THE COSTS AND BENEFITS OF OUTPATIENT SURVEILLANCE OF CONGENITAL HEART-DISEASE AFTER REPAIR

Regular outpatient re-evaluation in hopes of recognizing treatable pos t-operative problems is common practice after repair of congenital hea rt disease. The purpose of this investigation is to audit resource uti lization in the care of outpatients after repair of congenital heart d isease and to determine what relationship, if any, this utilization ma y have to active medical management. A chart review of a population of outpatients after surgical repair of secundum or sinus venosus atrial septal defect, surgical or catheter mediated relief of pulmonic steno sis, surgical repair of coarctation of the aorta, repair of tetralogy of Fallot, and Mustard operation for transposition of the great arteri es yielded 1252 patient-years of follow-up between 1987 and 1993. Each patient-year was analyzed for management changes and for utilization of outpatient services. Cost of these services was translated to 1994 dollars. More complicated forms of congenital heart disease were assoc iated with more management changes and more outpatient services. Atria l septal defect had no management changes in 254 patient-years of foll ow-up. Costs per patient-year varied over 6-fold ($237 for atrial sept al defect to $1485 for tetralogy of Fallot). Lesion by lesion variatio n in types of resources utilized in surveillance of repaired congenita l heart disease reflected the variation in lesion-specific anticipated late complications. Distribution of costs and management changes were highly skewed within individual forms of repaired heart disease, conc entrating 44% of cost and 45% of management changes in the costliest 1 0% of patient-years within each diagnosis. Outpatient surveillance of repaired congenital heart disease is presently a high technology under taking, with large expenditures for echocardiography and 24-h ambulato ry electrocardiography. Resource allocation decisions that may be mand ated in times of austerity must be made in light of the heterogeneity of risk for late complications across and within forms of repaired con genital heart disease.