Circ: Congenital heart surgery costs high, vary between centers
Routine MR images of the heart of an infant with complex congenital heart disease were transformed by the 3D Lab at the University of Colorado into an accurate physical model. Image Sorce: Joseph Kay, MD, University of Colorado Hospital, Aurora, Colo.
The costs associated with congenital heart diseases soak up $6 billion per year. And while data surrounding the costs of these congenital conditions are sparse, a new study has shown that resource utilization for congenital heart surgeries differs among hospitals despite patient and center characteristics and length of stay. The study was published in the May issue of Circulation: Cardiovascular Quality and Outcomes.

Of all birth defects, congenital heart defects have been linked to high hospital charges and mortality and greater length of stay, according to the study’s principal investigator Sara K. Pasquali, MD, of the Duke Clinical Research Institute and Duke University Medical Center in Durham, N.C., and colleagues. In the current study, Pasquali and colleagues sought to evaluate cost variation between four congenital heart operations to pinpoint the factors that affect these high hospital costs.

To do so, the researchers used the Premier Database that included 2,124 patients who survived to hospital discharge. The study included 719 patients who underwent atrial septal defect (ASD) repair at 19 centers, 792 patients who underwent ventricular septal defect (VSD) repair at 20 centers, 420 patients undergoing tetralogy of Fallot (TOF) repair in 17 centers and 193 patients undergoing arterial switch operations (ASO) in 13 centers.

The study reported total unadjusted hospital costs per patient.

The (median) figures were reported to be:
  • $12,761 for ASD repair;
  • $18,834 for VSD repair;
  • $28,223 for TOF repair; and
  • $55,430 for ASO.

Inpatient room and board accounted for the largest proportion of these total costs; patients within the upper cost quartiles had longer length of stay compared with those in lower quartiles. Length of stay for ASO repair was 22 days compared with 15 days for those in the lowest cost quartiles. Length of stay for TOF repair was 12 days versus seven days.

The researchers reported that mortality rates were higher in the upper cost quartiles versus lower cost quartiles. These rates were 5 percent versus 2 percent for TOF and 15 percent versus 1 percent for ASO. Rates were similar for ASD and VSD, 1 percent versus 1 percent and 0.5 percent versus 1 percent, respectively.

Cost variation decreased as the complexity of surgery increased: 19 percent for ASO repair, 11 percent for VSD repair, 6 percent for TOF repair and 3 percent for ASO.

Additionally, the authors reported that hospitals with higher volumes had significantly lower hospital surgery costs. In fact, for ASO repair, the cost difference between upper and lower center volume quartiles was $1,782. The researchers speculated that this could be because patients at higher-volume centers have fewer postoperative complications.

High-volume hospitals also have greater resources and standardized protocols of care to facilitate recovery, the authors wrote. Additionally, multidisciplinary standardized care protocols have been shown to decrease length of stay.

The researchers also adjusted cost savings for patient to see the figures if all centers performed as well as lowest cost quartiles. The estimated numbers were: $3,741 for ASD repair, $6,323 for VSD repair, $5,789 for TOF and $12,846 for ASO.

“Interestingly, we found that although total hospital costs varied significantly by center for all operations evaluated, these differences were most prominent for the lower complexity procedures (atrial septal defect and ventricular septal defect repair),” the authors wrote. However, reasoning for this remains unclear. The authors speculated that for more complex cases, procedural complexity or patient factors outweigh center-related factors that affect cost.

“Our data suggest that although higher complexity operations account for greater relative cost, there is greater variation in cost from center to center for lower complexity operations," they wrote.

“Further evaluation of patient outcomes in conjunction with cost and associated factors may elucidate strategies to both improve outcome and reduce cost variation across centers,” the authors concluded. They noted that future efforts should focus on lower complexity, common operations where cost variation if greater amongst centers. Lastly, clinical data registries collecting data on congenital heart surgeries will be able to further evaluate costs associated with certain complications in hopes to improve cost-savings and outcomes.

The study was supported by a grant from the National Heart, Lung and Blood Institute and the American Heart Association Mid-Atlantic Affiliate Clinical Research Program.