RISK-FACTORS FOR HIGHER COST IN CONGENITAL HEART OPERATIONS

Background For many congenital heart defects, hospital mortality is no longer a sensitive parameter by which to measure outcome. Although ho spital survival rates are now excellent for a wide variety of lesions, many patients require expensive and extensive hospital-based services during the perioperative period to enable their convalescence. These services can substantially increase the cost of care delivery. in toda y's managed care environment, it would be useful if risk factors for h igher cost could be identified preoperatively so that appropriate reso urces could be made available for the care of these patients. The focu s of this retrospective investigation is to determine if risk factors for high cost for repair of congenital heart defects can be identified . Methods. We assessed financial risk by tracking actual hospital cost s (not charges) for 144 patients undergoing repair of atrial septal de fect (58 patients), ventricular septal defect (48 patients), atriovent ricular canals (14 patients), or tetralogy of Fallot (24 patients) at Duke University Medical Center between July 1, 1992, and September 15, 1995. Furthermore, we were able to identify where the costs occurred within the hospital. Financial risk was defined as a large (>60% of me an costs) standard deviation, which indicated unpredictability and var iability in the treatment for a group of patients. Results. Cost for a trial septal defect repair was predictably consistent flow standard de viation) and was related to hospital length of stay. There were factor s, however, for ventricular septal defect, atrioventricular canal, and tetralogy of Fallot repair that are identifiable preoperatively that predict low- and high-risk groups using cost as an outcome parameter. Patients undergoing ventricular septal defect repair who were younger than 6 months of age at the time of repair, who required preoperative hospital stays of longer than 7 days before surgical repair, or who ha d Down's syndrome had a less predictable cost picture than patients un dergoing ventricular septal defect repair who were older than 2 years, who had short (<4 days) preoperative hospitalization, or who did not have Down's syndrome ($48,252 +/- $42,539 versus $15,819 +/- $7,219; p = 0.008). Patients with atrioventricular canals who had long preopera tive hospitalization (>7 days), usually due to pneumonia (respiratory syncytial virus) with preoperative mechanical ventilation had signific antly higher cost than patients with atrioventricular canals who under went elective repair with short preoperative hospitalization ($83,324 +/- $60,138 versus $26,904 +/- $5,384; p = 0.05). Patients with tetral ogy of Fallot had higher costs if they had multiple congenital anomali es, previous palliation (combining costs of both surgical procedures a nd hospital stays), or severe ''tet'' spells at the time of presentati on for operation compared with patients without these risk factors ($1 14,202 +/- $88,524 versus $22,241 +/- $7,071; p = 0.0005). One patient (with tetralogy of Fallot) with multiple congenital anomalies died 42 days after tetralogy of Fallot repair of sepsis after a gastrointesti nal operation. Otherwise, hospital mortality was 0% for all groups. Co nclusions. Low mortality and good long-term outcome for surgical corre ction of congenital heart defects is now commonplace, but can be expen sive as some patients with complex problems receive the care necessary to survive. This study demonstrates that it is possible to identify f actors preoperatively that predict financial risk. This knowledge may facilitate implementation of risk adjustments for managed care contrac ting and for strategic resource allocation. (C) 1997 by The Society of Thoracic Surgeons.