Fast-tracking simple CHD surgery offers huge cost savings, safety

Day-of-surgery admissions, early extubation and mobilization in pediatric surgeries to correct congenital heart defects (CHD) reduce costs of admissions by a third, with no increase in morbidity and mortality, according to a study published online Feb. 26 in Circulation: Cardiovascular Quality and Outcomes.

Fast-tracking is a series of steps designed to reduce lengths of stay (LOS) and perioperative mortality, and involves trimming preparatory and recovery time in hospital before and after surgical procedures. It is a concept that has gained widespread traction in adult cardiothoracic surgery, but has been slower to take hold in the pediatric cardiothoracic surgery space.

Bruce Gelb, MD, of the department of cardiology at Boston Children’s Hospital, and colleagues conducted a retrospective observational study of costs and outcomes of surgeries to correct atrial septal defect (ASD) and ventricular septal defect (VSD) at Mount Sinai Medical Center (MSMC) in New York City, during two thee-year blocks of time: before a fast-track system was introduced (T1—2001 through 2003) and after fast-tracking was fully implemented (T2—2007-2009). The authors then compared the data from MSMC to data from 40 other centers across the U.S. during the same time frames.

The researchers obtained data from MSMC from the facility’s internal database; information for the control group was obtained by querying the Pediatric Health Information Systems (PHIS) database. Cost data were adjusted for inflation.

They compared 77 ASD patients at MSMC (T1, 41; T2, 36) to 3,103 ASD patients (T1, 1,685; T2, 1,418) at other centers. Median LOS at MSMC during T1 was two days compared with three days for the other centers. During T2, LOS at MSMC declined to a median of one day, while LOS at the other centers held steady at three days.

There were no mortalities among any of the studied patients at any of the centers in the included time periods. At MSMC, no patients were readmitted within 14 days of ASD repair in T1 and 8.3 percent were readmitted in T2. The rate of readmission at other centers was 5 percent in T1, increasing to 6.1 percent in T2.

At MSMC, the costs of ASD repair decreased 33 percent between T1 and T2, from $11, 561 to $7,759. Cost data were available for only 22 centers in the PHIS database; at those centers, the costs of ASD repair increased by 15.6 percent, from $21,512 in T1 to $24,873 in T2.

At MSMC, 89 patients (T1, 37; T2, 52) underwent VSD, and data from these patients were compared with data from 4,180 patients (T1, 2,106; T2, 2,074) who underwent VSD correction at other centers. During T1 the LOS was the same for MSMC and the other centers, at four days. LOS at MSMC decreased during T2 to three days, but remained at four days at the other centers.

At the other centers, there were nine mortalities in T1 and one in T2; MSMC experienced no VSD repair mortalities in either time period. MSMC had no readmissions in T1 and one readmission (1.9 percent) in T2, compared with readmission rates at the other centers of 4.6 percent and 5.7 percent, respectively.

At MSMC the adjusted cost of the VSD procedure was $18,185 in T1, which declined 35 percent to $11,733 in T2. In contrast, at the 22 other centers for which cost data were available, the costs of VSD closure increased 16.7 percent, from $27,366 in T1 to $31,939 in T2.

The authors noted that others have produced similar results from single-center studies in the pediatrics arena and from multicenter studies of adult populations. Studies of fast-tracking in children with CHD are complicated by the complexity and variety of these conditions, making comparisons difficult. The authors attempted to overcome these criticisms by limiting their study to simple repairs of common lesions with established rates of morbidity and mortality, they explained.

“Concordant with fully implementing fast-tracking, we observed significant reductions in hospital LOS and cost savings of over 30 percent, which were not accompanied by increases in mortality or readmissions,” the authors summarized.  

They cited several limitations of their study: They did not know whether the PHIS hospitals had implemented a fast-track system during the relevant time frames or the surgical approach the PHIS hospitals used, and costs may have been calculated differently at different facilities.