1
|
Hogue SJ, Mehdizadeh-Shrifi A, Kulshrestha K, Cnota JF, Divanovic A, Ricci M, Ashfaq A, Lehenbauer DG, Cooper DS, Morales DLS. Birth in the Operating Room for Immediate Cardiac Surgery: A Rare but Effective Strategy. World J Pediatr Congenit Heart Surg 2024:21501351241269881. [PMID: 39252613 DOI: 10.1177/21501351241269881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
Background: With significant advancements in fetal cardiac imaging, patients with complex congenital heart disease (CHD) carrying a high risk for postnatal demise are now being diagnosed earlier. We sought to assess an interdisciplinary strategy for delivering these children in an operating room (OR) adjacent to a cardiac OR for immediate surgery or stabilization. Methods: All children prenatally diagnosed with CHD at risk for immediate postnatal hemodynamic instability and cardiogenic shock who were delivered in the operating room (OR) between 2012 and 2023 in which the senior author was consulted were included. Results: Eight patients were identified. Six (75%) patients were operated on day-of-life zero, all requiring obstructed total anomalous pulmonary venous return (TAPVR) repair. Of these six patients, 2 (33%) required a simultaneous Norwood procedure, 2 (33%) required pulmonary artery unifocalization and modified Blalock-Taussig-Thomas shunt, and 2 (33%) patients had repair of obstructed mixed TAPVR. The remaining 2 patients potentially planned for immediate surgery had nonimmune hydrops fetalis and went into cardiogenic shock at 12 and 72 hours postnatally, requiring a novel Norwood procedure with left-ventricular exclusion for severe aortic/mitral valve insufficiency. The median ventilation and inpatient durations were 19 [IQR: 11-26] days and 41 [IQR: 32-128] days, respectively. Three(38%) patients required one or more in-hospital reoperations. Subsequent staged procedures included Glenn (n = 5), Fontan (n = 3), biventricular repair (n = 2), ventricular assist device placement (n = 1), and heart transplant (n = 1). Median follow-up was 5.7 [IQR:1.3-7.8] years. The five-year postoperative survival was 88% (n = 7/8). Conclusion: While children with these diagnoses have historically had poor survival, the strategy of birth in the OR adjacent to a cardiac OR where emergent surgery is planned is a potentially promising strategy with excellent clinical outcomes. However, this is a high-resource strategy whose feasibility in any program requires thoughtful assessment.
Collapse
Affiliation(s)
- Spencer J Hogue
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Kevin Kulshrestha
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - James F Cnota
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Allison Divanovic
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Marco Ricci
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Awais Ashfaq
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David G Lehenbauer
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David S Cooper
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David L S Morales
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| |
Collapse
|
2
|
Tan-Recep BZ, Ozturk E. The relationship between the technical performance score (TPS) and outcomes and its discriminative ability in congenital heart surgery. Medicine (Baltimore) 2024; 103:e39516. [PMID: 39252287 PMCID: PMC11383715 DOI: 10.1097/md.0000000000039516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/11/2024] Open
Abstract
Various scoring systems have been used to predict mortality and morbidity after congenital heart surgery. While the ideal system is still controversial, the technical performance score (TPS) has recently gained popularity. In this study, was investigated the effect of the TPS in predicting mortality and morbidity in pediatric patients who underwent congenital heart surgery in our clinic. Patients aged < 18 years who underwent congenital heart surgery between 2020 and 2023, were retrospectively analyzed. The patients' TPS categorizations were assigned according to their echocardiographic results at discharge and whether they required reintervention. The primary endpoints of the study were mortality (death within 30 days postoperatively) and morbidity. The secondary endpoint was a comparison of the effectiveness of TPS with that of the widely used Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score. Included in this study were 1075 patients. The median patient age was 3 months (interquartile range, 1-5 months). The mortality and morbidity rates were 11% and 24%, respectively. Of the patients, 60% were categorized as TPS I (optimal), 25% as TPS 2 (adequate, minimal residual defect), and 15% as TPS 3 (inadequate, hemodynamically significant residual defect). Being categorized as TPS 3 was associated with mortality, prolonged ICU stay, and major adverse events. The predictive power of TPS for mortality and morbidity was an area under the receiver operating characteristic curve (AUC) of 0.810 (95% CI: 0.79-0.839, P < .001) and 0.78 (95% CI: 0.76-0.80, P < .001), respectively. These values were similar to those of the Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score (0.81 vs 0.83 and 0.78 vs 0.80 for mortality and morbidity, respectively). In patients with highly heterogeneous congenital heart disease, the use of intraoperative TPS may be helpful in predicting mortality and morbidity.
Collapse
Affiliation(s)
- Berra Zümrüt Tan-Recep
- Department of Pediatric Cardiovascular Surgery, Istanbul Başakşehir Çam and Sakura City Hospital, University of Science Turkey, Turkey
| | - Erkut Ozturk
- Department of Pediatric Cardiology, Istanbul Başakşehir Çam and Sakura City Hospital, University of Science Turkey, Turkey
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
Giamberti A, Ferrero P, Caldaroni F, Varrica A, Pasqualin G, D'Aiello F, Bergonzoni E, Ranucci M, Chessa M. The Appraisal of Adults with Congenital Heart Disease: Lesson from Comparison of Surgical Outcomes. Pediatr Cardiol 2024:10.1007/s00246-024-03517-6. [PMID: 38802599 DOI: 10.1007/s00246-024-03517-6] [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: 02/03/2024] [Accepted: 04/30/2024] [Indexed: 05/29/2024]
Abstract
The population of adults with congenital heart disease (ACHD) is constantly growing. There seems to be a consensus that these patients are difficult to manage especially if compared to patients with acquired heart disease. The aim of this study is to compare outcomes and results of cardiac surgery in ACHD patients with a reference population of adults with acquired cardiac disease. Retrospective study of 5053 consecutive patients older than 18 years hospitalized for cardiac surgery during a 5-years period in our Institution. Two groups of patients were identified. Group I: 419 patients operated for congenital heart disease; Group II: 4634 patients operated for acquired heart disease. In each Group were identified low, medium, and high-risk patients, according to validated scores. Right ventricular outflow tract surgery was the most frequent procedure in Group I, while coronary artery by-pass grafting was the most common in Group II. Patients with ACHD were younger (37.8 vs. 67.7 years), with higher number of previous operations (32.1% vs. 6.9%), had longer post-ICU hospital stay (11 vs. 8 days) but had lower ICU stay (1 vs. 2 days), shorter assisted mechanical ventilation (12 vs. 14 h) and lower surgical mortality (1 vs. 3.7%) (all p < 0.001). No differences were found in term of post-operative complications (12.4 vs. 15%). The surgical treatment of ACHD patients can be done with excellent results and if compared with acquired cardiac disease patients they have better results with shorter ICU stay and lower mortality.
Collapse
Affiliation(s)
- Alessandro Giamberti
- Department of Congenital Cardiac Surgery, IRCCS Policlinico San Donato, University Hospital, Via Morandi 30, 20097, San Donato M.se, MI, Italy.
| | - Paolo Ferrero
- ACHD Unit - Pediatric and Adult Congenital Heart Centre, IRCCS Policlinico San Donato, San Donato M.se, MI, Italy
| | - Federica Caldaroni
- Department of Congenital Cardiac Surgery, IRCCS Policlinico San Donato, University Hospital, Via Morandi 30, 20097, San Donato M.se, MI, Italy
| | - Alessandro Varrica
- Department of Congenital Cardiac Surgery, IRCCS Policlinico San Donato, University Hospital, Via Morandi 30, 20097, San Donato M.se, MI, Italy
| | - Giulia Pasqualin
- ACHD Unit - Pediatric and Adult Congenital Heart Centre, IRCCS Policlinico San Donato, San Donato M.se, MI, Italy
| | - Fabio D'Aiello
- ACHD Unit - Pediatric and Adult Congenital Heart Centre, IRCCS Policlinico San Donato, San Donato M.se, MI, Italy
| | - Emma Bergonzoni
- Department of Congenital Cardiac Surgery, IRCCS Policlinico San Donato, University Hospital, Via Morandi 30, 20097, San Donato M.se, MI, Italy
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Marco Ranucci
- Department of Cardiovascular Anesthesia, IRCCS Policlinico San Donato, San Donato M.se, MI, Italy
| | - Massimo Chessa
- ACHD Unit - Pediatric and Adult Congenital Heart Centre, IRCCS Policlinico San Donato, San Donato M.se, MI, Italy
- UniSR - Vita Salute San Raffaele University, Milan, Italy
| |
Collapse
|
5
|
Kuntz M, Valencia E, Staffa S, Nasr V. Inpatient Resource Utilization for Hypoplastic Left Heart Syndrome from Birth Through Fontan. Pediatr Cardiol 2024; 45:623-631. [PMID: 38159143 DOI: 10.1007/s00246-023-03372-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 11/30/2023] [Indexed: 01/03/2024]
Abstract
Completing 3-stage palliation for hypoplastic left heart syndrome requires significant resources. An analysis of recent data has not been performed. We aimed to determine total charges necessary to complete all 3 stages of single-ventricle palliation, including interstage encounters. We also aimed to determine overall resource utilization, including hospital days, interstage admissions, and interstage procedures. We performed a retrospective cohort study using data from the Pediatric Health Information System database between 2016 and 2021, including all patients who completed 3-stage palliation for hypoplastic left heart syndrome. We identified 199 patients who underwent 3-stage palliation of hypoplastic left heart syndrome between 2016 and 2021. Median total adjusted charges (interquartile range, IQR) over the course of 3-stage palliation were $1,475,800 ($1,028,900-2,191,700). Median adjusted charges (IQR) for stage 1, 2, and 3 hospitalizations were $604,300 ($419,000-891,400), $234,000 ($164,300-370,800), and $256,260 ($178,300-345,900), respectively. Median hospital length of stay (IQR) for stages 1, 2, and 3 was 36 (26,53), 9 (6,17), and 10 (7,14) days, respectively. Pulmonary artery stenosis was the most common admitting diagnosis for interstage hospitalizations (3.4% of hospitalizations). Cardiac catheterization (24.1% of procedures) and feeding tube placement (10.0% of procedures) were the most common principal procedures during interstage hospitalizations. Total inpatient charges incurred throughout 3-stage palliation of hypoplastic left heart syndrome are substantial and have risen since prior studies. Gastrointestinal comorbidities and feeding optimization contribute considerably to this resource utilization.
Collapse
Affiliation(s)
- Michael Kuntz
- Division of Pediatric Cardiac Anesthesia, Department of Anesthesiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Eleonore Valencia
- Division of Cardiovascular Intensive Care, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven Staffa
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Viviane Nasr
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA, 02115, USA.
| |
Collapse
|
6
|
Ogdon TL, Loomba RS, Penk JS. Reduced length of stay after implementation of a clinical pathway following repair of ventricular septal defect. Cardiol Young 2024; 34:101-104. [PMID: 37226503 DOI: 10.1017/s1047951123001245] [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: 05/26/2023]
Abstract
BACKGROUND There is variation in care and hospital length of stay following surgical repair of ventricular septal defects. The use of clinical pathways in a variety of paediatric care settings has been shown to reduce practice variability and overall length of stay without increasing the rate of adverse events. METHODS A clinical pathway was created and used to guide care following surgical repair of ventricular septal defects. A retrospective review was done to compare patients two years prior and three years after the pathway was implemented. RESULTS There were 23 pre-pathway patients and 25 pathway patients. Demographic characteristics were similar between groups. Univariate analysis demonstrated a significantly shorter time to initiation of enteral intake in the pathway patients (median time to first enteral intake after cardiac ICU admission was 360 minutes in pre-pathway patients and 180 minutes in pathway patients, p < 0.01). Multivariate regression analyses demonstrated that the pathway use was independently associated with a decrease in time to first enteral intake (-203 minutes), hospital length of stay (-23.1 hours), and cardiac ICU length of stay (-20.5 hours). No adverse events were associated with the use of the pathway, including mortality, reintubation rate, acute kidney injury, increased bleeding from chest tube, or readmissions. CONCLUSIONS The use of the clinical pathway improved time to initiation of enteral intake and decreased length of hospital stay. Surgery-specific pathways may decrease variability in care while also improving quality metrics.
Collapse
Affiliation(s)
- Tracey L Ogdon
- Pediatric Cardiac Intensive Care Unit, Advocate Children's Hospital, Oak Lawn, IL 60453, USA
| | - Rohit S Loomba
- Pediatric Cardiac Intensive Care Unit, Advocate Children's Hospital, Oak Lawn, IL 60453, USA
| | - Jamie S Penk
- Cardiac Care Unit, Anne and Robert H., Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA
| |
Collapse
|
7
|
Pater CM, Wilmot I, Russell JL, Madsen NL. Advanced fellowship training for cardiology fellows in acute care cardiology. Cardiol Young 2023; 33:1383-1386. [PMID: 35975463 DOI: 10.1017/s1047951122002487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Hospitalised children have become more medically complex and increasingly require specialised teams and units properly equipped to care for them. Within paediatric cardiology, this trend, which is well demonstrated by the expansion of cardiology-specific ICUs, has more recently led to the development of acute care cardiology units to deliver team-based and condition-focused inpatient care. These care teams are now led by paediatric cardiologists with particular investment in the acute care cardiology environment. Herein, we describe the foundation and development of an Acute Care Cardiology Advanced Training Fellowship to meet the clinical, scholarly, and leadership training needs of this emerging care environment.
Collapse
Affiliation(s)
- Colleen M Pater
- Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ivan Wilmot
- Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jennifer L Russell
- Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Nicolas L Madsen
- Heart Center at Children's Health Dallas, UT Southwestern, Dallas, TX, USA
| |
Collapse
|
8
|
O'Byrne ML. Commentary on: "Broad- Versus Narrow-Spectrum Perioperative Antibiotics and Outcomes in Pediatric Heart Disease Surgery: Analysis of the Vizient Clinical Data Base". J Pediatric Infect Dis Soc 2023; 12:319-321. [PMID: 37389892 DOI: 10.1093/jpids/piad034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 05/22/2023] [Indexed: 07/01/2023]
Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute and Cardiovascular Outcomes, Quality, and Evaluative Research Center, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
9
|
El-Amin A, Koehlmoos T, Yue D, Chen J, Benharash P, Franzini L. Does universal insurance influence disparities in high-quality hospital use for inpatient pediatric congenital heart defect care within the first year of diagnosis? BMC Health Serv Res 2023; 23:702. [PMID: 37381049 DOI: 10.1186/s12913-023-09668-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 06/07/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Healthcare disparities are an issue in the management of Congenital Heart Defects (CHD) in children. Although universal insurance may mitigate racial or socioeconomic status (SES) disparities in CHD care, prior studies have not examined these effects in the use of High-Quality Hospitals (HQH) for inpatient pediatric CHD care in the Military Healthcare System (MHS). To assess for racial and SES disparities in inpatient pediatric CHD care that may persist despite universal insurance coverage, we performed a cross-sectional study of the HQH use for children treated for CHD in the TRICARE system, a universal healthcare system for the U.S. Department of Defense. In the present work we evaluated for the presence of disparities, like those seen in the civilian U.S. healthcare system, among military ranks (SES surrogate) and races and ethnicities in HQH use for pediatric inpatient admissions for CHD care within a universal healthcare system (MHS). METHODS We conducted a cross-sectional study using claims data from the U.S. MHS Data Repository from 2016 to 2020. We identified 11,748 beneficiaries aged 0 to 17 years who had an inpatient admission for CHD care from 2016 to 2020. The outcome variable was a dichotomous indicator for HQH utilization. In the sample, 42 hospitals were designated as HQH. Of the population, 82.9% did not use an HQH at any point for CHD care and 17.1% used an HQH at some point for CHD care. The primary predictor variables were race and sponsor rank. Military rank has been used as an indicator of SES status. Patient demographic information at the time of index admission post initial CHD diagnosis (age, gender, sponsor marital status, insurance type, sponsor service branch, proximity to HQH based on patient zip code centroid, and provider region) and clinical information (complexity of CHD, common comorbid conditions, genetic syndromes, and prematurity) were used as covariates in multivariable logistic regression analysis. RESULTS After controlling for demographic and clinical factors including age, gender, sponsor marital status, insurance type, sponsor service branch, proximity to HQH based on patient zip code centroid, provider region, complexity of CHD, common comorbid conditions, genetic syndromes, and prematurity, we did not find disparities in HQH use for inpatient pediatric CHD care based upon military rank. After controlling for demographic and clinical factors, lower SES (Other rank) was less likely to use an HQH for inpatient pediatric CHD care; OR of 0.47 (95% CI of 0.31 to 0.73). CONCLUSIONS We found that for inpatient pediatric CHD care in the universally insured TRICARE system, historically reported racial disparities in care were mitigated, suggesting that this population benefitted from expanded access to care. Despite universal coverage, SES disparities persisted in the civilian care setting, suggesting that universal insurance alone cannot sufficiently address differences in SES disparities in CHD care. Future studies are needed to address the pervasiveness of SES disparities and potential interventions to mitigate these disparities such as a more comprehensive patient travel program.
Collapse
Affiliation(s)
- Amber El-Amin
- Center for Health Services Research, Uniformed Services University of Health Sciences, Bethesda, MD, US.
- Department of Health Policy and Management, School of Public Health, University of Maryland, College Park, MD, US.
| | - Tracey Koehlmoos
- Center for Health Services Research, Uniformed Services University of Health Sciences, Bethesda, MD, US
| | - Dahai Yue
- Department of Health Policy and Management, School of Public Health, University of Maryland, College Park, MD, US
| | - Jie Chen
- Department of Health Policy and Management, School of Public Health, University of Maryland, College Park, MD, US
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, US
- Department of Surgery, University of California, Los Angeles, CA, US
| | - Luisa Franzini
- Department of Health Policy and Management, School of Public Health, University of Maryland, College Park, MD, US
| |
Collapse
|
10
|
Crook S, Dragan K, Woo JL, Neidell M, Jiang P, Cook S, Hannan EL, Newburger JW, Jacobs ML, Bacha EA, Petit CJ, Vincent R, Walsh-Spoonhower K, Mosca R, Kumar TKS, Devejian N, Kamenir SA, Alfieris GM, Swartz MF, Meyer D, Paul EA, Billings J, Anderson BR. Long-Term Health Care Utilization After Cardiac Surgery in Children Covered Under Medicaid. J Am Coll Cardiol 2023; 81:1605-1617. [PMID: 37076215 DOI: 10.1016/j.jacc.2023.02.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/25/2023] [Accepted: 02/02/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Understanding the longitudinal burden of health care expenditures and utilization after pediatric cardiac surgery is needed to counsel families, improve care, and reduce outcome inequities. OBJECTIVES The purpose of this study was to describe and identify predictors of health care expenditures and utilization for Medicaid-insured pediatric cardiac surgical patients. METHODS All Medicaid enrolled children age <18 years undergoing cardiac surgery in the New York State CHS-COLOUR database, from 2006 to 2019, were followed in Medicaid claims data through 2019. A matched cohort of children without cardiac surgical disease was identified as comparators. Expenditures and inpatient, primary care, subspecialist, and emergency department utilization were modeled using log-linear and Poisson regression models to assess associations between patient characteristics and outcomes. RESULTS In 5,241 New York Medicaid-enrolled children, longitudinal health care expenditures and utilization for cardiac surgical patients exceeded noncardiac surgical comparators (cardiac surgical children: $15,500 ± $62,000 per month in year 1 and $1,600 ± $9,100 per month in year 5 vs noncardiac surgical children: $700 ± $6,600 per month in year 1 and $300 ± $2,200 per month in year 5). Children after cardiac surgery spent 52.9 days in hospitals and doctors' offices in the first postoperative year and 90.5 days over 5 years. Being Hispanic, compared with non-Hispanic White, was associated with having more emergency department visits, inpatient admissions, and subspecialist visits in years 2 to 5, but fewer primary care visits and greater 5-year mortality. CONCLUSIONS Children after cardiac surgery have significant longitudinal health care needs, even among those with less severe cardiac disease. Health care utilization differed by race/ethnicity, although mechanisms driving disparities should be investigated further.
Collapse
Affiliation(s)
- Sarah Crook
- Division of Pediatric Cardiology; NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Kacie Dragan
- New York University, Wagner Graduate School of Public Service, New York, New York, USA; Interfaculty Initiative in Health Policy, Harvard University, Cambridge, Massachusetts, USA
| | - Joyce L Woo
- Division of Pediatric Cardiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matthew Neidell
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Pengfei Jiang
- Division of Pediatric Cardiology; NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Stephen Cook
- Department of Pediatrics, Internal Medicine, and Center for Community Health, University of Rochester Medical Center, Rochester, New York, USA; New York State Department of Health, Offices of Health Insurance Programs, Albany, New York, USA
| | - Edward L Hannan
- University at Albany School of Public Health, Rensselaer, New York, USA
| | - Jane W Newburger
- Department of Pediatric Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Marshall L Jacobs
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Emile A Bacha
- Department of Cardiothoracic Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center and Weill Cornell Medical Center, New York, New York, USA
| | - Christopher J Petit
- Division of Pediatric Cardiology; NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Robert Vincent
- Division of Pediatric Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | | | - Ralph Mosca
- Department of Cardiothoracic Surgery, New York University, New York, New York, USA
| | - T K Susheel Kumar
- Department of Cardiothoracic Surgery, New York University, New York, New York, USA
| | - Neil Devejian
- Division of Pediatric Cardiothoracic Surgery, Albany Medical College, Albany, New York, USA
| | - Steven A Kamenir
- Division of Pediatric Cardiology, Albany Medical College, Albany, New York, USA
| | - George M Alfieris
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York, USA; Department of Surgery, State University of New York Upstate Medical Center, Syracuse, New York, USA
| | - Michael F Swartz
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - David Meyer
- Departments of Cardiothoracic Surgery and Pediatrics, Hofstra-Northwell School of Medicine, Uniondale, New York, USA
| | - Erin A Paul
- Division of Pediatric Cardiology, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | - John Billings
- New York University, Wagner Graduate School of Public Service, New York, New York, USA
| | - Brett R Anderson
- Division of Pediatric Cardiology; NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA.
| |
Collapse
|
11
|
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.
Collapse
|
12
|
He Q, Dou Z, Su Z, Shen H, Mok TN, Zhang CJ, Huang J, Ming WK, Li S. Inpatient costs of congenital heart surgery in China: results from the National Centre for Cardiovascular Diseases. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2023; 31:100623. [PMID: 36879787 PMCID: PMC9985056 DOI: 10.1016/j.lanwpc.2022.100623] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 10/04/2022] [Accepted: 10/11/2022] [Indexed: 11/11/2022]
Abstract
Background Economic data on congenital heart disease (CHD) in China are scarce. Therefore, this study aimed to explore the inpatient costs of congenital heart surgery and related healthcare policies from a hospital perspective. Method We used data from the Chinese Database for Congenital Heart Surgery (CDCHS) to prospectively analyse the inpatient costs of congenital heart surgery from May 2018 to December 2020. The total expenditure was divided into 11 columns (medications, imaging, consumable items, surgery, medical cares, laboratory tests, therapy, examinations, medical services, accommodations, and others), and explored according to the Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category, year, different age group, and CHD complexity. Authority economic data (index for gross domestic product [GDP], GDP per capita, per capita disposable income and average annual exchange rate of 2020 Chinese Yuan against US dollar) were accessed via the National Bureau of Statistics of China to better describe the burden. In addition, potential factors contributing to the costs were also investigated by using generalised linear model. Findings All values are presented in 2020 Chinese Yuan (¥). A total of 6568 hospitalisations were enrolled. The median of overall total expenditure was ¥64,900 (≈9409 US Dollar [USD], interquartile range [IQR]: ¥35,819), with the lowest in STAT 1 (¥57,014 ≈ 8266 USD, [IQR]: ¥16,774) and the highest in STAT 5 (¥194,862 ≈ 28,251 USD, [IQR]: ¥130,010). The median costs during the 2018 to 2020 period were ¥62,014 (≈8991 USD, [IQR]: ¥32,628), ¥64,846 (≈9401 USD, [IQR]: ¥34,469) and ¥67,867 (≈9839 USD, [IQR]: ¥41,496). Regarding to age, the median costs were highest in the ≤1 month group (¥144,380 ≈ 20,932 USD, [IQR]: ¥92,584). Age, STAT category, emergency, genetic syndrome, delay sternal closure, mechanical ventilation time, and complications were significantly contributed to the inpatient costs. Interpretation For the first time, the inpatient costs of congenital heart surgery in China are delineated in detail. According to the results, CHD treatment has achieved significant progress in China, but it still causes substantial economic burden to both families and society. In addition, ascending trend of the inpatient costs was observed during the period of 2018-2020, and the neonatal was revealed to be the most challenging group. Funding This study was supported by the CAMS Innovation Fund for Medical Sciences (CIFMS,2020-I2M-C&T-A-009), Capital Health Research and Development of Special Fund (2022-1-4032), and The City University of Hong Kong New Research Initiatives/Infrastructure Support from Central (APRC, 9610589).
Collapse
Affiliation(s)
- Qiyu He
- Pediatric Cardiac Surgery Centre, Fuwai Hospital, National Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100037, China
| | - Zheng Dou
- Pediatric Cardiac Surgery Centre, Fuwai Hospital, National Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100037, China
| | - Zhanhao Su
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Huayan Shen
- Department of Laboratory Medicine, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Peking Union Medical College, Beijing, China
| | - Tsz-Ngai Mok
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Hong Kong, China
| | - Casper J.P. Zhang
- School of Public Health, The University of Hong Kong, Hong Kong SAR, China
| | - Jian Huang
- Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A∗STAR), Singapore
| | - Wai-Kit Ming
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Hong Kong, China
| | - Shoujun Li
- Pediatric Cardiac Surgery Centre, Fuwai Hospital, National Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100037, China
| |
Collapse
|
13
|
Jacobs JP, Kumar SR, St Louis JD, Al-Halees ZY, Habib RH, Parsons N, Hill KD, Pasquali SK, Gaynor JW, Mascio CE, Overman DM, Dearani JA, Mayer JE, Shahian DM, Jacobs ML. Variation in Case-Mix Across Hospitals: Analysis of The Society of Thoracic Surgeons Congenital Heart Surgery Database. Ann Thorac Surg 2023; 115:485-492. [PMID: 35940312 DOI: 10.1016/j.athoracsur.2022.06.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/11/2022] [Accepted: 06/18/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database was queried to document variation of patient characteristics, procedure types, and programmatic case-mix. METHODS All index cardiac operations in patients less than 18 years of age in the STS Congenital Heart Surgery Database (July 2016 to June 2020) were eligible for inclusion except patients weighing ≤2.5 kg undergoing isolated patent ductus arteriosus closure. At the hospital level, we describe variations in patient and procedural characteristics known from previous analyses to be associated with outcomes. We also report variations across hospitals of programmatic case-mix. RESULTS Data were analyzed from 117 sites (90 322 total operations, 87 296 total index cardiac operations eligible for STAT [STS-European Association for Cardio-Thoracic Surgery] 2020 Mortality Score). The median annual total index cardiac operations eligible for STAT 2020 Mortality Score per hospital was 157 (interquartile range [IQR], 94-276). Wide variability was documented in total annual index cardiac operations eligible for STAT 2020 Mortality Score per hospital (ratio 90th/10th percentile = 9.01), operations in neonates weighing <2.5 kg (ratio 90th/10th percentile = 4.09), operations in patients with noncardiac anatomic abnormalities (ratio 90th/10th percentile = 3.46), and operations in patients with preoperative mechanical ventilation (ratio 90th/10th percentile = 3.97). At the hospital level, the median percentage of all index cardiac operations in STAT 2020 Mortality Category 5 was 3.7% (IQR, 1.7%-4.9%), the median percentage of all index cardiac operations in STAT 2020 Mortality Category 4 or 5 was 24.4% (IQR, 19.0%-28.4%), the median hospital-specific mean STAT Mortality Category was 2.39 (IQR, 2.20-2.47), and the median hospital-specific mean STAT Mortality Score was 0.86 (IQR, 0.73-0.91). CONCLUSIONS Substantial variation of patient characteristics, procedure types, and case-mix exists across pediatric and congenital cardiac surgical programs. Knowledge about programmatic case-mix augments data about indirectly standardized programmatic observed-to-expected (O/E) mortality. Indirectly standardized O/E ratios do not provide a complete description of a given pediatric and congenital cardiac surgical program. The indirectly standardized programmatic O/E ratios associated with a given program apply only to its specific case-mix of patients and may represent a quite different case-mix than that of another program.
Collapse
Affiliation(s)
- Jeffrey Phillip Jacobs
- Congenital Heart Center, Division of Cardiovascular Surgery, Departments of Surgery and Pediatrics, University of Florida, Gainesville, Florida.
| | - S Ram Kumar
- Department of Surgery, University of Southern California, Los Angeles, California
| | - James D St Louis
- Department of Surgery and Pediatrics, Children's Hospital of Georgia, Augusta University, Augusta, Georgia
| | - Zohair Y Al-Halees
- Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Robert H Habib
- The Society of Thoracic Surgeons Research Center, Chicago, Illinois
| | - Niharika Parsons
- The Society of Thoracic Surgeons Research Center, Chicago, Illinois
| | - Kevin D Hill
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - J William Gaynor
- Cardiac Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christopher E Mascio
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - David M Overman
- Division of Cardiovascular Surgery, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, Minnesota
| | - Joseph A Dearani
- Division of Cardiovascular Surgery, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, Minnesota
| | - John E Mayer
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David M Shahian
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
14
|
O'Byrne ML, Wilensky R, Glatz AC. Incorporating economic analysis in interventional cardiology research. Catheter Cardiovasc Interv 2023; 101:122-130. [PMID: 36480805 DOI: 10.1002/ccd.30506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 11/08/2022] [Accepted: 11/19/2022] [Indexed: 12/13/2022]
Abstract
Evaluative research in interventional cardiology has focused on clinical and technical outcomes. Inclusion of economic data can enhance evaluative research by quantifying the relative economic burden incurred by different therapies. When combined with clinical outcomes, cost data can provide a measure of value (e.g., marginal cost-effectiveness). In some select situations, cost data can also be used as surrogates for complexity of care and morbidity. In this narrative review, we aim to provide a framework for the application of cost data in clinical trials and observational research, detailing how to incorporate this kind of data into interventional cardiology research.
Collapse
Affiliation(s)
- Michael L O'Byrne
- Department of Pediatrics, Division of Cardiology and Clinical Futures, The Children's Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute For Healthcare Economics, The University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert Wilensky
- Center for Cardiovascular Outcomes, Quality, and Evaluative Research, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Internal Medicine, Division of Cardiology, The Hospital of The University of Pennsylvania, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew C Glatz
- Department of Pediatrics, Division of Cardiology, Washington University School of Medicine, and St. Louis Children's Hospital, St. Louis, Missouri, USA
| |
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
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.
Collapse
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
| |
Collapse
|
17
|
Seo YJ, Sareh S, Hadaya J, Sanaiha Y, Ziaeian B, Shemin RJ, Benharash P. Factors Associated With High Resource Use in Elective Adult Cardiac Surgery From 2005 to 2016. Ann Thorac Surg 2022; 113:58-65. [PMID: 33689737 PMCID: PMC8419207 DOI: 10.1016/j.athoracsur.2021.02.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 11/02/2020] [Accepted: 02/23/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Lack of consensus remains about factors that may be associated with high resource use (HRU) in adult cardiac surgical patients. This study aimed to identify patient-related, hospital, and perioperative characteristics associated with HRU admissions involving elective cardiac operations. METHODS Data from the National Inpatient Sample was used to identify patients who underwent coronary artery bypass graft, valve replacement, and valve repair operations between 2005 and 2016. Admissions with HRU were defined as those in the highest decile for total hospital costs. Multivariable regressions were used to identify factors associated with HRU. RESULTS An estimated 1,750,253 hospitalizations coded for elective cardiac operations. The median hospitalization cost was $34,700 (interquartile range, $26,800- to $47,100), with the HRU (N = 175,025) cutoff at $66,029. Although HRU patients comprised 10% of admissions, they accounted for 25% of cumulative costs. On multivariable regression, patient-related characteristics predictive of HRU included female sex, older age, higher comorbidity burden, non-White race, and highest income quartile. Hospital factors associated with HRU were low-volume hospitals for both coronary artery bypass graft and valvular operations. Among postoperative outcomes, mortality, infectious complications, extracorporeal membrane oxygenation use, and hospitalization for more than 8 days were associated with greater odds of HRU. CONCLUSIONS In this nationwide study of elective cardiac surgical patients, several important patient-related and hospital factors, including patients' race, comorbidities, postoperative infectious complications, and low hospital operative volume were identified as predictors of HRU. These highly predictive factors may be used for benchmarking purposes and improvement in surgical planning.
Collapse
Affiliation(s)
- Young-Ji Seo
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Sohail Sareh
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Boback Ziaeian
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Richard J Shemin
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California.
| |
Collapse
|
18
|
Standardization of Care Reduces Length of Stay for Postoperative Congenital Heart Disease Patients. Pediatr Qual Saf 2021; 6:e493. [PMID: 34934877 PMCID: PMC8678001 DOI: 10.1097/pq9.0000000000000493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 07/17/2021] [Indexed: 11/26/2022] Open
Abstract
Congenital heart disease (CHD), the most common congenital malformation, often requires surgical correction. As surgical mortality rates are low, a common quality marker linked with surgical outcomes is hospital length of stay (LOS). Reduced LOS is associated with better long-term outcomes, reduced hospital-acquired complications, and improved patient-family satisfaction. This project aimed to reduce aggregate median postoperative LOS for four CHD lesions from a baseline of 6.2 days by 10%. Methods This single-center study utilized the Institute for Healthcare Improvement model to achieve the project aim. A diuretic wean protocol implemented in April 2018 entailed weaning to a homegoing diuretic regimen upon transfer from the cardiac intensive care unit to the inpatient step-down unit. A discharge milestone checklist implemented in September 2018 contained milestones necessary for discharge and an anticipated date of discharge. Outcome measures included aggregate median postoperative LOS and ∆LOS. Balancing measures included cardiac intensive care unit bounce back, pleural chest tube replacement, and readmission rates. Results Our baseline aggregate median postoperative LOS for the lesions studied was 6.2 days. Following diuretic protocol implementation, the aggregate median LOS decreased to 4.4 days. Baseline ∆LOS decreased from 5.5 to 0.42 days. Postoperative cost fell by an average of $11,874. Balancing measures demonstrated no unintended consequences. Conclusions Implementation of a diuretic wean protocol led to sustained improvement in postoperative LOS, and ∆LOS in a subset of CHD patients with no unintended consequences supporting that standardization of postoperative care is effective for improvement efforts and can reduce overall practice variation.
Collapse
|
19
|
Chowdhury D, Johnson JN, Baker-Smith CM, Jaquiss RDB, Mahendran AK, Curren V, Bhat A, Patel A, Marshall AC, Fuller S, Marino BS, Fink CM, Lopez KN, Frank LH, Ather M, Torentinos N, Kranz O, Thorne V, Davies RR, Berger S, Snyder C, Saidi A, Shaffer K. Health Care Policy and Congenital Heart Disease: 2020 Focus on Our 2030 Future. J Am Heart Assoc 2021; 10:e020605. [PMID: 34622676 PMCID: PMC8751886 DOI: 10.1161/jaha.120.020605] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [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
The congenital heart care community faces a myriad of public health issues that act as barriers toward optimum patient outcomes. In this article, we attempt to define advocacy and policy initiatives meant to spotlight and potentially address these challenges. Issues are organized into the following 3 key facets of our community: patient population, health care delivery, and workforce. We discuss the social determinants of health and health care disparities that affect patients in the community that require the attention of policy makers. Furthermore, we highlight the many needs of the growing adults with congenital heart disease and those with comorbidities, highlighting concerns regarding the inequities in access to cardiac care and the need for multidisciplinary care. We also recognize the problems of transparency in outcomes reporting and the promising application of telehealth. Finally, we highlight the training of providers, measures of productivity, diversity in the workforce, and the importance of patient-family centered organizations in advocating for patients. Although all of these issues remain relevant to many subspecialties in medicine, this article attempts to illustrate the unique needs of this population and highlight ways in which to work together to address important opportunities for change in the cardiac care community and beyond. This article provides a framework for policy and advocacy efforts for the next decade.
Collapse
Affiliation(s)
| | - Jonathan N Johnson
- Division of Pediatric Cardiology Mayo Clinic Rochester MN.,Division of Cardiovascular Diseases Mayo Clinic Rochester MN
| | - Carissa M Baker-Smith
- Sidney Kimmel Medical College of Thomas Jefferson UniversityNemours'/Alfred I duPont Hospital for Children Cardiac Center Wilmington DE
| | - Robert D B Jaquiss
- Department of Cardiothoracic Surgery and Pediatrics Children's Hospital and University of Texas, Southwestern Medical Center Dallas TX
| | - Arjun K Mahendran
- Department of Pediatrics University of Florida-Congenital Heart Center Gainesville FL
| | - Valerie Curren
- Division of Cardiology Children's National Hospital Washington DC
| | - Aarti Bhat
- Seattle Children's Hospital and University of Washington Seattle WA
| | - Angira Patel
- Division of Cardiology Ann & Robert H. Lurie Children's Hospital of Chicago Chicago IL.,Department of Pediatrics Northwestern University Feinberg School of Medicine Chicago IL
| | - Audrey C Marshall
- Cardiac Diagnostic and Interventional Unit The Hospital for Sick Children Toronto Ontario Canada
| | - Stephanie Fuller
- Division of Cardiothoracic Surgery Children's Hospital of Philadelphia Philadelphia PA
| | - Bradley S Marino
- Division of Cardiology Ann & Robert H. Lurie Children's Hospital of Chicago Chicago IL.,Department of Pediatrics Northwestern University Feinberg School of Medicine Chicago IL
| | - Christina M Fink
- Department of Pediatric Cardiology Cleveland Clinic Cleveland OH
| | - Keila N Lopez
- Lillie Frank Abercrombie Section of Cardiology Department of Pediatrics Texas Children's HospitalBaylor College of Medicine Houston TX
| | - Lowell H Frank
- Division of Cardiology Children's National Hospital Washington DC
| | | | | | | | | | - Ryan R Davies
- Department of Cardiothoracic Surgery and Pediatrics Children's Hospital and University of Texas, Southwestern Medical Center Dallas TX
| | - Stuart Berger
- Division of Cardiology Ann & Robert H. Lurie Children's Hospital of Chicago Chicago IL.,Department of Pediatrics Northwestern University Feinberg School of Medicine Chicago IL
| | - Christopher Snyder
- Division of Pediatric Cardiology The Congenital Heart Collaborative University Hospital Rainbow Babies and Children's Hospital Cleveland OH
| | - Arwa Saidi
- Department of Pediatrics University of Florida-Congenital Heart Center Gainesville FL
| | - Kenneth Shaffer
- Texas Center for Pediatric and Congenital Heart Disease University of Texas Dell Medical School/Dell Children's Medical Center Austin TX
| |
Collapse
|
20
|
Murin P, Weixler VH, Romanchenko O, Schulz A, Redlin M, Cho MY, Sinzobahamvya N, Miera O, Kuppe H, Berger F, Photiadis J. Fast-track extubation after cardiac surgery in infants: Tug-of-war between performance and reimbursement? J Thorac Cardiovasc Surg 2021; 162:435-443. [DOI: 10.1016/j.jtcvs.2020.09.123] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 08/28/2020] [Accepted: 09/18/2020] [Indexed: 11/26/2022]
|
21
|
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.
Collapse
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
| |
Collapse
|
22
|
Chung EH, Lim SL, Havrilesky LJ, Steiner AZ, Dotters-Katz SK. Cost-effectiveness of prenatal screening methods for congenital heart defects in pregnancies conceived by in-vitro fertilization. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:979-986. [PMID: 32304621 DOI: 10.1002/uog.22048] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 03/28/2020] [Accepted: 04/03/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To determine if a policy of universal fetal echocardiography (echo) in pregnancies conceived by in-vitro fertilization (IVF) is cost-effective as a screening strategy for congenital heart defects (CHDs) and to examine the cost-effectiveness of various other CHD screening strategies in IVF pregnancies. METHODS A decision-analysis model was designed from a societal perspective with respect to the obstetric patient, to compare the cost-effectiveness of three screening strategies: (1) anatomic ultrasound (US): selective fetal echo following abnormal cardiac findings on detailed anatomic survey; (2) intracytoplasmic sperm injection (ICSI) only: fetal echo for all pregnancies following IVF with ICSI; (3) all IVF: fetal echo for all IVF pregnancies. The model initiated at conception and had a time horizon of 1 year post-delivery. The sensitivities and specificities for each strategy, the probabilities of major and minor CHDs and all other clinical estimates were derived from the literature. Costs, including imaging, consults, surgeries and caregiver productivity losses, were derived from the literature and Medicare databases, and are expressed in USA dollars ($). Effectiveness was quantified as quality-adjusted life years (QALYs), based on how the strategies would affect the quality of life of the obstetric patient. Secondary effectiveness was quantified as number of cases of CHD and, specifically, cases of major CHD, detected. RESULTS The average base-case cost of each strategy was as follows: anatomic US, $8119; ICSI only, $8408; and all IVF, $8560. The effectiveness of each strategy was as follows: anatomic US, 1.74487 QALYs; ICSI only, 1.74497 QALYs; and all IVF, 1.74499 QALYs. The ICSI-only strategy had an incremental cost-effectiveness ratio (ICER) of $2 840 494 per additional QALY gained when compared to the anatomic-US strategy, and the all-IVF strategy had an ICER of $5 692 457 per additional QALY when compared with the ICSI-only strategy. Both ICERs exceeded considerably the standard willingness-to-pay threshold of $50 000-$100 000 per QALY. In a secondary analysis, the ICSI-only strategy had an ICER of $527 562 per additional case of major CHD detected when compared to the anatomic-US strategy. All IVF had an ICER of $790 510 per case of major CHD detected when compared with ICSI only. It was determined that it would cost society five times more to detect one additional major CHD through intensive screening of all IVF pregnancies than it would cost to pay for the neonate's first year of care. CONCLUSION The most cost-effective method of screening for CHDs in pregnancies following IVF, either with or without ICSI, is to perform a fetal echo only when abnormal cardiac findings are noted on the detailed anatomy scan. Performing routine fetal echo for all IVF pregnancies is not cost-effective. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- E H Chung
- Duke University, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - S L Lim
- Duke University, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - L J Havrilesky
- Duke University, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - A Z Steiner
- Duke University, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - S K Dotters-Katz
- Duke University, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
23
|
Tirotta CF, Lin JH, Tran MH. Effectiveness of Liposomal Bupivacaine Compared With Standard- of-Care Measures in Pediatric Cardiothoracic Surgery: A Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2021; 35:3681-3687. [PMID: 33975790 DOI: 10.1053/j.jvca.2021.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 03/22/2021] [Accepted: 04/02/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Effective postsurgical pain management is important for pediatric patients to improve outcomes while reducing resource use and waste. The authors examined opioid consumption and economic outcomes associated with liposomal bupivacaine (LB) or non-LB analgesia use in pediatric patients undergoing cardiothoracic surgery. DESIGN The authors retrospectively analyzed Premier Healthcare Database records. SETTING The data extracted from the database included patient records from hospitals across the United States in both rural and urban locations. PARTICIPANTS The records included data from patients aged 12-to-<18 years. INTERVENTIONS The records belonged to patients undergoing video-assisted thoracoscopic procedures (VATS) who received LB or non-LB analgesia after surgery. MEASUREMENTS AND MAIN RESULTS Outcomes included in-hospital postsurgical opioid consumption in morphine milligram equivalents (MMEs), hospital length of stay (LOS), and total hospital costs; the LB and non-LB cohorts were compared using a generalized linear model with inverse probability of treatment weighting to balance the cohorts. For VATS procedures, pediatric patients receiving LB had significant reductions in in-hospital opioid consumption (632 v 991 MMEs; p < 0.0001), shorter LOS (5.1 v 5.6 days; p = 0.0023), and lower total hospital costs ($18,084 v $21,962; p < 0.0001) compared with those receiving non-LB analgesia. CONCLUSIONS These results support use of LB in multimodal analgesia regimens for managing pain in pediatric patients after cardiothoracic surgery.
Collapse
|
24
|
Williamson CG, Verma A, Tran ZK, Federman MD, Benharash P. Clinical and Financial Outcomes Associated With Vocal Fold Paralysis in Congenital Cardiac Surgery. J Cardiothorac Vasc Anesth 2021; 36:208-214. [PMID: 33875352 DOI: 10.1053/j.jvca.2021.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Vocal fold paralysis (VFP) has proven to increase resource use in several surgical fields. However, its burden in congenital cardiac surgery, a specialty known to be associated with high resource use, has not yet been examined. The authors aimed to assess the impact of VFP on costs, lengths of stay, and readmissions following congenital cardiac surgery. DESIGN A retrospective analysis of administrative data. SETTING The 2010-2017 National Readmissions Database. PARTICIPANTS All pediatric patients undergoing congenital cardiac surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Vocal fold paralysis was defined using International Classification of Diseases, Ninth and Tenth Revisions, diagnosis codes. The primary outcome of interest was 30-day nonelective readmissions and 90-day readmissions; costs, length of stay, and discharge status also were considered. Of an estimated 124,486 patients meeting study criteria, 2,868 (2.3%) were identified with VFP. Incidence of VFP increased during the study period (0.7% in 2010 to 3.2% in 2017, nptrend < 0.001). Rates of nonhome discharge (30.0% v 16.4%, p < 0.001), 30-day readmission (23.9% v 12.4%, p < 0.001), and 90-day readmission (8.3% v 4.4%, p = 0.03) were increased in the VFP cohort, as were lengths of stay (42.1 v 27.0 days, p < 0.001) and costs ($196,000 v $128,000, p < 0.001). After adjustment for patient and hospital factors, VFP was independently associated with greater odds of nonhome discharge (adjusted odds ratios [AOR], 1.66, 95% CI, 1.14-2.40), 30-day readmission (AOR, 1.58, 95% CI, 1.03-2.42), 90-day readmission (AOR, 2.07, 95% CI, 1.22-3.52), longer lengths of stay (+ 6.1 days, 95% CI, 1.3-10.8), and higher hospitalization costs (+$22,000, 95% CI, 3,000-39,000). CONCLUSIONS Readmission rates after congenital cardiac surgery are significantly greater among those with VFP, as are costs, lengths of stay, and nonhome discharges. Therefore, further efforts are necessary to increase awareness and reduce the incidence of VFP in this vulnerable population to minimize the financial burden of congenital cardiac surgery on the US medical system.
Collapse
Affiliation(s)
- Catherine G Williamson
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Zachary K Tran
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Myke D Federman
- Division of Pediatric Critical Care, UCLA Mattel Children's Hospital, University of California, Los Angeles, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.
| |
Collapse
|
25
|
Forecasting surgical costs: Towards informed financial consent and financial risk reduction. Pancreatology 2021; 21:253-262. [PMID: 33371980 DOI: 10.1016/j.pan.2020.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 12/13/2020] [Accepted: 12/15/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Health care expenditure is increasing around the world and surgery is a major cause of financial hardship to patients and their families. Using pancreatoduodenectomy (PD), one of the most complex, morbid and costly operation as an example, this study aimed to identify the cost drivers of surgery, estimate relative contribution of these drivers, and derive and validate a cohort-specific cost forecasting tool. METHODS Data on the costs of 1406 patients undergoing PD in three tertiary hospitals in India, Italy and the United States were analysed. Cost drivers were identified and cost models developed using a 4-stage process. RESULTS There was a significant difference in overall cost of PD between the 3 cohorts. The cost drivers common to the 3 cohorts included duration of hospital stay and the outcome of death (Clavien-Dindo 5). Significant cohort-specific cost drivers included co-morbidities, operating theatre utilisation times and operative blood loss, development of pancreatectomy-specific complications (POPF, DGE, PPH), and need for interventional radiology to manage complications. Based on this, a cost forecasting tool was developed. CONCLUSIONS Drivers of costs for a surgical procedure (e.g. PD) are different between hospitals. Developing cost models/nomograms to predict the expected cost of surgery and perioperative care will not be applicable between hospitals. However, the approach could be used to develop context-specific data that will provide patients (at the time of the informed financial consent) and funding agencies with a more realistic cost estimate for a given operation. The developed cost forecasting tool warrants future validation.
Collapse
|
26
|
Hudson E, Brown K, Pagel C, Wray J, Barron D, Rodrigues W, Stoica S, Tibby SM, Tsang V, Ridout D, Morris S. Costs of postoperative morbidity following paediatric cardiac surgery: observational study. Arch Dis Child 2020; 105:1068-1074. [PMID: 32381518 PMCID: PMC7588404 DOI: 10.1136/archdischild-2019-318499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 02/27/2020] [Accepted: 04/11/2020] [Indexed: 12/04/2022]
Abstract
OBJECTIVE Early mortality rates for paediatric cardiac surgery have fallen due to advancements in care. Alternative indicators of care quality are needed. Postoperative morbidities are of particular interest. However, while health impacts have been reported, associated costs are unknown. Our objective was to calculate the costs of postoperative morbidities following paediatric cardiac surgery. DESIGN Two methods of data collection were integrated into the main study: (1) case-matched cohort study of children with and without predetermined morbidities; (2) incidence rates of morbidity, measured prospectively. SETTING Five specialist paediatric cardiac surgery centres, accounting for half of UK patients. PATIENTS Cohort study included 666 children (340 with morbidities). Incidence rates were measured in 3090 consecutive procedures. METHODS Risk-adjusted regression modelling to determine marginal effects of morbidities on per-patient costs. Calculation of costs for hospital providers according to incidence rates. Extrapolation using mandatory audit data to report annual financial burden for the health service. OUTCOME MEASURES Impact of postoperative morbidities on per-patient costs, hospital costs and UK health service costs. RESULTS Seven of the 10 morbidity categories resulted in significant costs, with mean (95% CI) additional costs ranging from £7483 (£3-£17 289) to £66 784 (£40 609-£103 539) per patient. On average all morbidities combined increased hospital costs by 22.3%. Total burden to the UK health service exceeded £21 million each year. CONCLUSION Postoperative morbidities are associated with a significant financial burden. Our findings could aid clinical teams and hospital providers to account for costs and contextualise quality improvement initiatives.
Collapse
Affiliation(s)
- Emma Hudson
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Katherine Brown
- Cardiorespiratory Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Christina Pagel
- Clinical Operational Research Unit, University College of London, London, UK,Paediatric Intensive Care Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Jo Wray
- Cardiorespiratory Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - David Barron
- Department of Cardiac Surgery, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Warren Rodrigues
- Paediatric Intensive care Unit, NHS Greater Glasgow and Clyde Inverclyde Royal Hospital, Glasgow, UK
| | - Serban Stoica
- Department of Cardiac Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Shane M Tibby
- Department of Paediatric Intensive Care, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Victor Tsang
- Cardiorespiratory Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Deborah Ridout
- Paediatric Epidemiology Biostatistics, Institute of Child Health, London, UK
| | - Stephen Morris
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| |
Collapse
|
27
|
Global Leadership in Paediatric and Congenital Cardiac Care: "Using data to improve outcomes - an interview with Jennifer S. Li, MD, MHS". Cardiol Young 2020; 30:1226-1230. [PMID: 32921334 DOI: 10.1017/s1047951120002875] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Dr. Jennifer Li is the focus of our second in a planned series of interviews in Cardiology in the Young entitled, "Global Leadership in Paediatric and Congenital Cardiac Care". Dr. Li was born in Boston, Massachusetts, United States of America, and moved to Indianapolis, Indiana where she completed her secondary education. She then attended Stanford University, majoring in Chemistry and English and graduating with distinction in 1983. Dr. Li then attended Duke University School of Medicine, graduating in 1987. She then completed her internship at Children's Hospital of Philadelphia in 1987-1989, returning to Duke University Medical Center to complete both her residency in general paediatrics in 1989-1990 followed by her fellowship in paediatric cardiology in 1990-1993. She would later complete her Master's Degree in Health Sciences at Duke University in 2005.Dr. Li has spent her entire career as a paediatric cardiologist at Duke University Medical Center, where she was appointed a Professor of Pediatrics and Professor of Medicine in 2008 and has held the position as Beverly C. Morgan Endowed Professor of Pediatrics since 2012. She has served as the Chief of Paediatric Cardiology at Duke University Medical Center since 2006. She also was the Director of Paediatric Research at Duke Clinical Research Institute from 2001-2015. Dr. Li has played an instrumental role in evaluating the safety and efficacy of drugs in children, as well as in analysing and linking large multicentric databases to evaluate the outcomes, quality, and cost of paediatric and congenital cardiac care. Dr. Li has received funding from the National Institute of Health of the United States of America, as well as from industry and foundation grants. This article presents our interview with Dr. Li, an interview that covers her experience collaborating with governmental organizations and industry in the pursuit of common interests to design clinical drug trials, link and analyse large, multicentric databases, and improve paediatric health care.
Collapse
|
28
|
Welke KF, Pasquali SK, Lin P, Backer CL, Overman DM, Romano JC, Karamlou T. Theoretical Model for Delivery of Congenital Heart Surgery in the United States. Ann Thorac Surg 2020; 111:1628-1635. [PMID: 32860751 DOI: 10.1016/j.athoracsur.2020.06.057] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/27/2020] [Accepted: 06/15/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Over 150 hospitals perform congenital heart surgery (CHS) in the United States. Many hospitals are close together, with a median patient travel distance of 38.5 miles. We began with a theoretical blank slate and used objective methodology guided by population density and volume thresholds to estimate the optimal number and locations of hospitals to provide CHS in the United States. METHODS Guided by published data, we estimated the number of CHS operations in the United States in to be 32,500 per year. We distributed patients geographically based on population density. Metropolitan Statistical Areas (population centers and surrounding areas with close economic/social ties) were used as potential hospital locations. Patients were assigned to the closest hospital location such that all hospitals had a CHS volume of ≥300 operations. RESULTS We estimated 57 hospitals could serve the contiguous United States. Median theoretical hospital volume after regionalization was 451 operations (interquartile range, 366-648). Median patient travel distance was 35.1 miles. Some patients (6396/31,895, 20%) traveled more than 100 miles. CONCLUSIONS Our model suggests the United States could be served by approximately 100 fewer CHS hospitals than currently exist. With hospitals optimally placed, patient travel burden would decrease. This model serves as a platform to improve care delivery by regionalization of CHS.
Collapse
Affiliation(s)
- Karl F Welke
- Division of Congenital Cardiac Surgery, Levine Children's Hospital/Atrium Health, Charlotte, North Carolina.
| | - Sara K Pasquali
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan C. S. Mott Children's Hospital, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, Michigan
| | - Paul Lin
- Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, Michigan
| | - Carl L Backer
- Division of Cardiovascular-Thoracic Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - David M Overman
- Division of Cardiovascular Surgery, The Children's Heart Clinic, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Jennifer C Romano
- Department of Cardiac Surgery, University of Michigan C. S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery and the Heart and Vascular Institute, The Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
29
|
Johnson JT, Scholtens DM, Kuang A, Feng XY, Eltayeb OM, Post LA, Marino BS. Does Value Vary by Center Surgical Volume for Neonates With Truncus Arteriosus? A Multicenter Study. Ann Thorac Surg 2020; 112:170-177. [PMID: 32768429 DOI: 10.1016/j.athoracsur.2020.05.178] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 05/18/2020] [Accepted: 05/28/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Truncus arteriosus is a congenital heart defect with high resource use, cost, and mortality. Value assessment (outcome relative to cost) can improve quality of care and decrease cost. This study hypothesized that truncus arteriosus repair at a high-volume center would result in better outcomes at lower cost (higher value) compared with a low-volume center. METHODS This study retrospectively analyzed a multicenter cohort of neonates undergoing truncus arteriosus repair (2004 to 2015) by using the Pediatric Health Information Systems database. Multivariate quantile, logistic, and negative binomial regression models were used to evaluate total hospital cost, in-hospital mortality, ventilation days, intensive care unit length of stay (LOS), hospital LOS, and days of inotropic agent use by center volume (high-volume >3/year) and age at repair while adjusting for sex, ethnicity, race, genetic abnormality, prematurity, low birth weight, concurrent interrupted arch repair, and truncal valve repair. RESULTS Of 1024 neonates with truncus arteriosus, 495 (48%) were treated at high-volume centers. Costs at the 75th percentile were lower at high-volume vs low-volume centers by $28,456 (P = .02) at all ages at repair. Patients at high-volume centers had lower median postoperative ventilation days (5 days vs 6 days; P < .001), intensive care unit LOS (13 days vs 19 days; P < .001), hospital LOS (23 days vs 28 days; P = .02), and inotropic agent use (3 days vs 4 days; P = .004). In-hospital mortality did not differ by center volume. CONCLUSIONS In neonates undergoing truncus arteriosus repair, costs are lower and outcomes are better at high-volume centers, thus resulting in higher value at all ages of repair. Value-based interventions should be considered to improve outcomes and decrease cost in truncus arteriosus care.
Collapse
Affiliation(s)
- Joyce T Johnson
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Denise M Scholtens
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Alan Kuang
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Xiang Yu Feng
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Osama M Eltayeb
- Division of Cardiothoracic Surgery, Department of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Lori A Post
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Bradley S Marino
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| |
Collapse
|
30
|
O'Byrne ML, Glatz AC, Faerber JA, Seshadri R, Millenson ME, Mi L, Shinohara RT, Dori Y, Gillespie MJ, Rome JJ, Kawut SM, Groeneveld PW. Interhospital Variation in the Costs of Pediatric/Congenital Cardiac Catheterization Laboratory Procedures: Analysis of Data From the Pediatric Health Information Systems Database. J Am Heart Assoc 2020; 8:e011543. [PMID: 31023121 PMCID: PMC6512131 DOI: 10.1161/jaha.118.011543] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Cardiac catheterization is an important but costly component of health care for young patients with cardiac disease. Measurement of variation in their cost between hospitals and identification of the reasons for this variation may help reduce cost without compromising quality. Methods and Results Using data from Pediatric Health Information Systems Database from January 2007 to December 2015, the costs of 9 procedures were measured. Mixed‐effects multivariable models were used to generate case‐mix–adjusted estimates of each hospital's cost for each procedure and measure interhospital variation. Procedures (n=35 637) from 43 hospitals were studied. Median costs varied from $8249 (diagnostic catheterization after orthotopic heart transplantation) to $38 909 (transcatheter pulmonary valve replacement). There was marked variation in the cost of procedures between hospitals with 3.5‐ to 8.9‐fold differences in the case‐mix–adjusted cost between the most and least expensive hospitals. No significant correlation was found between hospitals’ procedure‐specific mortality rates and costs. Higher procedure volume was not associated with lower cost except for diagnostic procedures in heart transplant patients and pulmonary artery angioplasty. At the hospital level, the proportion of cases that were outliers (>95th percentile) was significantly associated with rank in terms of cost (Spearman's ρ ranging from 0.37 to 0.89, P<0.01). Conclusions Large‐magnitude hospital variation in cost was not explained by case‐mix or volume. Further research is necessary to determine the degree to which variation in cost is the result of differences in the efficiency of the delivery of healthcare services and the rate of catastrophic adverse outcomes and resultant protracted and expensive hospitalizations.
Collapse
Affiliation(s)
- Michael L O'Byrne
- 1 Division of Cardiology Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,2 Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia Philadelphia PA.,3 Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA
| | - Andrew C Glatz
- 1 Division of Cardiology Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,2 Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia Philadelphia PA
| | - Jennifer A Faerber
- 2 Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia Philadelphia PA
| | - Roopa Seshadri
- 2 Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia Philadelphia PA
| | - Marisa E Millenson
- 2 Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia Philadelphia PA
| | - Lanyu Mi
- 2 Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia Philadelphia PA
| | - Russell T Shinohara
- 4 Department of Biostatistics Center for Clinical Epidemiology and Biostatistics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Yoav Dori
- 1 Division of Cardiology Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Matthew J Gillespie
- 1 Division of Cardiology Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Jonathan J Rome
- 1 Division of Cardiology Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Steven M Kawut
- 5 Division of Pulmonology and Critical Care Department of Medicine Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Peter W Groeneveld
- 3 Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA.,6 Division of General Internal Medicine Department of Medicine Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,7 Corporal Michael J. Crescenz VA Medical Center Philadelphia PA
| |
Collapse
|
31
|
O'Byrne ML, DeCost G, Katcoff H, Savla JJ, Chang J, Goldmuntz E, Groeneveld PW, Rossano JW, Faerber JA, Mercer-Rosa L. Resource Utilization in the First 2 Years Following Operative Correction for Tetralogy of Fallot: Study Using Data From the Optum's De-Identified Clinformatics Data Mart Insurance Claims Database. J Am Heart Assoc 2020; 9:e016581. [PMID: 32691679 PMCID: PMC7792257 DOI: 10.1161/jaha.120.016581] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Despite excellent operative survival, correction of tetralogy of Fallot frequently is accompanied by residual lesions that may affect health beyond the incident hospitalization. Measuring resource utilization, specifically cost and length of stay, provides an integrated measure of morbidity not appreciable in traditional outcomes. Methods and Results We conducted a retrospective cohort study, using de‐identified commercial insurance claims data, of 269 children who underwent operative correction of tetralogy of Fallot from January 2004 to September 2015 with ≥2 years of continuous follow‐up (1) to describe resource utilization for the incident hospitalization and subsequent 2 years, (2) to determine whether prolonged length of stay (>7 days) in the incident hospitalization was associated with increased subsequent resource utilization, and (3) to explore whether there was regional variation in resource utilization with both direct comparisons and multivariable models adjusting for known covariates. Subjects with prolonged incident hospitalization length of stay demonstrated greater resource utilization (total cost as well as counts of outpatient visits, hospitalizations, and catheterizations) after hospital discharge (P<0.0001 for each), though the number of subsequent operative and transcatheter interventions were not significantly different. Regional differences were observed in the cost of incident hospitalization as well as subsequent hospitalizations, outpatient visits, and the costs associated with each. Conclusions This study is the first to report short‐ and medium‐term resource utilization following tetralogy of Fallot operative correction. It also demonstrates that prolonged length of stay in the initial hospitalization is associated with increased subsequent resource utilization. This should motivate research to determine whether these differences are because of modifiable factors.
Collapse
Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA.,Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA
| | - Grace DeCost
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Hannah Katcoff
- Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA
| | - Jill J Savla
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Joyce Chang
- Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA.,Division of Rheumatology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Elizabeth Goldmuntz
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Peter W Groeneveld
- Division of General Internal Medicine Department of Medicine Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,Corporal Michael J. Crescenz VA Medical Center Philadelphia PA
| | - Joseph W Rossano
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA
| | - Jennifer A Faerber
- Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA
| | - Laura Mercer-Rosa
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| |
Collapse
|
32
|
Brown KL, Pagel C, Ridout D, Wray J, Tsang VT, Anderson D, Banks V, Barron DJ, Cassidy J, Chigaru L, Davis P, Franklin R, Grieco L, Hoskote A, Hudson E, Jones A, Kakat S, Lakhani R, Lakhanpaul M, McLean A, Morris S, Rajagopal V, Rodrigues W, Sheehan K, Stoica S, Tibby S, Utley M, Witter T. Early morbidities following paediatric cardiac surgery: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08300] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Background
Over 5000 paediatric cardiac surgeries are performed in the UK each year and early survival has improved to > 98%.
Objectives
We aimed to identify the surgical morbidities that present the greatest burden for patients and health services and to develop and pilot routine monitoring and feedback.
Design and setting
Our multidisciplinary mixed-methods study took place over 52 months across five UK paediatric cardiac surgery centres.
Participants
The participants were children aged < 17 years.
Methods
We reviewed existing literature, ran three focus groups and undertook a family online discussion forum moderated by the Children’s Heart Federation. A multidisciplinary group, with patient and carer involvement, then ranked and selected nine key morbidities informed by clinical views on definitions and feasibility of routine monitoring. We validated a new, nurse-administered early warning tool for assessing preoperative and postoperative child development, called the brief developmental assessment, by testing this among 1200 children. We measured morbidity incidence in 3090 consecutive surgical admissions over 21 months and explored risk factors for morbidity. We measured the impact of morbidities on quality of life, clinical burden and costs to the NHS and families over 6 months in 666 children, 340 (51%) of whom had at least one morbidity. We developed and piloted methods suitable for routine monitoring of morbidity by centres and co-developed new patient information about morbidities with parents and user groups.
Results
Families and clinicians prioritised overlapping but also different morbidities, leading to a final list of acute neurological event, unplanned reoperation, feeding problems, renal replacement therapy, major adverse events, extracorporeal life support, necrotising enterocolitis, surgical infection and prolonged pleural effusion. The brief developmental assessment was valid in children aged between 4 months and 5 years, but not in the youngest babies or 5- to 17-year-olds. A total of 2415 (78.2%) procedures had no measured morbidity. There was a higher risk of morbidity in neonates, complex congenital heart disease, increased preoperative severity of illness and with prolonged bypass. Patients with any morbidity had a 6-month survival of 81.5% compared with 99.1% with no morbidity. Patients with any morbidity scored 5.2 points lower on their total quality of life score at 6 weeks, but this difference had narrowed by 6 months. Morbidity led to fewer days at home by 6 months and higher costs. Extracorporeal life support patients had the lowest days at home (median: 43 days out of 183 days) and highest costs (£71,051 higher than no morbidity).
Limitations
Monitoring of morbidity is more complex than mortality, and hence this requires resources and clinician buy-in.
Conclusions
Evaluation of postoperative morbidity provides important information over and above 30-day survival and should become the focus of audit and quality improvement.
Future work
National audit of morbidities has been initiated. Further research is needed to understand the implications of feeding problems and renal failure and to evaluate the brief developmental assessment.
Funding
This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 30. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Katherine L Brown
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Christina Pagel
- Clinical Operational Research Unit, University College London, London, UK
| | - Deborah Ridout
- Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Jo Wray
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Victor T Tsang
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - David Anderson
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
| | - Victoria Banks
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - David J Barron
- Departments of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Jane Cassidy
- Departments of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Linda Chigaru
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Peter Davis
- Departments of Intensive Care and Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Rodney Franklin
- Paediatric Cardiology Department, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Luca Grieco
- Clinical Operational Research Unit, University College London, London, UK
| | - Aparna Hoskote
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Emma Hudson
- Department of Applied Health Research, University College London, London, UK
| | - Alison Jones
- Departments of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Suzan Kakat
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Rhian Lakhani
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
| | - Monica Lakhanpaul
- Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK
- Community Child Health, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Andrew McLean
- Department of Intensive care, Royal Hospital for Children, Glasgow, UK
| | - Steve Morris
- Department of Applied Health Research, University College London, London, UK
| | - Veena Rajagopal
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Warren Rodrigues
- Department of Intensive care, Royal Hospital for Children, Glasgow, UK
| | - Karen Sheehan
- Departments of Intensive Care and Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Serban Stoica
- Departments of Intensive Care and Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Shane Tibby
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
| | - Martin Utley
- Clinical Operational Research Unit, University College London, London, UK
| | - Thomas Witter
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
| |
Collapse
|
33
|
Montoro DV, Gómez JMG, Montoro AV, Manso GM. Predictors of early extubation after pediatric cardiac surgery: Fifteen months of institutional experience. PROGRESS IN PEDIATRIC CARDIOLOGY 2020. [DOI: 10.1016/j.ppedcard.2020.101224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
34
|
Vervoort D, Swain JD. Cardiothoracic surgery in the era of universal health coverage. J Thorac Cardiovasc Surg 2020; 159:e319. [DOI: 10.1016/j.jtcvs.2019.09.160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 09/16/2019] [Indexed: 10/25/2022]
|
35
|
Crethers D, Kalish J, Shafer B, Mathis L, Polimenakos AC. Right Ventricular Outflow Tract Reintervention in the Transcatheter Era: Outcomes and Cost Analysis. Pediatr Cardiol 2020; 41:599-606. [PMID: 31894397 DOI: 10.1007/s00246-019-02281-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 12/17/2019] [Indexed: 11/26/2022]
Abstract
Surgical pulmonary valve insertion (SPVI) for re-entry right ventricular outflow tract intervention (RVOTI) remains an established and reproducible approach. Fast-track in patients undergoing RVOTI of the comprehensive valve program targets early ICU and hospital discharge (Hd). Feasibility study for outcome and cost analysis was undertaken. Between January 2015 and December 2016, 34 patients underwent re-entry RVOTI. Seventeen had SPVI and 17 transcatheter PVI (TPVI). Surgical perioperative fast-track protocol was used. Echocardiographic evaluation preoperatively (TTE-1), after RVOTI (TTE-2), at hospital discharge (TTE-3), and follow-up (TTE-4) were obtained. Cost Analysis included procedural and hospital costs. Mean follow-up period was 11.3 ± 6.9 months. All patients were extubated prior to ICU arrival. Mean age was 8.5 ± 7.8 for SPVI [vs 28.5 ± 8.6 years for TPVI] (p < 0.05). There was no hospital mortality or 30-day readmission for SPVI (versus 1 for TPVI).Mean hospital length of stay (LOS) was 4.1 ± 1.1 days for SPVI [vs 1.1 ± 0.7 days for TPVI] (p < 0.05). Number of prior sternal re-entry had no influence on outcome. RV systolic pressure referenced to LVSP (rRVSP, %) and diastolic dimension (RVEDDi, z score) showed sustainable improvement (TTE-2, TTE-3, TTE-4) in both groups compared to TTE-1 (p < 0.05). Mean total hospital cost was $5475.86 ± 2503.91 lower after SPVI (p = 0.09), 21.7% procedural cost reduction. Patients undergoing RVOTI can be safely stratified, based on a customized concept, towards SPVI or TPVI. Standardized strategy can advocate a fast-track path. SPVI is associated with comparable mid-term outcomes to TPVI although SPVI is delivered in younger patients. Despite longer LOS SPVI is associated with reduced hospital cost. Multisite studies might help determine suitability for each strategy on cost containment/quality of life basis.
Collapse
Affiliation(s)
- Danielle Crethers
- Division of Congenital and Pediatric Cardiothoracic Surgery, Children's Hospital of Georgia Medical College of Georgia, Augusta, GA, USA
| | - Joshua Kalish
- Department of Educational Affairs, Medical College of Georgia, Augusta, GA, USA
| | - Brendan Shafer
- Division of Congenital and Pediatric Cardiothoracic Surgery, Children's Hospital of Georgia Medical College of Georgia, Augusta, GA, USA
| | - Lauren Mathis
- Division of Congenital and Pediatric Cardiothoracic Surgery, Children's Hospital of Georgia Medical College of Georgia, Augusta, GA, USA
| | - Anastasios C Polimenakos
- Division of Congenital and Pediatric Cardiothoracic Surgery, Children's Hospital of Georgia Medical College of Georgia, Augusta, GA, USA.
- Medical College of Georgia Congenital and Pediatric Cardiothoracic Surgery, Children's Hospital of Georgia, 1120 15th Street BAA 8222, Augusta, GA, 30912, USA.
| |
Collapse
|
36
|
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.
Collapse
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
| | | |
Collapse
|
37
|
Loomba RS, Flores S. Use of vasoactive agents in postoperative pediatric cardiac patients: Insights from a national database. CONGENIT HEART DIS 2019; 14:1176-1184. [DOI: 10.1111/chd.12837] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/11/2019] [Accepted: 08/16/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Rohit S. Loomba
- Division of Pediatric Cardiology, Chicago Medical School Advocate Children’s Hospital Chicago Illinois
| | - Saul Flores
- Division of Pediatric Cardiology, Baylor College of Medicine Texas Children’s Hospital Houston Texas
| |
Collapse
|
38
|
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.
Collapse
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
| |
Collapse
|
39
|
Tweddell S, Loomba RS, Cooper DS, Benscoter AL. Health care‐associated infections are associated with increased length of stay and cost but not mortality in children undergoing cardiac surgery. CONGENIT HEART DIS 2019; 14:785-790. [DOI: 10.1111/chd.12779] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/16/2019] [Accepted: 04/10/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Sarah Tweddell
- Division of Cardiology, Department of Pediatrics Cincinnati Children’s Hospital Medical Center Cincinnati Ohio
| | - Rohit S. Loomba
- Division of Cardiology, Department of Pediatrics Cincinnati Children’s Hospital Medical Center Cincinnati Ohio
| | - David S. Cooper
- Division of Cardiology, Department of Pediatrics Cincinnati Children’s Hospital Medical Center Cincinnati Ohio
| | - Alexis L. Benscoter
- Division of Cardiology, Department of Pediatrics Cincinnati Children’s Hospital Medical Center Cincinnati Ohio
| |
Collapse
|
40
|
Flynn-O’Brien KT, Richards MK, Wright DR, Rivara FP, Haaland W, Thompson L, Oldham K, Goldin A. Health outcomes and the healthcare and societal cost of optimizing pediatric surgical care in the United States. J Pediatr Surg 2019; 54:621-627. [PMID: 30598246 PMCID: PMC6511280 DOI: 10.1016/j.jpedsurg.2018.10.102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 10/21/2018] [Accepted: 10/26/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is a movement to ensure that pediatric patients are treated in appropriately resourced hospitals through the ACS Children's Surgery Verification (CSV) program. The objective of this study was to assess the potential difference in care provision, health outcomes and healthcare and societal costs after implementation of the CSV program. METHODS All 2011 inpatient admissions for selected complex pediatric patients warranting treatment at a hospital with Level I resources were evaluated across 6 states. Multivariate regressions were used to analyze differences in healthcare outcomes (postoperative complications including death, length of stay, readmissions and ED visits within 30 days) and costs by CSV level. Recycled predictions were used to estimate differences between the base case scenario, where children actually received care, and the optimized scenario, where all children were theoretically treated at Level I centers. RESULTS 8,006 children (mean age 3.06 years, SD 4.49) met inclusion criteria, with 45% treated at Level I hospitals, 30% at Level II and 25% at Level III. No statistically significant differences were observed in healthcare outcomes. Readmissions within 30 days were higher at Level II compared to Level I centers (adjusted IRR 1.61; 95% CI 1.11, 2.34), with an estimated 24 avoidable readmissions per 1000 children if treatment were shifted from Level II to Level I centers. Overall, costs per child were not significantly different between the base case and the optimized scenario. CONCLUSION Many complex surgical procedures are being performed at Level II/III centers. This study found no statistically significant increase in healthcare or societal costs if these were performed instead at Level I centers under the optimized scenario. Ongoing evaluation of efforts to match institutional resources with individual patient needs is needed to optimize children's surgical care in the United States. LEVEL OF EVIDENCE II.
Collapse
Affiliation(s)
- Katherine T. Flynn-O’Brien
- Department of Surgery, Children’s Hospital of Wisconsin, Division of Pediatric Surgery, Fellow, Pediatric Surgery, 999 North 92nd Street, C320, Milwaukee, WI 53226, 505.948.0220,
| | - Morgan K. Richards
- Department of Surgery, Children’s Healthcare of Atlanta, Division of Pediatric Surgery, Fellow, Pediatric Surgery, 1405 Clifton Rd NE, Atlanta, GA 30322, 206.369.8387,
| | - Davene R. Wright
- Department of Pediatrics, University of Washington and Seattle Children’s Research Institute, Center for Child Health, Behavior, and Development, Assistant Professor, Division of General Pediatrics, 2001 Eighth Ave, Suite 400, Seattle, WA 98121 USA, 206-884-8241,
| | - Frederick P. Rivara
- Department of Pediatrics, University of Washington, Seattle Children’s Research Institute, Center for Child Health, Behavior and Development, Professor, Division of General Pediatrics, Harborview Injury Prevention and Research Center, Box 359960, 325 Ninth Ave, Seattle, WA 98104 USA, 206-744-9449,
| | - Wren Haaland
- Seattle Children's Research Institute, Center for Child Health, Behavior, and Development, 2001 Eighth Ave, Suite 400, Seattle, WA 98121, USA.
| | - Leah Thompson
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
| | - Keith Oldham
- Children's Hospital of Wisconsin, Medical College of Wisconsin, 999 North 92(nd) Street, C320, Milwaukee, WI 53226.
| | - Adam Goldin
- Department of Surgery, Seattle Children's Hospital, Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Department of Surgery, University of Washington School of Medicine, 4800 Sand Point Way NE, Seattle, WA 98105, USA.
| |
Collapse
|
41
|
Godown J, Thurm C, Hall M, Dodd DA, Feingold B, Soslow JH, Mettler BA, Smith AH, Bearl DW, Schumacher KR. Center Variation in Hospital Costs for Pediatric Heart Transplantation: The Relationship Between Cost and Outcomes. Pediatr Cardiol 2019; 40:357-365. [PMID: 30343331 PMCID: PMC6494458 DOI: 10.1007/s00246-018-2011-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 10/11/2018] [Indexed: 12/20/2022]
Abstract
There are limited published data addressing the costs associated with pediatric heart transplantation and no studies evaluating the variation in costs across centers. We aimed to describe center variation in pediatric heart transplant costs and assess the association of transplant hospitalization costs with patient outcomes. Using a linkage between the Pediatric Health Information System and Scientific Registry of Transplant Recipients databases, hospital costs were assessed for patients (< 18 years of age) undergoing heart transplantation (2007-2016). Severity-adjusted patient costs were calculated using generalized linear mixed-effects models with a random hospital intercept. Center variation in hospital cost was described after adjusting for the predicted risk of in-hospital mortality. Post-transplant survival was compared between low- and high-cost centers using Cox proportional hazard models. A total of 2156 patients were included from 24 centers. There was 3.7-fold variation in transplant hospitalization costs across centers, ranging from $329,477 to $1,226,507. Patients transplanted at high-cost centers have a higher predicted risk of in-hospital mortality (8.1% vs. 6.1%, p < 0.001). Both early (p = 0.008) and long-term (p = 0.003) post-transplant survival were better in patients transplanted at low-cost centers. Transplant at low-cost centers was associated with improved post-transplant survival, independent of patient-specific risk (adjusted hazard ratio 0.72; 95%CI 0.57-0.92, p = 0.008). There is wide variation in cost for pediatric heart transplant inpatient care among U.S. centers with low-cost centers demonstrating the best patient survival. Differences in patient populations likely contribute to these findings, but cannot account for all the variation seen. This suggests that variability in the delivery of care across centers may influence post-transplant survival.
Collapse
Affiliation(s)
- Justin Godown
- Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Nashville, TN, USA.
| | - Cary Thurm
- Children's Hospital Association, Lenexa, KS, USA
| | - Matt Hall
- Children's Hospital Association, Lenexa, KS, USA
| | - Debra A Dodd
- Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Nashville, TN, USA
| | - Brian Feingold
- Pediatrics and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jonathan H Soslow
- Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Nashville, TN, USA
| | - Bret A Mettler
- Pediatric Cardiothoracic Surgery, Monroe Carell Jr. Children's Hospital, Nashville, TN, USA
| | - Andrew H Smith
- Pediatric Critical Care, Monroe Carell Jr. Children's Hospital, Nashville, TN, USA
| | - David W Bearl
- Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Nashville, TN, USA
| | - Kurt R Schumacher
- Pediatric Cardiology, C.S. Mott Children's Hospital, The University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
42
|
Welke KF, Pasquali SK, Lin P, Backer CL, Overman DM, Romano JC, Jacobs JP, Karamlou T. Hospital Distribution and Patient Travel Patterns for Congenital Cardiac Surgery in the United States. Ann Thorac Surg 2019; 107:574-581. [DOI: 10.1016/j.athoracsur.2018.07.047] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 07/12/2018] [Accepted: 07/16/2018] [Indexed: 10/28/2022]
|
43
|
Willems R, Tack P, François K, Annemans L. Direct Medical Costs of Pediatric Congenital Heart Disease Surgery in a Belgian University Hospital. World J Pediatr Congenit Heart Surg 2019; 10:28-36. [DOI: 10.1177/2150135118808747] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: The recent trend to optimize the efficiency of health-care systems requires objective clinical and economic data. European data on the cost of surgical procedures to repair or palliate congenital heart disease in pediatric patients are lacking. Methods: A single-center study was conducted. Bootstrap analysis of variance and bootstrap independent t test assessed the excess direct medical costs associated with minor and major complications in nine surgical procedure types, from a health-care payer perspective. Generalized linear models with log-link function and inverse Gaussian family were used to determine associated covariates with the total hospitalization cost. Descriptive statistics show the repartition between out-of-pocket expenditures and reimbursed costs. Results: Four hundred thirty-seven patients were included. Mean hospitalization costs ranged from €11,106 (atrial septal defect repair) to €33,865 (Norwood operation). Operations with major complications yielded excess costs compared to operations with no complications, ranging from €7,105 (+65.2%) for a truncus arteriosus repair to €27,438 (+251.7%) for a tetralogy of Fallot repair. Differences in costs were limited between operations with minor versus no complications. Age at procedure, intensive care unit stay, procedure risk category, reintervention, and postoperative mechanical circulatory support were associated with higher total hospitalization costs. Out-of-pocket expenditures represented 6% of total hospitalization costs. Conclusion: Operations with major complications yield excess costs, compared to operations with minor or no complications. Cost data and attribution are important to improve clinical practice in a cost-effective manner. The health-care system benefits from strategies and technological advancements that have an impact on modifiable cost-affecting parameters.
Collapse
Affiliation(s)
- Ruben Willems
- Department of Public Health, Ghent University, Ghent, Belgium
| | - Philip Tack
- Department of Innovation, Entrepreneurship and Service Management, Ghent University, Ghent, Belgium
| | - Katrien François
- Department of Cardiac Surgery, Ghent University Hospital, Ghent, Belgium
| | - Lieven Annemans
- Department of Public Health, Ghent University, Ghent, Belgium
| |
Collapse
|
44
|
Cost Savings Analysis of Early Extubation Following Congenital Heart Surgery. Pediatr Cardiol 2019; 40:138-146. [PMID: 30203291 DOI: 10.1007/s00246-018-1970-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 08/28/2018] [Indexed: 10/28/2022]
Abstract
The clinical benefit of early extubation following congenital heart surgery has been demonstrated; however, its effect on resource utilization has not been rigorously evaluated. We sought to determine the cost savings of implementing an early extubation pathway for children undergoing surgery for congenital heart disease. We performed a cost savings analysis after implementation of an early extubation strategy among children undergoing congenital heart surgery at British Columbia Children's Hospital (BCCH) over a 2.5-year period. All patients undergoing one of the eight Society of Thoracic Surgeons (STS) benchmark operations, ASD repair, or bidirectional cavopulmonary anastomosis were included in the analysis (n = 370). We compared our data to aggregate STS multi-institutional data from a contemporary cohort. We estimated daily costs for ICU care, ward care, medications, imaging, additional procedures, and allied health care using an administrative database. Direct costs, indirect costs, and cost savings were estimated. Simulation methods, Monte Carlo, and bootstrapping were used to calculate the 95% credible intervals for all estimates. The mean cost savings per procedure was $12,976 and the total estimated cost savings over the study period at BCCH was $4.8 million with direct costs accounting for 91% of cost savings. Sensitivity analysis demonstrated a mean cost savings range of $11,934-$14,059 per procedure. Early extubation is associated with substantial cost savings due to reduced hospital resource utilization. Implementation of an early extubation strategy following congenital heart surgery may contribute to improved resource utilization.
Collapse
|
45
|
Algaze CA, Shin AY, Nather C, Elgin KH, Ramamoorthy C, Kamra K, Kipps AK, Yarlagadda VV, Mafla MM, Vashist T, Krawczeski CD, Sharek PJ. Applying Lessons from an Inaugural Clinical Pathway to Establish a Clinical Effectiveness Program. Pediatr Qual Saf 2018; 3:e115. [PMID: 31334447 PMCID: PMC6581477 DOI: 10.1097/pq9.0000000000000115] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 09/19/2018] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Clinical effectiveness (CE) programs promote standardization to reduce unnecessary variation and improve healthcare value. Best practices for successful and sustainable CE programs remain in question. We developed and implemented our inaugural clinical pathway with the aim of incorporating lessons learned in the build of a CE program at our academic children's hospital. METHODS The Lucile Packard Children's Hospital Stanford Heart Center and Center for Quality and Clinical Effectiveness partnered to develop and implement an inaugural clinical pathway. Project phases included team assembly, pathway development, implementation, monitoring and evaluation, and improvement. We ascertained Critical CE program elements by focus group discussion among a multidisciplinary panel of experts and key affected groups. Pre and postintervention compared outcomes included mechanical ventilation duration, cardiovascular intensive care unit, and total postoperative length of stay. RESULTS Twenty-seven of the 30 enrolled patients (90%) completed the pathway. There was a reduction in ventilator days (mean 1.0 + 0.5 versus 1.9 + 1.3 days; P < 0.001), cardiovascular intensive care unit (mean 2.3 + 1.1 versus 4.6 + 2.1 days; P < 0.001) and postoperative length of stay (mean 5.9 + 1.6 versus 7.9 + 2.7 days; P < 0.001) compared with the preintervention period. Elements deemed critical included (1) project prioritization for maximal return on investment; (2) multidisciplinary involvement; (3) pathway focus on best practices, critical outcomes, and rate-limiting steps; (4) active and flexible implementation; and (5) continuous data-driven and transparent pathway iteration. CONCLUSIONS We identified multiple elements of successful pathway implementation, that we believe to be critical foundational elements of our CE program.
Collapse
Affiliation(s)
- Claudia A Algaze
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Palo Alto, Calif
- Center for Quality and Clinical Effectiveness, Lucile Packard Children's Hospital, Palo Alto, Calif
- Stanford University School of Medicine, Palo Alto, Calif
- Department of Pediatrics, Lucile Packard Children's Hospital, Palo Alto, Calif
| | - Andrew Y Shin
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Palo Alto, Calif
- Center for Quality and Clinical Effectiveness, Lucile Packard Children's Hospital, Palo Alto, Calif
- Stanford University School of Medicine, Palo Alto, Calif
- Department of Pediatrics, Lucile Packard Children's Hospital, Palo Alto, Calif
| | - Chealsea Nather
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Palo Alto, Calif
- Department of Pediatrics, Lucile Packard Children's Hospital, Palo Alto, Calif
| | - Krisa H Elgin
- Center for Quality and Clinical Effectiveness, Lucile Packard Children's Hospital, Palo Alto, Calif
- Division of Pediatric Cardiac Anesthesia, Lucile Packard Children's Hospital, Palo Alto, Calif
- Department of Pediatrics, Lucile Packard Children's Hospital, Palo Alto, Calif
| | - Chandra Ramamoorthy
- Stanford University School of Medicine, Palo Alto, Calif
- Division of Pediatric Cardiac Anesthesia, Lucile Packard Children's Hospital, Palo Alto, Calif
- Department of Pediatrics, Lucile Packard Children's Hospital, Palo Alto, Calif
| | - Komal Kamra
- Stanford University School of Medicine, Palo Alto, Calif
- Division of Pediatric Cardiac Anesthesia, Lucile Packard Children's Hospital, Palo Alto, Calif
- Department of Pediatrics, Lucile Packard Children's Hospital, Palo Alto, Calif
| | - Alaina K Kipps
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Palo Alto, Calif
- Center for Quality and Clinical Effectiveness, Lucile Packard Children's Hospital, Palo Alto, Calif
- Stanford University School of Medicine, Palo Alto, Calif
- Department of Pediatrics, Lucile Packard Children's Hospital, Palo Alto, Calif
| | - Vamsi V Yarlagadda
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Palo Alto, Calif
- Stanford University School of Medicine, Palo Alto, Calif
- Department of Pediatrics, Lucile Packard Children's Hospital, Palo Alto, Calif
| | - Monica M Mafla
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Palo Alto, Calif
| | - Tanushree Vashist
- Center for Quality and Clinical Effectiveness, Lucile Packard Children's Hospital, Palo Alto, Calif
| | - Catherine D Krawczeski
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Palo Alto, Calif
- Stanford University School of Medicine, Palo Alto, Calif
- Department of Pediatrics, Lucile Packard Children's Hospital, Palo Alto, Calif
| | - Paul J Sharek
- Center for Quality and Clinical Effectiveness, Lucile Packard Children's Hospital, Palo Alto, Calif
- Stanford University School of Medicine, Palo Alto, Calif
- Department of Pediatrics, Lucile Packard Children's Hospital, Palo Alto, Calif
- Division of Hospital Medicine, Lucile Packard Children's Hospital, Palo Alto, Calif
| |
Collapse
|
46
|
Papandria D, Sebastião YV, Deans KJ, Diefenbach KA, Minneci PC. Examining length of stay after commonly performed surgical procedures in ACS NSQIP pediatric. J Surg Res 2018; 231:186-194. [DOI: 10.1016/j.jss.2018.05.054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/02/2018] [Accepted: 05/24/2018] [Indexed: 01/19/2023]
|
47
|
Kon AA. Ethical Implications of Prenatal Screening for Congenital Heart Disease. JAMA Cardiol 2018; 3:837-838. [PMID: 30027261 DOI: 10.1001/jamacardio.2018.1944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Alexander A Kon
- Department of Pediatrics, University of California, San Diego School of Medicine
| |
Collapse
|
48
|
Technical Performance Score Predicts Resource Utilization in Congenital Cardiac Procedures. J Am Coll Cardiol 2018; 67:2696-8. [PMID: 27256837 DOI: 10.1016/j.jacc.2016.03.545] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 02/16/2016] [Accepted: 03/22/2016] [Indexed: 01/30/2023]
|
49
|
Longitudinal Health Care Cost in Hypoplastic Left Heart Syndrome Palliation. Pediatr Cardiol 2018; 39:1210-1215. [PMID: 29774394 DOI: 10.1007/s00246-018-1885-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 05/02/2018] [Indexed: 10/16/2022]
Abstract
Management of hypoplastic left heart syndrome (HLHS) is resource intensive. Heath care systems are pressured to provide value to patients by improving outcomes while decreasing costs. A single-center retrospective cohort of infants with HLHS who underwent Norwood procedure or hybrid Norwood from 2004 to 2014 and survived to first outpatient follow up were studied. The primary outcome was total cost through 12 months with a sub-analysis of patients with 60 months of data. Costs were calculated using internal cost accounting system and reported by cost center. Of the 152 HLHS patients identified, 69 met inclusion criteria. Stage I hospitalization (n = 69), with a median length of stay 34 days [interquartile range (IQR) 24-58 days], resulted in a median cost of $203,817 (IQR $136,236-272,453). Of survivors at 12 months (n = 55), the median cost was $369,393 (IQR $216,289-594,038) generated in part by a median of 67 (40-126 days) hospitalized days during that year. A subgroup analysis of patients who reached 60 months of age (n = 29) demonstrated a median total cost of $391,812 (IQR $293,801-577,443) and a median of 74 lifetime hospitalized days (IQR 58-116 days). High cost centers included intensive care (41%), non-ICU hospital (17%), operative services (11%), catheterization lab (9%), and pharmacy (9%). Using multiple regression analysis, significant drivers of cost included reoperation, length of hospitalization, low birthweight, and use of ECMO. Costs related to HLHS management are driven both by care-related complications such as surgical re-intervention and patient factors such as low birth weight.
Collapse
|
50
|
Essaid L, Strassle PD, Jernigan EG, Nelson JS. Regional Differences in Cost and Length of Stay in Neonates with Hypoplastic Left Heart Syndrome. Pediatr Cardiol 2018; 39:1229-1235. [PMID: 29754202 PMCID: PMC10900244 DOI: 10.1007/s00246-018-1887-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 05/02/2018] [Indexed: 11/25/2022]
Abstract
Hypoplastic left heart syndrome (HLHS) is a highly resource-intensive diagnosis. Geographic variation in cost and length of stay (LOS) in HLHS is not well described. Neonates diagnosed with HLHS between 2000 and 2012 were identified using the Kids' Inpatient Database. Hospitalizations were stratified into two groups: (1) birth and (2) secondary. United States regional differences in hospital charges and LOS were compared using adjusted linear regression. Of 2431 birth hospitalizations, 449 neonates (18.5%) died while inpatient and mortality rates differed by region (p = 0.02). After birth, 40.5% (n = 985) of neonates were transferred; transfers were most common in the Midwest (p < 0.0001). Adjusted average LOS was shortest in the West and longest in the South (26.1 days; 95% CI 24.0, 35.1 vs. 34.9 days; 95% CI 31.8, 38.1). Average adjusted charges were lowest in the Northeast ($324,600; 95% CI $271,400, $377,900) and highest in the West ($400,500; 95% CI $346,700, $454,300, p = 0.05). Among 1895 secondary hospitalizations, 24.9% of neonates died as inpatients, and the average adjusted LOS was shortest in the West (26.8 days; 95% CI 23.9, 29.7) and longest in the South (38.5 days; 95% CI 34.4, 42.4). Average adjusted charges were lowest in the Northeast ($326,900; 95% CI $270,700, $383,100) and highest in the South ($505,900; 95% CI $450,200, $561,500, p < 0.0001). Significant geographic variations in mortality, LOS, and hospital charges exist in care of US HLHS neonates. Reducing variation in care should remain a priority in national quality efforts in congenital heart disease.
Collapse
Affiliation(s)
- Luma Essaid
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Paula D Strassle
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Eric G Jernigan
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Jennifer S Nelson
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Department of Cardiothoracic Surgery, Nemours Children's Hospital, 13535 Nemours Parkway, Orlando, FL, 32827, USA.
| |
Collapse
|