Resource Utilization in Pediatric Patients Supported With Ventricular Assist Devices in the United States: A Multicenter Study From the Pediatric Interagency Registry for Mechanically Assisted Circulatory Support and the Pediatric Health Information System

Abstract

BackgroundFew data exist on resource utilization with pediatric ventricular assist devices (VADs). We tested the hypothesis that device type and adverse events are associated with increased resource utilization in pediatric patients supported with VADs.Methods and ResultsThe Pediatric Interagency Registry for Mechanically Assisted Circulatory Support, a national registry of VADs in patients <19 years old, and the Pediatric Health Information System, an administrative database, were merged. Univariate analysis was performed assessing the association of all factors with the total cost and length of stay first. Significant variables (P<0.05) were subjected to multivariable analysis. The study included 142 patients from 19 centers with VAD implants from October 2012 to June 2016. The median age was 9 years (interquartile range [IQR] 2‐15), 84 (59%) supported with a continuous‐flow VAD. Overall median hospital costs were $750 000 (IQR $539 000 to $1 100 000) with a median hospital length of stay of 81 days (IQR 54‐128). On multivariable analysis, device type and postoperative complications were not associated with resource utilization. Factors associated with increased costs included patient age, lower‐volume VAD center, being intubated, being on extracorporeal membrane oxygenation, number of complex chronic medical conditions, and length of stay. Among continuous‐flow VAD patients, discharge to home before transplant versus remaining hospitalized was associated with lower hospital costs (median $600 000 [IQR $400 000 to $820 000] versus median $680 000 [IQR $500 000 to $970 000], P=0.03).Conclusion VADs in pediatric patients are associated with high resource utilization. Increased resource utilization was associated with lower‐volume VAD centers, disease severity at VAD implantation, and the presence of complex chronic medical conditions. Further study is needed to develop cost‐effective strategies in this complex population.

Cost‐utility of continuous‐flow ventricular assist devices as bridge to transplant in pediatrics

“…These authors found, that while not meeting the WTP threshold compared to medical management, CF‐VAD was far superior in cost‐effectiveness to PF‐VAD with sensitivity analyses findings similar to our study: cost of device implantation, long‐term survival, cost per rehospitalization, and utility were important drivers of model conclusion. Our finding that the CF‐VAD capacity for outpatient device support is an important element resulting in higher QALY and lower costs is also mirrored in the literature . Cumulative costs and efficacy after implant for each model are illustrated in Figure where it is illustrated that CF‐VAD enjoys superiority in cumulative QALY across the first year, but bears an upfront cost that is overtaken by PF‐VAD at the end of week 12.…”

“…The cumulative costs for CF‐VAD the first year after implant is $1.12M while those of PF‐VAD is $1.39M. While the cost perspective and time horizon of our analysis differ from those of Rossano et al, the rough scale of our financial findings match those previously reported resource requirements in VAD care. This pattern—the cumulative cost for PF‐VAD being lower only in early cycles—explains why CF‐VADs are not cost‐effective if the anticipated length of time a patient needs device support is short.…”

“…It is important to note that there are not device support is an important element resulting in higher QALY and lower costs is also mirrored in the literature. 18 Cumulative costs and efficacy after implant for each model are illustrated in Figure 5 where it is illustrated that CF-VAD enjoys superiority in cumula- Of particular focus in the field of device support at this time is thromboembolic events and novel anticoagulation strategies to prevent them. The peak incidence of neurologic events is the 11th week and 16th week for PF-VAD and CF-VAD, respectively ( Figure 6).…”

Cost‐effectiveness of implantable ventricular assist devices in older children with stable, inotrope‐dependent dilated cardiomyopathy

“…20 Similarly, the costs of implantable continuous-flow VADs were taken from a retrospective analysis of PHIS data which also used CCRs. 4 These one-time costs were valued separately from costs of routine healthcare services, check-ups, and other treatments (eg, hospitalizations) borne by pediatric heart failure patients which were derived from previous costeffectiveness analyses. [21][22][23] Healthcare costs include healthcare service delivery (eg, physician and facility fees), medical device, and drug costs.…”

“…For children who received a VAD, median hospital costs including implantation were estimated to be $750 000, and the median length of stay was 81 days. 4,5 In children with end-stage heart failure, VAD implantation before the patient reaches a state of critical cardiogenic shock is associated with improved outcomes. 6 Beyond this, however, there is very little evidence to further guide the timing of implantation and patient selection in pediatrics.…”