PAYMENT AND PRACTICE VARIATION IN CONGENITAL HEART-DISEASE - AN INTERNATIONAL STUDY

Cost-effectiveness analyses suggest that if outcomes are approximately similar, examination of practice and price variation provides potenti al targets for improvement in quality and/or reduction in cost. We exa mined variations in practice patterns and price with regard to congeni tal heart disease in nine countries. Standardised descriptions of 5 ty pical patients, 1 each with aortic stenosis, pulmonary stenosis, atrio ventricular septal defect, tetralogy of Fallot and tricuspid atresia w ere provided to the investigators who quantitated a typical course (fr om birth to 21 years of age) for each patient in terms of: clinic visi ts, outpatient echocardiogram, outpatient Holter, diagnostic catheteri sation, therapeutic catheterisation, medical hospitalisation, surgical hospitalisation and years on medication. Payments for each service in the public and private system were based on data from each country. W e found that in respect of practice patterns, there was an average of 400% variation, with the greatest variation in clinic, outpatient echo cardiogram, outpatient Holter and medical hospitalisation costs. The o verall use of services was lowest in Australia and Japan and highest i n Canada and Italy. Pricewise, there was a 380% variation, with the gr eatest variation in the prices of medication and inpatient services. I n the private sector in particular, prices were highest in Japan, the USA and Germany, and lowest in South Africa and France; in the public sector, prices were highest in Canada, Japan and Germany, and lowest i n South Africa and Australia. Overall, the average worldwide payments for congenital heart disease from birth to 21 years of age were as fol lows: mild aortic stenosis $3 851; mild pulmonary stenosis $7 319; tet ralogy of Fallot $36 456; atrioventricular septal defect $39 772; tric uspid atresia $74 940. The mean was $32 968. Payments were highest in the USA, Japan and Italy, and lowest in Australia and South Africa. In conclusion: (i) there is significant practice and price variation in paediatric cardiology services throughout the world; and (ii) further study of the need for services in which there is high variation (outpa tient echocardiogram, Holter and medical admissions) is warranted, sin ce significant reduction in these services may be possible with consid erable savings and no reduction in quality.