Inpatient Resource Utilization for Hypoplastic Left Heart Syndrome from Birth Through Fontan.
Kuntz M, Valencia E, Staffa S, Nasr V. Pediatr Cardiol. 2024 Mar;45(3):623-631. doi: 10.1007/s00246-023-03372-x. Epub 2023 Dec 30. PMID: 38159143
Take home points:
- Between 2016-2021, median total adjusted charges over the course of 3-stage palliation for HLHS were $1,475,800 (stage 1 $604,300, stage 2 $234,000, and stage 3 $256,260) and higher than reported on previous studies
- Pulmonary artery stenosis was the most common admitting diagnosis for interstage hospitalizations (3.4%)
- Cardiac catheterization and feeding tube placement were the most common interstage procedures
Commentary from Dr. Jared Hershenson (Greater Washington DC), section editor of Pediatric Cardiology Journal Watch:
3-stage surgical palliation for HLHS requires substantial resources. There are also elective and emergent admission and procedures necessary during interstage periods. Over the past decades, survival has improved, and more patients are undergoing palliation. Resource allocation is important for an individual hospital as well as from a public health perspective, so with cost changes, inflation, etc., defining the amount currently needed/expected is necessary.
This study searched the Pediatric Health Information System (PHIS) database that contains data from over 50 children’s hospitals in the US for HLHS (ICD-10 Q23.4) between 2016-2021. Admissions corresponding to all 3 stages were identified and patients were excluded if they did not complete all 3 at the same institution. Comorbid conditions, length of stay (total and ICU), duration of mechanical ventilation, ECMO, readmission, and cardiac arrests were reported. All admissions that occurred interstage were also analyzed. Charges for each stage and interstage admissions/procedures were determined. 199 patients were identified. Table 1 shows demographic data and Table 2 shows the comorbid conditions, with rhythm disturbances and NEC most common in stage 1 (or combined stage 1 and 2 in the same hospitalization), and rhythm disturbances and gastrostomy in stage 2 and 3.
Table 3 shows the index hospitalization data. There were 474 interstage hospitalizations among the cohort which represents 2.4 admissions/per patient; 1/3 required a procedure/surgery which were most commonly cardiac catheterization for pulmonary artery stenosis and enteral feeding access, and 1/3 required ICU admission. See table 5.
Median total charges were $1,475,800. Stage 1 had the highest charges compared to the other 2 planned stages (median charges for stage 1 $604,300, stage 2 $234,000, and stage 3 $256,260). The highest interstage charges occurred with admissions within 30 days after stage 3, median $173,100. See the article for a breakdown of charges (clinical, imaging, laboratory, pharmacy, supply, other).
The authors note that this is updated data from the last decade, and costs are significantly higher for all stages than previously reported. Reasons for this were not specifically determined in this study, but there are likely more higher risk patients having surgical palliation than in prior eras. Patient specific risk characteristics associated with resource utilization could also not be determined using the PHIS database, but future studies looking at this would be useful. While charges may overestimate actual cost, they still allow for planning for future resource utilization. LOS was higher in this study than in previous reports; this may be due to better survival, but there may be other factors as well. Additionally, charges may be higher for non-surviving HLHS patients, so this study may underestimate true total charges amongst all patients that may not reach stage 3 palliation. Interstage hospitalizations at other hospitals were also not included.
