Feature: Adult congenital heart diseasewhere are patients best treated?

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Female doctor and patient - 39.53 Kb
Thanks to innovations in medicine, more and more adult patients with congenital heart disease (CHD) are living longer and need specialty care. Many of these adult patients have complex anatomies and/or comorbidities, which raises the question: where are these patients best treated, pediatric hospitals or adult hospitals?

During a session Feb. 24 at the Cardiology 2012 conference sponsored by the Children’s Hospital of Philadelphia (CHOP) in Orlando, Fla., panel members discussed just that.

“We recognize the fact that there are more and more adults living with CHD,”  Yuli Y. Kim, MD, director of the adult CHD center at Penn Heart and Vascular Center in Philadelphia, told Cardiovascular Business during an interview. “More of these babies are surviving until adulthood and we have recognized that more of them are being taken care of in the pediatric setting.”

But, are these adult patients being adequately cared for safely and effectively in these pediatric settings? “It has created a lot of friction in the field because pediatric hospitals are oftentimes not designed to take care of these adult patients,” she said.

Today, more and more adults are living with childhood diseases such as CHD, and many adult hospital settings are also not equipped to care for these extremely complex patients, Kim said. Hospitals that treat this growing population of adults in the pediatric setting face a large knowledge gap.

“We want to obviously ensure that we are administering care that is safe, effective, consistent and most up to date for these patients,” Kim added. “We want to be patient-centered but there are many challenges involved with caring for these adult patients who have pediatric diseases in pediatric hospitals.”

To add to that, many of these patients also have comorbidities such as diabetes, renal failure or stroke, she said. “These combinations bring up the issue of safety. How will we address these comorbidities in this adult patient population, cared for in the pediatric setting?”

While she said that no panel members offered a direct solution, there may be a few viable care models. One would be transitioning these adult patients to adult hospitals after a certain age (21, for example). While she said that many pediatric hospitals may feel comfortable caring for patients until a certain age, there are no stringent accreditation standards for these centers.

“Every pediatric hospital will have to think about what their mission is when it comes to caring for these adult patients,” Kim advised. This will include providing the right resources and equipment, having trained personnel and executing proper resource utilization.

Kim added that this will be a big investment for pediatric hospitals because they will need to hire internal medicine physicians, etc., to care for a usually very small patient population.

Another issue is ensuring that physicians are both comfortable and qualified to care for this adult subset, she said. “Just because you are qualified doesn't mean you are comfortable or competent with this patient population."

Additionally, Kim added that most hospitals must discuss how appropriate it is to have a 45-year-old CHD patient being treated next to a toddler. “How will the patient feel about this?” she asked. “We must identify a model where a patient-driven organization sets the standards of who should care for these patients and how quality outcomes are measured."

Lastly, she added that there is a “very real” financial component to deciding where to treat these patients and how. For either pediatric hospitals or adult hospitals, this patient population requires intensive resource use. One model that could help resolve these issues is ensuring that free-standing pediatric hospitals are in close proximity to an adult hospital; however, that will cost money, she said.

“Free-standing pediatric hospitals cannot just take care of these adult patients, you need to have some sort of access and communication from close-by adult hospitals to properly care for this patient subset,” Kim added.

But while Kim said that the financial components of these joint ventures are “very real,” she offered that they should not be the driving force to delivering quality care. “There will be adults being treated in pediatric hospitals and we will need to address that,” Kim summed.