Economic and Safety Implications of Introducing Fast Tracking in Congenital Heart Surgery

Abstract

Background-The feasibility of fast-tracking children undergoing congenital heart disease surgery has not been assessed adequately. Current knowledge is based on limited single-center experiences without contemporaneous control groups. Methods and Results-We compared administrative data for atrial septal defect (ASD) and ventricular septal defect (VSD) surgeries in children 2 months to 19 years of age at the Mount Sinai Medical Center (MSMC) with data from comparable patients at 40 centers contributing to the Pediatric Health Information System. Three-year blocks, early in and after fast tracking had been implemented at the MSMC, were examined. Seventy-seven and 89 children at MSMC undergoing ASD and VSD closure, respectively, were compared with 3103 ASD and 4180 VSD patients nationally. With fast tracking fully implemented, median length of stay at the MSMC decreased by 1 day compared with the earlier era (length of stay, 1 and 3 days for ASD and VSD, respectively). Nationally, median length of stay remained unchanged (3 days for ASD and 4 days for VSD) in the observed time periods. Hospitalization costs fell by 33% and 35% at MSMC (ASD and VSD, respectively), whereas they rose by 16% to 17% nationally. When analyzed in multiple regression models, the decrease in both length of stay and cost remained significantly greater at MSMC compared with nationally (P<0.0001 for all). Hospital mortality and 2-week readmission rates were unchanged at MSMC between the 2 time periods and were not different from the national rates. Key Words: cardiac anesthesia ◼ mechanical ventilator ◼ pediatric cardiac surgery ◼ pediatric and congenital heart disease ◼ pediatric intensive care unit Conclusion-Shorter

Hospitalization charges for children with birth defects in Texas, 2001 to 2010

“…Numerous studies have observed median hospitalization stay lengths for children with ASDs ranging from 3 to 6 days (Hughes et al, 2002;Thomson et al, 2002;Pasquali et al, 2011;Lawrence et al, 2013), which is in line with the 3-day LOS in the present study. Elsewhere researchers have noted comparable LOS for various heart defects, VSD (5 days in Texas, 5-6 days in other U.S. samples and 7-11 in China) (Pasquali et al, 2011;Liu et al, 2012;Lawrence et al, 2013); ToF (Texas 7, elsewhere 3-17) (Pasquali et al, 2011;Peterson et al, 2013a); HLHS (Texas 12, elsewhere 9-28) (Dean et al, 2011;Peterson et al, 2013a).…”

“…Elsewhere researchers have noted comparable LOS for various heart defects, VSD (5 days in Texas, 5-6 days in other U.S. samples and 7-11 in China) (Pasquali et al, 2011;Liu et al, 2012;Lawrence et al, 2013); ToF (Texas 7, elsewhere 3-17) (Pasquali et al, 2011;Peterson et al, 2013a); HLHS (Texas 12, elsewhere 9-28) (Dean et al, 2011;Peterson et al, 2013a).…”

Variation in Congenital Heart Surgery Costs Across Hospitals

“…We were also able to assess complications specific to congenital heart surgery. [3][4][5][6][7] Standardized information collected across hospitals within the PHIS Database allowed calculation of total hospital costs, which better estimate the resources consumed to carry out the service provided, compared with charge data reported in previous studies, which only reflect what the hospital billed for a service, may vary across hospitals, and overestimate cost. 6,7 These types of data linkages can maximize the strengths and mitigate the weaknesses of each data set, and allow for analyses not possible within each individual data set alone.…”

“…A previous single center report demonstrated that LOS (and associated hospital costs) could be reduced by standardization of care involving practices aimed at early extubation and mobilization in children undergoing certain types of heart surgery. 5 In adult surgical subspecialties, multicenter quality improvement collaboratives have proven to be successful models for sharing these types of best practices across hospitals, and reducing variation in clinical outcomes and costs. [31][32][33] A regional collaborative in Michigan is estimated to reduce complications after general and vascular surgery in ∼2500 patients each year, translating into annual savings of ∼$20 million.…”

“…Previous studies have been limited by the use of administrative data sets and inherent difficulties related to case ascertainment and risk adjustment, such that there are limited data available to hospitals, payers, and policymakers regarding average costs for the most common operations, the range of costs across institutions, and potential mechanisms underlying any variation identified. [3][4][5][6][7][8] This information has become increasingly important in an era of rising health care expenditures, where recent initiatives aim to provide hospitals with incentives to both improve quality of care and reduce costs. 9 A better understanding of factors impacting hospital costs for common and resource-intense conditions such as congenital heart disease is critical to the successful design and implementation of such initiatives.…”