adult life and longer-term outcomes have yet to be elucidated. In this article we focus on contemporary clinical management strategies for patients with HLHS across the lifespan, from fetal to adult life. Nomenclature and diagnostic considerations are discussed and current literature pertaining to putative genetic etiologies is reviewed. The spectrum of fetal and pediatric interventional strategies, both percutaneous and surgical, are described. Clinical, patient-reported and neurodevelopmental outcomes of HLHS are delineated. Finally, note is made of current areas of clinical uncertainty and suggested directions for future research are highlighted.
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Affiliation(s)
- Rachel Wald
- Labatt Family Heart Centre, Division of Cardiology, Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Division of Cardiology, University Health Network, Department of Medicine,University of Toronto, Toronto, Ontario, Canada
| | - Luc Mertens
- Labatt Family Heart Centre, Division of Cardiology, Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Division of Cardiology, University Health Network, Department of Medicine,University of Toronto, Toronto, Ontario, Canada
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10
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Eckhauser AW. Neonatal Tetralogy of Fallot, You're the Next Contestant on The Price Is Right! J Am Coll Cardiol 2022; 79:1181-1182. [PMID: 35331413 DOI: 10.1016/j.jacc.2022.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/21/2022] [Accepted: 01/24/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Aaron W Eckhauser
- Section of Pediatric Cardiothoracic Surgery, Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, USA.
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11
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Ghandour HZ, Vervoort D, Welke KF, Karamlou T. Regionalization of congenital cardiac surgical care: what it will take. Curr Opin Cardiol 2022; 37:137-143. [PMID: 34654032 DOI: 10.1097/hco.0000000000000940] [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] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Decentralized, inconsistent healthcare delivery results in variable outcomes and wastes nearly one trillion dollars annually in the United States (US). Congenital heart surgery (CHS) is not immune due to high, variable costs and inconsistent outcomes across hospitals. Many European countries and Canada have addressed these issues by regionalizing CHS. Centralizing resources lowers costs, reduces in-hospital mortality and improves long-term survival. Although the impact on travel distance for patients is limited, the effect on healthcare disparities requires study. This review summarizes current data and integrates these into paths to regionalization through health policy, research, and academic collaboration. RECENT FINDINGS There are too many CHS programs in the US with unnecessarily high densities of centers in certain regions. This distribution lowers center and surgeon case volumes, creates redundancy, and increases variation in costs and outcomes. Simultaneously, adhering to suboptimal allocation impedes the understanding of optimal regionalization models to optimize congenital cardiac care delivery. SUMMARY CHS regionalization models developed for the US increase surgeon and center volume, decrease healthcare spending, and improve patient outcomes without substantially increasing travel distance. Regionalization in countries with few or no existing CHS programs is yet to be explored, but may be associated with more efficient spending and procedural complexity expansion.
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Affiliation(s)
- Hiba Z Ghandour
- Department of Thoracic & Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Dominique Vervoort
- Institute of Health Policy, Management and Evaluation
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Karl F Welke
- Division of Pediatric Cardiothoracic Surgery, Atrium Health Levine Children's Hospital Charlotte, North Carolina
| | - Tara Karamlou
- Department of Pediatric Cardiac Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Pasquali SK, Thibault D, Hall M, Chiswell K, Romano JC, Gaynor JW, Shahian DM, Jacobs ML, Gaies MG, O'Brien SM, Norton EC, Hill KD, Cowper PA, Shah SS, Mayer JE, Jacobs JP. Evolving Cost-Quality Relationship in Pediatric Heart Surgery. Ann Thorac Surg 2021; 113:866-873. [PMID: 34116004 DOI: 10.1016/j.athoracsur.2021.05.050] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/16/2021] [Accepted: 05/14/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND For the >40,000 US children undergoing congenital heart surgery annually, the relationship between hospital quality and costs remains unclear. Prior studies report conflicting results and clinical outcomes have continued to improve over time. We examined a large contemporary cohort, aiming to better inform ongoing initiatives seeking to optimize healthcare value in this population. METHODS Clinical information (Society of Thoracic Surgeons Congenital Database) was merged with standardized cost data (Pediatric Health Information Systems) for children undergoing heart surgery from 2010-2015. In-hospital cost variability was analyzed using Bayesian hierarchical models adjusted for case-mix. Quality metrics examined included in-hospital mortality, post-operative complications, length of stay (PLOS), and a composite. RESULTS Overall 32 hospitals (n=45,315 patients) were included. Median adjusted cost/case varied across hospitals from $67,700 to $51,200 in the high vs. low cost tertile (ratio 1.32, 95% credible interval 1.29-1.35), and all quality metrics also varied across hospitals. Across cost tertiles there were no significant differences in the quality metrics examined, with the exception of PLOS. The PLOS findings were driven by high-risk STAT 4-5 cases [adjusted median LOS 16.8 vs. 14.9 days in high vs. low cost tertile (ratio 1.13, 1.05-1.24)], and ICU PLOS. CONCLUSIONS Contemporary congenital heart surgery costs vary across hospitals but were not associated with most quality metrics examined, highlighting that performance in one area does not necessarily convey to others. Cost variability was associated with PLOS, particularly related to ICU PLOS and high-risk cases. Care processes influencing PLOS may provide targets for value-based initiatives in this population.
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Affiliation(s)
- Sara K Pasquali
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan.
| | - Dylan Thibault
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Jennifer C Romano
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - J William Gaynor
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David M Shahian
- Department of Surgery, Center for Quality and Safety, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael G Gaies
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Sean M O'Brien
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Edward C Norton
- Department of Health Management and Policy, Department of Economics, University of Michigan, Ann Arbor, Michigan
| | - Kevin D Hill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Patricia A Cowper
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Samir S Shah
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - John E Mayer
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Jeffrey P Jacobs
- Department of Surgery, University of Florida, Gainesville, Florida
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Karamlou T, Johnston DR, Backer CL, Roselli EE, Welke KF, Caldarone CA, Svensson LG. Access or excess? Examining the argument for regionalized cardiac care. J Thorac Cardiovasc Surg 2020; 160:813-819. [DOI: 10.1016/j.jtcvs.2019.12.125] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 12/20/2019] [Accepted: 12/31/2019] [Indexed: 12/24/2022]
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Vervoort D, Guetter CR, Trager L, Shah P, Diaz-Castrillon CE, Etchill EW, Salenger R. Adult cardiac surgical cost variation around the world: Protocol for a systematic review. Int J Surg Protoc 2020; 23:11-14. [PMID: 32803024 PMCID: PMC7417884 DOI: 10.1016/j.isjp.2020.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 07/24/2020] [Accepted: 07/25/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Globally, over one million cardiac operations occur each year, whereas cardiac surgery is expensive and largely inaccessible without insurance or philanthropic support. Substantial cost variation has been reported within cardiac surgery in the United States and among non-cardiac surgical procedures globally, but little is known on the global procedural cost variation for common adult cardiac surgical procedures. OBJECTIVES AND SIGNIFICANCE This review seeks to assess variation in procedural costs of coronary artery bypass grafting (CABG), mitral valve repair, mitral valve replacement, aortic valve repair, aortic valve replacement, and combined CABG-mitral or CABG-aortic valve procedures between and within countries. Results may give insights in the scope and drivers of cost variation around the world, posing cost reduction lessons. Results may further inform the potential of economies of scale in reducing procedural costs, benefiting patients, hospitals, governments, and insurers. METHODS AND ANALYSIS A systematic review will be performed using the EconLit, Embase, PubMed/MEDLINE, Web of Science, and WHO Global Index Medicus databases to identify articles published between January 1, 2000 and June 1, 2020. Studies describing procedural costs for CABG, mitral valve repair, mitral valve replacement, aortic valve repair, aortic valve replacement, and combined CABG-mitral or CABG-aortic valve procedures will be identified. Articles describing other types of cardiac surgery, concomitant aortic surgery, only describing costs related to non-surgical care, or with incomplete cost data will be excluded from the analysis. No exclusion will be based solely on article type or language. Identified costs will be converted to 2019 USD to account for local currency unit inflation and exchange fluctuations. ETHICS AND DISSEMINATION This study protocol has been prospectively registered on the International Platform of Registered Systematic Review and Meta-analysis Protocols. This review requires no institutional review board approval. Results of this study will be summarized and disseminated in a peer-review journal.
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Affiliation(s)
- Dominique Vervoort
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
| | - Camila R. Guetter
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
| | - Lena Trager
- University of Minnesota Medical School, Minneapolis, Minnesota, United States
| | | | | | - Eric W. Etchill
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Rawn Salenger
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, United States
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Intensive Care Unit and Acute Care Unit Length of Stay After Congenital Heart Surgery. Ann Thorac Surg 2020; 110:1396-1403. [PMID: 32114048 DOI: 10.1016/j.athoracsur.2020.01.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 01/02/2020] [Accepted: 01/13/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND Postoperative length of stay (LOS) is an important quality metric and is known to vary widely across hospitals after congenital heart surgery. Whether this variability is explained by factors associated with the intensive care unit (ICU) or acute care unit (ACU) remains unclear. We evaluated the relationship between ICU and ACU LOS and the impact of ACU characteristics on postoperative LOS. METHODS Hospitalizations for congenital heart surgery within the Pediatric Cardiac Critical Care Consortium (PC4) registry (August 2014 to February 2018) were included. Models were developed for ICU, ACU, and postoperative LOS by adjusting for differences in case-mix across hospitals. PC4 hospitals participating in the Pediatric Acute Care Cardiology Collaborative (PAC3) were also surveyed on ACU organizational factors and practice patterns. RESULTS Overall, 19,674 hospitalizations across 27 hospitals were included. There was significant variation in ICU and ACU LOS. Postperative LOS appeared to be most closely related to ICU LOS; 75% (6 of 8) of hospitals with shorter than expected postoperative LOS also had shorter than expected ICU LOS. A clear relationship between postoperative and ACU LOS was not observed. Hospitals with an ACU able to provide higher-acuity care as indexed according to the PAC3 survey were more likely to have shorter postoperative LOS (P < .01). CONCLUSIONS For hospitals that achieve shorter than expected postoperative LOS after congenital heart surgery, ICU LOS appears to be the primary driver. Higher-acuity resources in the ACU may be an important factor facilitating earlier transfer from the ICU. These data are key to informing quality improvement initiatives geared toward reducing postoperative LOS.
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Pasquali SK, Chiswell K, Hall M, Thibault D, Romano JC, Gaynor JW, Shahian DM, Jacobs ML, Gaies MG, O'Brien SM, Norton EC, Hill KD, Cowper PA, Pinto NM, Shah SS, Mayer JE, Jacobs JP. Estimating Resource Utilization in Congenital Heart Surgery. Ann Thorac Surg 2020; 110:962-968. [PMID: 32105714 DOI: 10.1016/j.athoracsur.2020.01.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 12/20/2019] [Accepted: 01/02/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Optimal methods to assess resource utilization in congenital heart surgery remain unclear. We compared traditional cost-to-charge ratio methods with newer standardized cost methods that aim to more directly assess resources consumed. METHODS Clinical data from The Society of Thoracic Surgeons Database were linked with resource use data from the Pediatric Health Information Systems Database (2010 to 2015). Standardized cost methods specific to the congenital heart surgery population were developed and compared with cost-to-charge ratio methods. Resource use in the overall population and variability across hospitals were described using hierarchical mixed effect models adjusting for case-mix. RESULTS Overall, 43 hospitals (65,331 patients) were included. There were minimal population-level differences in the distribution of resource use as estimated by the two methods. At the hospital level, there was less apparent variability in resource use across centers with the standardized cost vs cost-to-charge ratio method, overall (coefficient of variation 20% vs 25%) and across complexity (The Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery [STAT]) categories. When hospitals were categorized into tertiles by resource use, 33% changed classification depending on which resource use method was used (26% by one tertile and 7% by two tertiles). CONCLUSIONS In this first evaluation of standardized cost methodology in the congenital heart population, we found minimal differences vs traditional methods at the population level. At the hospital level, the magnitude of variation in resource use was less with standardized cost methods, and approximately one third of centers changed resource use categories depending on the methodology used. Because of these differences, care should be taken in future studies and in benchmarking and reporting efforts in selecting optimal methodology.
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Affiliation(s)
- Sara K Pasquali
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan.
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Dylan Thibault
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Jennifer C Romano
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - J William Gaynor
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David M Shahian
- Department of Surgery, Division of Cardiac Surgery and Center for Quality and Safety, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael G Gaies
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Sean M O'Brien
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Edward C Norton
- Department of Health Management and Policy, Department of Economics, University of Michigan, Ann Arbor, Michigan
| | - Kevin D Hill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Patricia A Cowper
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Nelangi M Pinto
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Samir S Shah
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - John E Mayer
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, Massachusetts
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Enhancing efficiency and scientific impact of a clinical trials network: the Pediatric Heart Network Integrated CARdiac Data and Outcomes (iCARD) Collaborative. Cardiol Young 2019; 29:1121-1126. [PMID: 31385565 PMCID: PMC6980390 DOI: 10.1017/s104795111900163x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Recent years have seen an exponential increase in the variety of healthcare data captured across numerous sources. However, mechanisms to leverage these data sources to support scientific investigation have remained limited. In 2013 the Pediatric Heart Network (PHN), funded by the National Heart, Lung, and Blood Institute, developed the Integrated CARdiac Data and Outcomes (iCARD) Collaborative with the goals of leveraging available data sources to aid in efficiently planning and conducting PHN studies; supporting integration of PHN data with other sources to foster novel research otherwise not possible; and mentoring young investigators in these areas. This review describes lessons learned through the development of iCARD, initial efforts and scientific output, challenges, and future directions. This information can aid in the use and optimisation of data integration methodologies across other research networks and organisations.
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Hospital Costs Related to Early Extubation After Infant Cardiac Surgery. Ann Thorac Surg 2018; 107:1421-1426. [PMID: 30458158 DOI: 10.1016/j.athoracsur.2018.10.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/25/2018] [Accepted: 10/05/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND The Pediatric Heart Network Collaborative Learning Study (PHN CLS) increased early extubation rates after infant tetralogy of Fallot (TOF) and coarctation of the aorta (CoA) repair across participating sites by implementing a clinical practice guideline (CPG). The impact of the CPG on hospital costs has not been studied. METHODS PHN CLS clinical data were linked to cost data from Children's Hospital Association by matching on indirect identifiers. Hospital costs were evaluated across active and control sites in the pre- and post-CPG periods using generalized linear mixed-effects models. A difference-in-difference approach was used to assess whether changes in cost observed in active sites were beyond secular trends in control sites. RESULTS Data were successfully linked on 410 of 428 eligible patients (96%) from four active and four control sites. Mean adjusted cost per case for TOF repair was significantly reduced in the post-CPG period at active sites ($42,833 vs $56,304, p < 0.01) and unchanged at control sites ($47,007 vs $46,476, p = 0.91), with an overall cost reduction of 27% in active versus control sites (p = 0.03). Specific categories of cost reduced in the TOF cohort included clinical (-66%, p < 0.01), pharmacy (-46%, p = 0.04), lab (-44%, p < 0.01), and imaging (-32%, p < 0.01). There was no change in costs for CoA repair at active or control sites. CONCLUSIONS The early extubation CPG was associated with a reduction in hospital costs for infants undergoing repair of TOF but not CoA. This CPG represents an opportunity to both optimize clinical outcome and reduce costs for certain infant cardiac surgeries.
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Analysis of Healthcare Institutional Costs of Pediatric Home Parenteral Nutrition Central Line Infections. J Pediatr Gastroenterol Nutr 2018; 67:e77-e81. [PMID: 29912033 DOI: 10.1097/mpg.0000000000002058] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although previous literature suggests home parenteral nutrition (HPN)-dependent children experience frequent complications like community-acquired central line-associated bloodstream infections (CLABSI), few studies have characterized the cost. OBJECTIVE The aim of this study was to evaluate institutional cost of community-acquired CLABSI in pediatric patients with HPN. METHODS This is a single-center retrospective review of institutional costs for patients with HPN with community-acquired CLABSI at a tertiary care children's hospital. Inclusion was age 18 years or less between October 2011 and April 2016. Exclusions were death during hospitalization and readmission within 2 days of discharge. Patient-level factors were compared between high-cost group and all others using Welch 2-sample t test and analysis of variance. Multivariable logistic regression was used to determine predictors of higher cost. RESULTS There were 176 CLABSI admissions among 68 patients during the study period (median 2 hospitalizations per patients). The mean cost and length of stay per hospital admission are $28,375 (2015 US dollars) and 8 days, and both were associated with intensive care unit admission (ICU), central venous catheter removal, private insurance, and age <2 years at admission. Nine percent of patients were classified as "super-utilizers" whose 54 hospitalizations accounted for 28% of total institutional costs. CONCLUSIONS Among pediatric patients with HPN, community-acquired CLABSI is associated with significant cost and length of stay. Healthcare utilization is disproportionately concentrated in a small number of patients. These study findings may help inform cost analysis for future CLABSI prevention strategies.
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