EFFECT OF REPAIR STRATEGY ON HOSPITAL COST FOR INFANTS WITH TETRALOGYOF FALLOT

Objective This study compares the total hospital cost (HC) for one-sta ge versus ''two-stage'' repair of tetralogy of Fallot (TOF) in infants younger than 1 year of age. Summary Background Data Total (one-stage) correction of TOF is now being performed with excellent results in in fancy. Alternatively, a two-stage approach, with palliation of infants in the first year of life, followed by complete repair at a later tim e can be used. In some institutions, the two-stage approach is standar d practice for infants younger than 1 year of age or is used selective ly in patients with an anomalous coronary artery across the right vent ricular outflow tract (RVOT), ''small pulmonary arteries,'' multiple c ongenital anomalies, critical illnesses (CI), which increase the risk of bypass (e.g., sepsis or DIG), or severe hypercyanotic spells (HS) a t the time of presentation. The cost implications of these two approac hes are unknown. Methods The authors reviewed 22 patients younger than 1 year of age who underwent repair of TOF at their institution betwee n 1993 and 1995. Eighteen patients had one-stage (1 degrees) repair (m ean age, 3.4 +/- 3.1 months; range, 3 days-9 months) and 4 patients we re treated by a staged approach with initial palliation (1.6 +/- 0.4 m onth; range, 1.5-2 months) followed by later repair (14.75 +/- 1.5 mon ths; range, 13-16 months). The reasons for palliation were severe HS a t time of presentation (two patients), anomalous coronary artery (one patient) and CI (one patient). In the 18 patients undergoing 1 degrees repair, 3 (16.6%) presented with HS, 6 (33.3%) had a transanular repa ir, and 6 (33.3%) were able to be repaired through an entirely transat rial approach (youngest patient, 1.5 months). The HC (1996 dollars) an d hospital length of stay (LOS; days) were evaluated for all patients. The HCs were calculated using transition I, which is a cost accountin g system used by our medical center since July 1992. Transition I prov ides complete data on all direct and indirect hospital-based, nonprofe ssional costs. Results There was no mortality in either group. The gro up undergoing 1 degrees repair had an average LOS of 14.5 +/- 11.2 day s compared to an average LOS for palliation of 14 +/- 6.4 days, When t he palliated group returned for complete repair, the average LOS was 2 8.8 +/- 25 days, yielding a total LOS for the two-stage strategy of 43 +/- 30.8 days (p = 0.003 compared to 1 degrees repair). The HC for 1 degrees repair was $32,541 +/- $15,968 compared to $25,737 +/- $1900 f or palliation (p = not significant compared to 1 degrees repair) and $ 54,058 +/- $39,395 for subsequent complete repair (p = not significant compared to 1 degrees repair) (total two-stage repair HC = $79,795 +/ - $40,625; p = 0.001 compared to 1 degrees repair), The LOS and HC for the two-stage group combine a total of palliation plus later repair a nd, as such, reflect two separate hospitalizations and convalescent pe riods, To eliminate cost outliers, a best-case analysis was performed by eliminating 50% of patients from each group. Using this analysis, t he two-stage approach resulted in an average (total) LOS of 16.5 +/- 2 .1 days compared to 8.5 +/- 1.4 days for the 1 degrees group. Total co st for the two-stage strategy in this best-case group was $44,660 +/- $3645 compared to $22,360 +/- $3331 for 1 degrees repair (p = 0.00001) . Conclusions The data from this review show that palliation alone gen erates HC similar to that from 1 degrees infant repair of TOF, and tot al combined HC and LOS for palliation plus eventual repair of TOF (two -stage approach) are significantly higher than from 1 degrees repair. Furthermore, these data do not include additional costs for care deliv ered between palliation and repair (e.g., outpatient visits, cardiac c atheterization, serial echocardiography). Although there may be occasi ons when a strategy using initial palliation followed by later repair may seem prudent, the cost is clearly higher and use of health care re sources greater.