Andersons pediatric cardiology 304

costforaNorwoodoperationwas$165,168.18Thecareaftersurgeryhasan
impactoncostsaswell.Animportantcontributortohighercostsistheoverall
lengthofstay.19Forcomplexsurgeries,reducingthelengthofstaymaybe
difficult.Interventionssuchasearlierextubation20andincreasedresource
utilizationintheearlierpostoperativeperiodaftertherepairofatetralogyof
Fallot21didnotresultinshorterlengthofstayinanintensivecareunit.
Complicationssuchasrenalfailure,sepsis,needforextracorporealmembrane
oxygenation,andneedformechanicalventilationareallassociatedwith
increasedcosts.12,19,22Similarly,hospitalizationsthatresultinmortalitytypically
incurthegreatestcosts.23However,costsofcarearenotrestrictedtotheinitial
surgicalencounter.Anyeffortstoreducecostsofthesurgicalencountermustbe
balancedwiththeimpacttheseeffortsmayhaveonthelikelihoodof
readmission,asreadmissionhospitalizationshavebeenshowntobeakeydriver
ofincreasedcostsfortheCHDpopulation.5,17

VariationinCosts
ThereportedcostsofcareforpatientswithCHDvaryremarkablybetween
hospitals.Forsomeprocedures,thedifferenceincostsbetweencentersinthe
UnitedStateshasbeenashighasninefold.18Differencesinlengthofstayand
complicationsfollowingsurgerycanexplainsomeofthesedifferencesbutnot
all.Forthemostcommonandlesscomplexsurgeries,increasingthevolumeof
casesappearstobeassociatedwithlowercosts,consistentwitheconomiesof
scale.24,25

OpportunitiestoReduceCosts
Ascostshavecontinuedtoincreaseovertime,evenafteradjustingforinflation,
hospitalsandhealthsystemshaveimplementedeffortstocontainorevenreduce
costs,particularlyforresource-intensesurgicalencounters.Forexample,
countriessuchasMexicohavepromotedtheregionalizationofcardiacsurgical
caresoastoreducebothcostsandmortality,26althoughthismodelis
controversialintheUnitedStates.27,28Datingasfarbackastheearly1980s,

hospitalshaveinvestigatedwaystoreducecosts,suchasbyminimizing
laboratorytestsand“surveillancecatheterizations”withsomesuccess.29Itmay
beimportanttotargetinterventionsinsomelower-severitybuthighlyprevalent


typesofCHD,asthesecontributegreatlytopopulationcosts.30Forexample,
“fasttrack”programshavebeendevelopedinvariouscountriestoacceleratethe
postoperativeperiodforselectcardiacoperationssuchasclosureofventricular
oratrialseptaldefects.31–33Suchfocusedcost-containmenteffortshavebeen
showntoreducecostsbyasmuchas34%withoutincreasingmortalityor
readmissionrates.34However,costreductionshouldnotbepursuedifitcomes
withagreaterriskofadverseoutcomes.Althoughhigher-volumehospitalsmay
havelowercostsandmortality,thefactremainsthatwhenotherfactorsare
controlled,highercostsmaybeassociatedwithlowermortality.24,25,35Itis
importanttoweighthebalanceofanycost-containmentmeasureswithpotential
impactsonoutcomes;areductionincoststhatisachievedbysacrificingquality
andincreasingadverseoutcomeswilldiminishthevalueofthecaredelivered.36


CoststoPatients,Families,andSociety
(SeeAlsoBox14.1)
AnoftenignoredbutlikewiseimportantcostofcareforthepatientwithCHDis
thefinancialburdenandtimecostsbornebythefamiliesofaffectedchildrenand
thepatientsthemselves.37Thesefinancialburdensareinadditiontothe
numerousemotional,psychosocial,andpsychologicaspectsofgrowingupwith
CHD.38–42Frequentdoctorvisits,extendedhospitalizations,andintricatecare
needsplaceafinancialandemotionaltollonfamilies.43–45Manycaregiversmay
giveupemploymentinordertoprovidecareforafragilechildwithCHDor
mayaddasecondjobinordertomeettheassociatedfinancialneeds.46The
greatestnonmedicalcoststofamiliesofchildrenwithCHDincludelostincome,

thecostsoftransportation,andtheneedtocareforsiblings.47–49


Box14.1

IndirectCostConsiderationsofCongenital
HeartDiseasetothePatient,Family,and
Society
PatientandSociety
■Neurodevelopmentalcare(e.g.,autism,attentiondeficithyperactivity
disorder,disordersofexecutivefunction)
■Speech,physical,andoccupationaltherapy,includingspecialeducation
■CostsassociatedwithmanagingconditionsassociatedwithCHD,suchas
prematuredementia,obesity,hearingloss,andinfections
■Additionalspecialtycare
■Additionalimmunizations
■LessfinanciallybeneficialemploymentopportunitiesforadultswithCHD
■Accommodationsfordisabilities