- Email: [email protected]
Resource Utilization for Noncardiac Admissions in Pediatric Patients With Single Ventricle Disease
Resource Utilization for Noncardiac Admissions in Pediatric Patients With Single Ventricle Disease Ian D. Thomas, MDa,*, and Michael D. Seckeler, MD, MScb Patients with single ventricle (SV) congenital heart disease (CHD) incur high hospital costs during staged surgical palliation. Health care resource utilization for noncardiac admissions in patients with SV has not been reported. This study sought to compare costs and outcomes for common noncardiac hospital admissions between patients with SV and patients without CHD. Hospital discharge data from the University Health System Consortium from January 2011 to December 2013 was queried for patients aged £18 years with International Classification of Diseases, Ninth Revision (ICD-9) codes for SV lesions: hypoplastic left heart syndrome (746.7), tricuspid atresia (746.1), or common ventricle (745.3). Primary diagnosis, direct cost, length of stay (LOS), intensive care unit admission rate and mortality data were obtained. The 10 most common noncardiac admission diagnoses were compared between patients with SV and patients without CHD using t test and Fisher’s exact test. Total direct cost, LOS, and intensive care unit admission rate were higher for patients with SV for all diagnoses with the exception of LOS for dehydration, which was not different between groups. Hospital mortality was significantly higher for patients with SV admitted for acute kidney injury, esophageal reflux, failure to thrive, respiratory syncytial virus bronchiolitis and pneumonia. In conclusion, our study demonstrates that patients with SV CHD admitted with noncardiac diagnoses have higher health care resource utilization compared to those without CHD. As long-term survival increases, it can be expected that this patient group will use a disproportionate amount of medical dollars. Further characterization of costs will be important so steps can be taken to reduce or prevent hospitalization in these patients. Ó 2016 Elsevier Inc. All rights reserved. (Am J Cardiol 2016;-:-e-) Survival of patients with single ventricle congenital heart disease (SV CHD) has markedly improved since the advent of staged surgical palliation and cardiac transplantation.1 As a result, the prevalence of subjects living with SV CHD has increased, changing a once fatal disease into a chronic one.2e4 Health care costs for patients with CHD are high compared with the general population.5 As health care costs have increased, an emphasis has been placed on further characterizing resource utilization for patients with CHD in an attempt to better understand the public health impact of the disease.6 Health care resource utilization (HCRU) has been reported in patients with SV CHD, but data remain sparse. Single-center and multicenter studies have focused on the costs of surgical palliation and hospital admissions related to CHD in both pediatric and adult populations.7e14 Recent studies have attempted to further characterize inpatient hospital costs by specific lesions and patient demographics.15 However, hospitalizations for noncardiac diagnoses are likely to be far more common than procedural admissions, and there are no published data on the resource utilization for hospitalizations for noncardiac diagnoses in patients with SV CHD. The primary aim of this study was to describe the
Departments of aPediatrics and bPediatrics (Cardiology), University of Arizona, Tucson, Arizona. Manuscript received November 17, 2015; revised manuscript received and accepted February 23, 2016. See page 5 for disclosure information. *Corresponding author: Tel: (520) 694-8291; fax: (520) 626-5652. E-mail address: [email protected] (I.D. Thomas). 0002-9149/16/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjcard.2016.02.043
HCRU and outcomes for hospitalizations for common noncardiac diagnoses in pediatric patients with SV CHD in the United States. We hypothesized that resource utilization for noncardiac hospital admissions in pediatric patients with SV CHD would be higher than for children without CHD. Methods The University Health System Consortium (UHC) is an alliance of 115 academic medical centers and 165 affiliated hospitals. Their Clinical Data Base/Resource Manager (CDB/RM) is a large administrative database with discharge data from these institutions. After approval from the University of Arizona Institutional Review Board, we performed a retrospective review of deidentified discharge data from inpatient hospitalizations by querying the UHC CDB/ RM from January 2011 to December 2013 for patients aged 18 years at the time of hospital admission. Neonates (<30 days old) were excluded to minimize the inclusion of admissions for stage 1 palliation/Norwood procedure. Patients with SV were defined as having a primary or secondary admission diagnosis of hypoplastic left heart syndrome (ICD-9 code 746.7), tricuspid atresia (ICD-9 code 746.1), or common ventricle (ICD-9 code 745.3). To exclude admissions for staged surgical palliation, procedure codes associated with any stage of palliative surgery, as previously defined, were excluded.1 Admissions associated with procedural codes for cardiac catheterizations and electrophysiology procedures were also excluded to further limit the data set to noncardiac encounters. For the www.ajconline.org
2
The American Journal of Cardiology (www.ajconline.org)
Figure 1. Age at admission for patients with SV CHD (A) and those without CHD (B). Data from the UHC Clinical Data Base/Resource Manager used by permission of UHC. All rights reserved.
Congenital Heart Disease/Resource Use in SV Noncardiac Admissions
comparison group, the UHC CDB/RM was queried for patients without CHD, as defined by the 32nd Bethesda Conference, by excluding the appropriate ICD-9 codes.16 Primary diagnosis, age at admission, length of stay (LOS), direct hospital costs, ICU admission rate, mean ICU LOS, and mortality rate were collected. The 10 most common noncardiac admission diagnoses were identified for the patients with SV CHD, and the costs and outcomes were compared between SV CHD and patients without CHD using t tests for continuous variables and chi-square or Fisher’s exact test, as appropriate, for categorical variables. Results There were a total of 893,264 admissions for patients without CHD (median age 8.1 years, range 1 month to 18 years) and 2,515 noncardiac admissions for patients with SV CHD (median age 1.8 years, range 1 month to 18 years). Figure 1 shows the distribution of ages for both groups. Non-CHD admissions had a bimodal age distribution, whereas patients with SV CHD were skewed to younger ages. The 10 most common noncardiac admission diagnoses (and ICD-9 codes) are included in Table 1. The ICU admission and mortality rates for each diagnosis are presented in Table 1. ICU admission rates were significantly higher for all diagnoses for patients with SV CHD. With the exception of acute upper respiratory infection, asthma, dehydration, and fever, mortality rates were also higher in patients with SV CHD. Acute kidney injury (AKI) had the highest ICU admission rate and mortality in patients with SV CHD. Fifteen (88%) of the deaths in patients with SV CHD were in children aged <1 year. Direct costs were greater in patients with SV CHD for all diagnoses (Figure 2). AKI had the highest direct costs for patients with SV CHD, followed by esophageal reflux, and failure to thrive. The diagnoses with the highest direct costs for patients without SV CHD were the same, but these were significantly lower than for patients with SV CHD. Total LOS was significantly longer for all diagnoses for patients with SV CHD, with the exception of dehydration (Figure 3). AKI had the longest LOS for both SV CHD and patients without SV CHD. Discussion In this large retrospective database review, we were able to compare the admission rates, direct costs, LOS, ICU admission, and mortality rates for common noncardiac admissions for patients with SV CHD to those without CHD. The findings of this study show that there is significant HCRU for noncardiac hospital admissions in patients with SV CHD. LOS, direct cost, ICU admission rate, and mortality were higher for patients with SV CHD for almost all diagnoses compared with children without CHD. Characterization and recognition of how hospital resources are used has become an increasingly important aspect of patient management as health care costs have dramatically increased in recent decades. Even with, or perhaps because of, advancements in surgical techniques, costs of staged SV palliation have continued to increase.17 It is prudent, therefore, to understand the reasons why
3
Table 1 Common noncardiac admission diagnoses with costs and outcomes for patients with single ventricle congenital heart disease and those without congenital heart disease Admission diagnosis (ICD-9 code)
Non-CHD admissions (n ¼ 893,264)
Acute URI NOS (465.9) Admissions 7,774 (0.9%) ICU cases 10.3% Mean ICU days 2.32 Mortality 0% Acute kidney injury (584.9) Admissions 1,315 (0.2%) ICU cases 24.8% Mean ICU days 5.53 Mortality 0.9% Asthma NOS (493.90) Admissions 1,802 (0.2%) ICU cases 8.5% Mean ICU days 1.77 Mortality 0% Dehydration (276.51) Admissions 12,888 (1.4%) ICU cases 3.7% Mean ICU days 2.23 Mortality 0.1% Esophageal reflux (530.81) Admissions 5,004 (0.6%) ICU cases 13% Mean ICU days 4.49 Mortality 0% Failure to thrive (783.41) Admissions 4,593 (0.5%) ICU cases 4.1% Mean ICU days 5.13 Mortality 0% Fever NOS (780.60) Admissions 7,432 (0.8%) ICU cases 4.6% Mean ICU days 2.67 Mortality 0.1% Non-RSV bronchiolitis (466.19) Admissions 13,353 (1.5%) ICU cases 15.2% Mean ICU days 3.01 Mortality 0% Pneumonia organism NOS (486) Admissions 22,978 (2.6%) ICU cases 13.8% Mean ICU days 3.36 Mortality 0.2% RSV bronchiolitis (466.11) Admissions 19,945 (2.2%) ICU cases 19.4% Mean ICU days 4.19 Mortality 0.1%
SV CHD admissions (n ¼ 2,515)
p
108 (4%) 31% 3.15 1%
<0.001 <0.001 0.06
21 (1%) 70% 11.56 24%
<0.001 <0.001 <0.001
21 (1%) 33% 6.94 0%
<0.001 <0.001 1.000
72 (3%) 35% 1.98 0%
<0.001 <0.001 0.855
103 (4%) 52% 8.58 5%
<0.001 <0.001 <0.001
79 (3%) 40% 8.07 3.8%
<0.001 <0.001 <0.001
26 (1%) 28% 5.47 0%
0.27 <0.001 1.000
51 (2%) 43% 7.13 0%
0.03 <0.001 0.89
52 (2%) 29% 9.23 4%
0.11 0.002 <0.001
42 (2%) 50% 4.66 2%
0.06 <0.001 0.004
NOS ¼ not otherwise specified; RSV ¼ respiratory syncytial virus; URI ¼ upper respiratory infection. Data from the UHC Clinical Data Base/Resource Manager used by permission of UHC. All rights reserved.
resources are used so steps can be taken to decrease the factors that lead to increased costs.
4
The American Journal of Cardiology (www.ajconline.org)
Figure 2. Direct hospital costs (in dollars) for each noncardiac diagnosis. Patients with SV CHD are indicated with dark shaded columns, those without CHD are indicated with light shaded columns. Bars are the standard error of the mean. FTT ¼ failure to thrive; GER ¼ esophageal reflux; URI ¼ upper respiratory infection. Data from the UHC Clinical Data Base/Resource Manager used by permission of UHC. All rights reserved.
Our study better defines how pediatric patients with SV CHD use health care dollars. Direct hospital costs for noncardiac diagnoses in patients with SV CHD are consistently higher than patients without CHD. LOS and ICU admission rates were almost always greater for patients with SV CHD, and ICU admissions were associated with higher total hospital LOS. When taking into account that patients with SV pathology are at a similar, if not greater, risk of developing common conditions which require hospitalization, it can be extrapolated that patients with SV pathology will not only continue to require a significant amount of health care resources for their cardiac pathology but will also need increased resources for common, noncardiac issues. An important aspect of our study is the identification of the most common noncardiac admission diagnoses in this group of patients (Table 1). For primary care providers, treating patients with chronic diseases can be challenging. Improved survival of complex congenital heart lesions has created a group of patients that require close, collaborative outpatient management. This study underscores the importance of risk avoidance and identification of common ailments in this group of patients to prevent unneeded hospitalizations and subsequent resource utilization. In addition, our study shows that pediatric patients are at the greatest risk for hospital admission for noncardiac diagnoses before completing staged surgical palliation, with most admissions during the first year of life (Figure 1). This
is compared to the general pediatric population, which has a bimodal distribution of age at hospital admission (Figure 1). Furthermore, of the 17 deaths in the SV CHD during the study period, 15 of them occurred in patients aged<1 year. This emphasizes the fragility of patients with SV CHD in the interstage period for all types of mortality, not just perioperative. There are several limitations to this study. Administrative databases that rely on ICD-9 codes are limited by the lack of specific codes for all forms of CHD and the potential for coding errors. Studies have shown a wide variance in specificity and sensitivity in regards to the use of ICD-9 codes to identify cases of CHD.18,19 There are many other diagnoses that account for patients with SV anatomy (unbalanced AV septal defects, mitral atresia, pulmonary atresia/intact ventricular septum, and so on), but the limitations of ICD-9 codes made it difficult to include such patients in this study without including many patients without SV. Taking this limitation of the database into account, we chose to only query the database for the 3 ICD-9 codes based on previous studies of patients with SV anatomy.20,21 Because of our deidentified data query of the UHC CDB/ RM, we were unable to follow patients longitudinally, making it impossible to know which of the staged palliative procedures the patients had undergone. It is possible that some of these admissions were patients who were considered too high risk to complete staged palliation, making
Congenital Heart Disease/Resource Use in SV Noncardiac Admissions
5
Figure 3. Total hospital LOS for each noncardiac diagnosis. Patients with SV CHD are indicated with dark shaded columns, those without CHD are indicated with light shaded columns. Bars are the standard error of the mean. FTT ¼ failure to thrive; GER ¼ esophageal reflux; URI ¼ upper respiratory infection. Data from the UHC Clinical Data Base/Resource Manager used by permission of UHC. All rights reserved.
them overall sicker and potentially higher users of health care resources. However, this would not be expected to be a large enough portion of the patients with SV CHD to account for the differences identified in this study. Although UHC contains patient data from a large number of academic institutions, most large freestanding children’s hospitals are not included, which could limit the generalizability of the findings. However, freestanding children’s hospitals have been found to have higher total charges per admission compared with nonchildren’s hospitals, so the hospital costs in our study may be underestimates.22 Institutional protocols may also have an affect our findings as some institutions may admit interstage patients to the ICU regardless of the reason for hospitalization, which would increase hospital costs and ICU LOS. This may be a component of the wide variation of direct cost for each admission diagnosis. Furthermore, our data focus only on in-hospital resource utilization and does not include care in the outpatient setting or emergency department. It has been shown that younger patients with chronic conditions have a higher number of emergency room visits.23 Therefore, it is possible that the younger age at admission for the patients with SV CHD in our study led to an increase in cost and LOS; however, it should be noted that our data query did not include emergency room encounters, only hospital admissions. This study identified and characterized hospitalizations for noncardiac diagnoses in pediatric patients with SV CHD. These findings stress the importance of good access to
primary care for this patient population as many of the noncardiac diagnoses may be preventable with good outpatient management, averting the need for hospitalization. With this knowledge, future studies may be able to find additional strategies to mitigate the impact of these noncardiac diagnoses in this patient population. Disclosures The authors have no conflicts of interest to disclose. 1. McHugh KE, Hillman DG, Gurka MJ, Gutgesell HP. Three-stage palliation of hypoplastic left heart syndrome in the University HealthSystem Consortium. Congenit Heart Dis 2010;5:8e15. 2. O’Leary JM, Siddiqi OK, de Ferranti S, Landzberg MJ, Opotowsky AR. The changing demographics of congenital heart disease hospitalizations in the United States, 1998 through 2010. JAMA 2013;309: 984e986. 3. Marelli AJ, Ionescu-Ittu R, Mackie AS, Guo L, Dendukuri N, Kaouache M. Lifetime prevalence of congenital heart disease in the general population from 2000 to 2010. Circulation 2014;130:749e756. 4. Oster ME, Lee KA, Honein MA, Riehle-Colarusso T, Shin M, Correa A. Temporal trends in survival among infants with critical congenital heart defects. Pediatrics 2013;131:e1502ee1508. 5. Faraoni D, Nasr VG, DiNardo JA. Overall hospital cost estimates in children with congenital heart disease: analysis of the 2012 kid’s inpatient database. Pediatr Cardiol 2016;37:37e43. 6. Oster ME, Riehle-Colarusso T, Simeone RM, Gurvitz M, Kaltman JR, McConnell M, Rosenthal GL, Honein MA. Public health science agenda for congenital heart defects: report from a Centers for Disease Control and Prevention experts meeting. J Am Heart Assoc 2013;2: e000256.
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7. Connor JA, Gauvreau K, Jenkins KJ. Factors associated with increased resource utilization for congenital heart disease. Pediatrics 2005;116: 689e695. 8. Dean PN, Hillman DG, McHugh KE, Gutgesell HP. Inpatient costs and charges for surgical treatment of hypoplastic left heart syndrome. Pediatrics 2011;128:e1181ee1186. 9. Ermis P, Dietzman T, Franklin W, Kim J, Moodie D, Parekh D. Cardiac resource utilization in adults at a freestanding children’s hospital. Congenit Heart Dis 2014;9:178e186. 10. Furck AK, Uebing A, Hansen JH, Scheewe J, Jung O, Fischer G, Rickers C, Holland-Letz T, Kramer HH. Outcome of the Norwood operation in patients with hypoplastic left heart syndrome: a 12-year single-center survey. J Thorac Cardiovasc Surg 2010;139:359e365. 11. Lu Y, Agrawal G, Lin CW, Williams RG. Inpatient admissions and costs of congenital heart disease from adolescence to young adulthood. Am Heart J 2014;168:948e955. 12. Mackie AS, Pilote L, Ionescu-Ittu R, Rahme E, Marelli AJ. Health care resource utilization in adults with congenital heart disease. Am J Cardiol 2007;99:839e843. 13. Menon SC, Keenan HT, Weng HY, Lambert LM, Burch PT, Edwards R, Spackman A, Korgenski KE, Tani LY. Outcome and resource utilization of infants born with hypoplastic left heart syndrome in the Intermountain West. Am J Cardiol 2012;110:720e727. 14. Tibballs J, Kawahira Y, Carter BG, Donath S, Brizard C, Wilkinson J. Outcomes of surgical treatment of infants with hypoplastic left heart syndrome: an institutional experience 1983-2004. J Paediatr Child Health 2007;43:746e751. 15. Simeone RM, Oster ME, Cassell CH, Armour BS, Gray DT, Honein MA. Pediatric inpatient hospital resource use for congenital heart defects. Birth Defects Res A Clin Mol Teratol 2014;100:934e943.
16. Warnes CA, Liberthson R, Danielson GK, Dore A, Harris L, Hoffman JI, Somerville J, Williams RG, Webb GD. Task force 1: the changing profile of congenital heart disease in adult life. J Am Coll Cardiol 2001;37:1170e1175. 17. Czosek RJ, Anderson JB, Heaton PC, Cassedy A, Schnell B, Cnota JF. Staged palliation of hypoplastic left heart syndrome: trends in mortality, cost, and length of stay using a national database from 2000 through 2009. Am J Cardiol 2013;111:1792e1799. 18. Frohnert BK, Lussky RC, Alms MA, Mendelsohn NJ, Symonik DM, Falken MC. Validity of hospital discharge data for identifying infants with cardiac defects. J Perinatol 2005;25:737e742. 19. Gutgesell HP, Hillman DG, McHugh KE, Dean P, Matherne GP. Use of an administrative database to determine clinical management and outcomes in congenital heart disease. World J Pediatr Congenit Heart Surg 2011;2:593e596. 20. Collins RT 2nd, Fram RY, Tang X, Robbins JM, St John Sutton M. Hospital utilization in adults with single ventricle congenital heart disease and cardiac arrhythmias. J Cardiovasc Electrophysiol 2014;25: 179e186. 21. Seckeler MD, Moe TG, Thomas ID, Meziab O, Andrews J, Heller E, Klewer SE. Hospital resource utilization for common noncardiac diagnoses in adult survivors of single cardiac ventricle. Am J Cardiol 2015;116:1756e1761. 22. Merenstein D, Egleston B, Diener-West M. Lengths of stay and costs associated with children’s hospitals. Pediatrics 2005;115: 839e844. 23. Neuman MI, Alpern ER, Hall M, Kharbanda AB, Shah SS, Freedman SB, Aronson PL, Florin TA, Mistry RD, Berry JG. Characteristics of recurrent utilization in pediatric emergency departments. Pediatrics 2014;134:e1025ee1031.
Departments of aPediatrics and bPediatrics (Cardiology), University of Arizona, Tucson, Arizona. Manuscript received November 17, 2015; revised manuscript received and accepted February 23, 2016. See page 5 for disclosure information. *Corresponding author: Tel: (520) 694-8291; fax: (520) 626-5652. E-mail address: [email protected] (I.D. Thomas). 0002-9149/16/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjcard.2016.02.043
HCRU and outcomes for hospitalizations for common noncardiac diagnoses in pediatric patients with SV CHD in the United States. We hypothesized that resource utilization for noncardiac hospital admissions in pediatric patients with SV CHD would be higher than for children without CHD. Methods The University Health System Consortium (UHC) is an alliance of 115 academic medical centers and 165 affiliated hospitals. Their Clinical Data Base/Resource Manager (CDB/RM) is a large administrative database with discharge data from these institutions. After approval from the University of Arizona Institutional Review Board, we performed a retrospective review of deidentified discharge data from inpatient hospitalizations by querying the UHC CDB/ RM from January 2011 to December 2013 for patients aged 18 years at the time of hospital admission. Neonates (<30 days old) were excluded to minimize the inclusion of admissions for stage 1 palliation/Norwood procedure. Patients with SV were defined as having a primary or secondary admission diagnosis of hypoplastic left heart syndrome (ICD-9 code 746.7), tricuspid atresia (ICD-9 code 746.1), or common ventricle (ICD-9 code 745.3). To exclude admissions for staged surgical palliation, procedure codes associated with any stage of palliative surgery, as previously defined, were excluded.1 Admissions associated with procedural codes for cardiac catheterizations and electrophysiology procedures were also excluded to further limit the data set to noncardiac encounters. For the www.ajconline.org
2
The American Journal of Cardiology (www.ajconline.org)
Figure 1. Age at admission for patients with SV CHD (A) and those without CHD (B). Data from the UHC Clinical Data Base/Resource Manager used by permission of UHC. All rights reserved.
Congenital Heart Disease/Resource Use in SV Noncardiac Admissions
comparison group, the UHC CDB/RM was queried for patients without CHD, as defined by the 32nd Bethesda Conference, by excluding the appropriate ICD-9 codes.16 Primary diagnosis, age at admission, length of stay (LOS), direct hospital costs, ICU admission rate, mean ICU LOS, and mortality rate were collected. The 10 most common noncardiac admission diagnoses were identified for the patients with SV CHD, and the costs and outcomes were compared between SV CHD and patients without CHD using t tests for continuous variables and chi-square or Fisher’s exact test, as appropriate, for categorical variables. Results There were a total of 893,264 admissions for patients without CHD (median age 8.1 years, range 1 month to 18 years) and 2,515 noncardiac admissions for patients with SV CHD (median age 1.8 years, range 1 month to 18 years). Figure 1 shows the distribution of ages for both groups. Non-CHD admissions had a bimodal age distribution, whereas patients with SV CHD were skewed to younger ages. The 10 most common noncardiac admission diagnoses (and ICD-9 codes) are included in Table 1. The ICU admission and mortality rates for each diagnosis are presented in Table 1. ICU admission rates were significantly higher for all diagnoses for patients with SV CHD. With the exception of acute upper respiratory infection, asthma, dehydration, and fever, mortality rates were also higher in patients with SV CHD. Acute kidney injury (AKI) had the highest ICU admission rate and mortality in patients with SV CHD. Fifteen (88%) of the deaths in patients with SV CHD were in children aged <1 year. Direct costs were greater in patients with SV CHD for all diagnoses (Figure 2). AKI had the highest direct costs for patients with SV CHD, followed by esophageal reflux, and failure to thrive. The diagnoses with the highest direct costs for patients without SV CHD were the same, but these were significantly lower than for patients with SV CHD. Total LOS was significantly longer for all diagnoses for patients with SV CHD, with the exception of dehydration (Figure 3). AKI had the longest LOS for both SV CHD and patients without SV CHD. Discussion In this large retrospective database review, we were able to compare the admission rates, direct costs, LOS, ICU admission, and mortality rates for common noncardiac admissions for patients with SV CHD to those without CHD. The findings of this study show that there is significant HCRU for noncardiac hospital admissions in patients with SV CHD. LOS, direct cost, ICU admission rate, and mortality were higher for patients with SV CHD for almost all diagnoses compared with children without CHD. Characterization and recognition of how hospital resources are used has become an increasingly important aspect of patient management as health care costs have dramatically increased in recent decades. Even with, or perhaps because of, advancements in surgical techniques, costs of staged SV palliation have continued to increase.17 It is prudent, therefore, to understand the reasons why
3
Table 1 Common noncardiac admission diagnoses with costs and outcomes for patients with single ventricle congenital heart disease and those without congenital heart disease Admission diagnosis (ICD-9 code)
Non-CHD admissions (n ¼ 893,264)
Acute URI NOS (465.9) Admissions 7,774 (0.9%) ICU cases 10.3% Mean ICU days 2.32 Mortality 0% Acute kidney injury (584.9) Admissions 1,315 (0.2%) ICU cases 24.8% Mean ICU days 5.53 Mortality 0.9% Asthma NOS (493.90) Admissions 1,802 (0.2%) ICU cases 8.5% Mean ICU days 1.77 Mortality 0% Dehydration (276.51) Admissions 12,888 (1.4%) ICU cases 3.7% Mean ICU days 2.23 Mortality 0.1% Esophageal reflux (530.81) Admissions 5,004 (0.6%) ICU cases 13% Mean ICU days 4.49 Mortality 0% Failure to thrive (783.41) Admissions 4,593 (0.5%) ICU cases 4.1% Mean ICU days 5.13 Mortality 0% Fever NOS (780.60) Admissions 7,432 (0.8%) ICU cases 4.6% Mean ICU days 2.67 Mortality 0.1% Non-RSV bronchiolitis (466.19) Admissions 13,353 (1.5%) ICU cases 15.2% Mean ICU days 3.01 Mortality 0% Pneumonia organism NOS (486) Admissions 22,978 (2.6%) ICU cases 13.8% Mean ICU days 3.36 Mortality 0.2% RSV bronchiolitis (466.11) Admissions 19,945 (2.2%) ICU cases 19.4% Mean ICU days 4.19 Mortality 0.1%
SV CHD admissions (n ¼ 2,515)
p
108 (4%) 31% 3.15 1%
<0.001 <0.001 0.06
21 (1%) 70% 11.56 24%
<0.001 <0.001 <0.001
21 (1%) 33% 6.94 0%
<0.001 <0.001 1.000
72 (3%) 35% 1.98 0%
<0.001 <0.001 0.855
103 (4%) 52% 8.58 5%
<0.001 <0.001 <0.001
79 (3%) 40% 8.07 3.8%
<0.001 <0.001 <0.001
26 (1%) 28% 5.47 0%
0.27 <0.001 1.000
51 (2%) 43% 7.13 0%
0.03 <0.001 0.89
52 (2%) 29% 9.23 4%
0.11 0.002 <0.001
42 (2%) 50% 4.66 2%
0.06 <0.001 0.004
NOS ¼ not otherwise specified; RSV ¼ respiratory syncytial virus; URI ¼ upper respiratory infection. Data from the UHC Clinical Data Base/Resource Manager used by permission of UHC. All rights reserved.
resources are used so steps can be taken to decrease the factors that lead to increased costs.
4
The American Journal of Cardiology (www.ajconline.org)
Figure 2. Direct hospital costs (in dollars) for each noncardiac diagnosis. Patients with SV CHD are indicated with dark shaded columns, those without CHD are indicated with light shaded columns. Bars are the standard error of the mean. FTT ¼ failure to thrive; GER ¼ esophageal reflux; URI ¼ upper respiratory infection. Data from the UHC Clinical Data Base/Resource Manager used by permission of UHC. All rights reserved.
Our study better defines how pediatric patients with SV CHD use health care dollars. Direct hospital costs for noncardiac diagnoses in patients with SV CHD are consistently higher than patients without CHD. LOS and ICU admission rates were almost always greater for patients with SV CHD, and ICU admissions were associated with higher total hospital LOS. When taking into account that patients with SV pathology are at a similar, if not greater, risk of developing common conditions which require hospitalization, it can be extrapolated that patients with SV pathology will not only continue to require a significant amount of health care resources for their cardiac pathology but will also need increased resources for common, noncardiac issues. An important aspect of our study is the identification of the most common noncardiac admission diagnoses in this group of patients (Table 1). For primary care providers, treating patients with chronic diseases can be challenging. Improved survival of complex congenital heart lesions has created a group of patients that require close, collaborative outpatient management. This study underscores the importance of risk avoidance and identification of common ailments in this group of patients to prevent unneeded hospitalizations and subsequent resource utilization. In addition, our study shows that pediatric patients are at the greatest risk for hospital admission for noncardiac diagnoses before completing staged surgical palliation, with most admissions during the first year of life (Figure 1). This
is compared to the general pediatric population, which has a bimodal distribution of age at hospital admission (Figure 1). Furthermore, of the 17 deaths in the SV CHD during the study period, 15 of them occurred in patients aged<1 year. This emphasizes the fragility of patients with SV CHD in the interstage period for all types of mortality, not just perioperative. There are several limitations to this study. Administrative databases that rely on ICD-9 codes are limited by the lack of specific codes for all forms of CHD and the potential for coding errors. Studies have shown a wide variance in specificity and sensitivity in regards to the use of ICD-9 codes to identify cases of CHD.18,19 There are many other diagnoses that account for patients with SV anatomy (unbalanced AV septal defects, mitral atresia, pulmonary atresia/intact ventricular septum, and so on), but the limitations of ICD-9 codes made it difficult to include such patients in this study without including many patients without SV. Taking this limitation of the database into account, we chose to only query the database for the 3 ICD-9 codes based on previous studies of patients with SV anatomy.20,21 Because of our deidentified data query of the UHC CDB/ RM, we were unable to follow patients longitudinally, making it impossible to know which of the staged palliative procedures the patients had undergone. It is possible that some of these admissions were patients who were considered too high risk to complete staged palliation, making
Congenital Heart Disease/Resource Use in SV Noncardiac Admissions
5
Figure 3. Total hospital LOS for each noncardiac diagnosis. Patients with SV CHD are indicated with dark shaded columns, those without CHD are indicated with light shaded columns. Bars are the standard error of the mean. FTT ¼ failure to thrive; GER ¼ esophageal reflux; URI ¼ upper respiratory infection. Data from the UHC Clinical Data Base/Resource Manager used by permission of UHC. All rights reserved.
them overall sicker and potentially higher users of health care resources. However, this would not be expected to be a large enough portion of the patients with SV CHD to account for the differences identified in this study. Although UHC contains patient data from a large number of academic institutions, most large freestanding children’s hospitals are not included, which could limit the generalizability of the findings. However, freestanding children’s hospitals have been found to have higher total charges per admission compared with nonchildren’s hospitals, so the hospital costs in our study may be underestimates.22 Institutional protocols may also have an affect our findings as some institutions may admit interstage patients to the ICU regardless of the reason for hospitalization, which would increase hospital costs and ICU LOS. This may be a component of the wide variation of direct cost for each admission diagnosis. Furthermore, our data focus only on in-hospital resource utilization and does not include care in the outpatient setting or emergency department. It has been shown that younger patients with chronic conditions have a higher number of emergency room visits.23 Therefore, it is possible that the younger age at admission for the patients with SV CHD in our study led to an increase in cost and LOS; however, it should be noted that our data query did not include emergency room encounters, only hospital admissions. This study identified and characterized hospitalizations for noncardiac diagnoses in pediatric patients with SV CHD. These findings stress the importance of good access to
primary care for this patient population as many of the noncardiac diagnoses may be preventable with good outpatient management, averting the need for hospitalization. With this knowledge, future studies may be able to find additional strategies to mitigate the impact of these noncardiac diagnoses in this patient population. Disclosures The authors have no conflicts of interest to disclose. 1. McHugh KE, Hillman DG, Gurka MJ, Gutgesell HP. Three-stage palliation of hypoplastic left heart syndrome in the University HealthSystem Consortium. Congenit Heart Dis 2010;5:8e15. 2. O’Leary JM, Siddiqi OK, de Ferranti S, Landzberg MJ, Opotowsky AR. The changing demographics of congenital heart disease hospitalizations in the United States, 1998 through 2010. JAMA 2013;309: 984e986. 3. Marelli AJ, Ionescu-Ittu R, Mackie AS, Guo L, Dendukuri N, Kaouache M. Lifetime prevalence of congenital heart disease in the general population from 2000 to 2010. Circulation 2014;130:749e756. 4. Oster ME, Lee KA, Honein MA, Riehle-Colarusso T, Shin M, Correa A. Temporal trends in survival among infants with critical congenital heart defects. Pediatrics 2013;131:e1502ee1508. 5. Faraoni D, Nasr VG, DiNardo JA. Overall hospital cost estimates in children with congenital heart disease: analysis of the 2012 kid’s inpatient database. Pediatr Cardiol 2016;37:37e43. 6. Oster ME, Riehle-Colarusso T, Simeone RM, Gurvitz M, Kaltman JR, McConnell M, Rosenthal GL, Honein MA. Public health science agenda for congenital heart defects: report from a Centers for Disease Control and Prevention experts meeting. J Am Heart Assoc 2013;2: e000256.
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7. Connor JA, Gauvreau K, Jenkins KJ. Factors associated with increased resource utilization for congenital heart disease. Pediatrics 2005;116: 689e695. 8. Dean PN, Hillman DG, McHugh KE, Gutgesell HP. Inpatient costs and charges for surgical treatment of hypoplastic left heart syndrome. Pediatrics 2011;128:e1181ee1186. 9. Ermis P, Dietzman T, Franklin W, Kim J, Moodie D, Parekh D. Cardiac resource utilization in adults at a freestanding children’s hospital. Congenit Heart Dis 2014;9:178e186. 10. Furck AK, Uebing A, Hansen JH, Scheewe J, Jung O, Fischer G, Rickers C, Holland-Letz T, Kramer HH. Outcome of the Norwood operation in patients with hypoplastic left heart syndrome: a 12-year single-center survey. J Thorac Cardiovasc Surg 2010;139:359e365. 11. Lu Y, Agrawal G, Lin CW, Williams RG. Inpatient admissions and costs of congenital heart disease from adolescence to young adulthood. Am Heart J 2014;168:948e955. 12. Mackie AS, Pilote L, Ionescu-Ittu R, Rahme E, Marelli AJ. Health care resource utilization in adults with congenital heart disease. Am J Cardiol 2007;99:839e843. 13. Menon SC, Keenan HT, Weng HY, Lambert LM, Burch PT, Edwards R, Spackman A, Korgenski KE, Tani LY. Outcome and resource utilization of infants born with hypoplastic left heart syndrome in the Intermountain West. Am J Cardiol 2012;110:720e727. 14. Tibballs J, Kawahira Y, Carter BG, Donath S, Brizard C, Wilkinson J. Outcomes of surgical treatment of infants with hypoplastic left heart syndrome: an institutional experience 1983-2004. J Paediatr Child Health 2007;43:746e751. 15. Simeone RM, Oster ME, Cassell CH, Armour BS, Gray DT, Honein MA. Pediatric inpatient hospital resource use for congenital heart defects. Birth Defects Res A Clin Mol Teratol 2014;100:934e943.
16. Warnes CA, Liberthson R, Danielson GK, Dore A, Harris L, Hoffman JI, Somerville J, Williams RG, Webb GD. Task force 1: the changing profile of congenital heart disease in adult life. J Am Coll Cardiol 2001;37:1170e1175. 17. Czosek RJ, Anderson JB, Heaton PC, Cassedy A, Schnell B, Cnota JF. Staged palliation of hypoplastic left heart syndrome: trends in mortality, cost, and length of stay using a national database from 2000 through 2009. Am J Cardiol 2013;111:1792e1799. 18. Frohnert BK, Lussky RC, Alms MA, Mendelsohn NJ, Symonik DM, Falken MC. Validity of hospital discharge data for identifying infants with cardiac defects. J Perinatol 2005;25:737e742. 19. Gutgesell HP, Hillman DG, McHugh KE, Dean P, Matherne GP. Use of an administrative database to determine clinical management and outcomes in congenital heart disease. World J Pediatr Congenit Heart Surg 2011;2:593e596. 20. Collins RT 2nd, Fram RY, Tang X, Robbins JM, St John Sutton M. Hospital utilization in adults with single ventricle congenital heart disease and cardiac arrhythmias. J Cardiovasc Electrophysiol 2014;25: 179e186. 21. Seckeler MD, Moe TG, Thomas ID, Meziab O, Andrews J, Heller E, Klewer SE. Hospital resource utilization for common noncardiac diagnoses in adult survivors of single cardiac ventricle. Am J Cardiol 2015;116:1756e1761. 22. Merenstein D, Egleston B, Diener-West M. Lengths of stay and costs associated with children’s hospitals. Pediatrics 2005;115: 839e844. 23. Neuman MI, Alpern ER, Hall M, Kharbanda AB, Shah SS, Freedman SB, Aronson PL, Florin TA, Mistry RD, Berry JG. Characteristics of recurrent utilization in pediatric emergency departments. Pediatrics 2014;134:e1025ee1031.