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Excess Costs Associated With Complications and Prolonged Length of Stay

After Congenital Heart Surgery

Article in The Annals of Thoracic Surgery · November 2014

DOI: 10.1016/j.athoracsur.2014.06.032

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 Excess Costs Associated With Complications and
Prolonged Length of Stay After Congenital Heart
CONGENITAL HEART

Surgery
Sara K. Pasquali, MD, MHS, Xia He, MS, Marshall L. Jacobs, MD,
Samir S. Shah, MD, MSCE, Eric D. Peterson, MD, MPH, Michael G. Gaies, MD, MPH,
Matthew Hall, PhD, J. William Gaynor, MD, Kevin D. Hill, MD, MS, John E. Mayer, MD,
Jennifer S. Li, MD, MHS, and Jeffrey P. Jacobs, MD
Department of Pediatrics, University of Michigan C. S. Mott Children’s Hospital, Ann Arbor, Michigan; Duke Clinical Research
Institute, Duke University Medical Center, Durham, North Carolina; Department of Surgery, Johns Hopkins University School of
Medicine, Baltimore, Maryland; Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; Children’s
Hospital Association, Overland Park, Kansas; Department of Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania;
and Department of Cardiac Surgery, Children’s Hospital Boston, Boston, Massachusetts

Background. While there is an increasing emphasis on complications, renal failure, and unplanned reoperation
both optimizing quality of care and reducing health care or reintervention (ranging from $57,137 to $179,350). Pa-
costs, there are limited data regarding how to best achieve tients with an additional day of LOS above the median
these goals for common and resource-intense conditions had an average excess cost per case of $19,273 (D$40,688
such as congenital heart disease. We evaluated excess for LOS 4 to 7 days above median). Potential cost savings
costs associated with complications and prolonged length in the study cohort achievable through reducing major
of stay (LOS) after congenital heart surgery in a large complications (by 10%) and LOS (by 1 to 3 days) were
multicenter cohort. greatest for the Norwood operation ($7,944,128 and
Methods. Clinical data from The Society of Thoracic $3,929,351, respectively) and several other commonly
Surgeons Database were linked to estimated costs from the performed operations of more moderate complexity.
Pediatric Health Information Systems Database (2006 to Conclusions. Complications and prolonged LOS after
2010). Excess cost per case associated with complications congenital heart surgery are associated with significant
and prolonged LOS was modeled for 9 operations of vary- costs. Initiatives able to achieve even modest reductions
ing complexity adjusting for patient baseline characteristics. in these morbidities may lead to both improved outcomes
Results. Of 12,718 included operations (27 centers), and cost savings across both moderate and high
average excess cost per case in those with any complica- complexity operations.
tion (versus none) was $56,584 (D$132,483 for major
complications). The 5 highest cost complications were (Ann Thorac Surg 2014;98:1660–6)
tracheostomy, mechanical circulatory support, respiratory Ó 2014 by The Society of Thoracic Surgeons

I n this era of rising health care expenditures, hospitals

face increasing pressure to provide high quality care
at low cost [1]. Congenital heart disease is known to
that may lead to both improved outcomes, and the
greatest potential cost savings, is crucial in informing
initiatives focused on delivering high value care to these
be a commonly treated and resource-intense condition patients. In addition, this information could also provide
across US children’s hospitals, compared with other insight into whether children’s hospitals, pediatric heart
birth defects and pediatric diseases [2, 3]. In addition, programs, and other stakeholders participating in qual-
it has recently been demonstrated that there is sig- ity improvement collaboratives and other initiatives
nificant variation in the cost of surgical care for these could expect to offset participation costs through po-
patients across hospitals, related in part to differences tential savings related to reduction in postoperative
in postoperative complication rates and length of stay morbidities [5].
(LOS) [4]. Therefore, the purpose of this study was to describe
However, the specific costs associated with common excess costs associated with prolonged LOS and post-
postoperative morbidities remain undefined across the operative complications across a wide spectrum of
spectrum of congenital heart surgery. Identifying targets congenital heart operations. We utilized a unique multi-
center dataset consisting of linked clinical information
Accepted for publication June 3, 2014. from the Society of Thoracic Surgeons Congenital Heart
Surgery (STS-CHS) Database and resource utilization
Address correspondence to Dr Pasquali, C.S. Mott Children’s Hospital,
1540 E Hospital Dr, Ann Arbor, MI 48105; e-mail: [email protected]. data from the Pediatric Health Information Systems
edu. (PHIS) Database.

Ó 2014 by The Society of Thoracic Surgeons 0003-4975/$36.00

Published by Elsevier http://dx.doi.org/10.1016/j.athoracsur.2014.06.032
Ann Thorac Surg PASQUALI ET AL 1661
2014;98:1660–6 EXCESS COSTS AFTER CONGENITAL HEART SURGERY

Material and Methods Data Collection

Data Source Data collected from the STS-CHS database included de-
mographics, standard STS-defined preoperative risk fac-
The STS-CHS and PHIS data were linked at the patient-
tors, noncardiac or genetic abnormalities, presence of
level using the method of indirect identifiers as previ-

CONGENITAL HEART
prematurity, history of previous cardiothoracic surgery,
ously described and verified [6, 7]. The STS-CHS
diagnosis and procedure data as described above, post-
database is the largest existing pediatric heart surgery
operative complications, and LOS [9]. Both the occur-
registry, and collects perioperative data on all children
rence of any postoperative complication collected and
undergoing heart surgery at greater than 100 North
defined in the STS-CHS Database, and major complica-
American centers. Data quality is evaluated through
tions were evaluated. Major complications included renal
intrinsic data verification (eg, identification and correc-
failure requiring dialysis, neurologic deficit persisting at
tion of missing or out of range values and inconsistencies
discharge, arrhythmia requiring permanent pacemaker,
across fields), and random site audits at 10% of partici-
mechanical circulatory support, phrenic nerve injury/
pating institutions annually. The PHIS database is a large
paralyzed diaphragm, and unplanned reoperation or
administrative database that collects hospital billing in-
reintervention [8].
formation from greater than 40 US children’s hospitals.
Resource utilization information collected from the
Systematic monitoring in the PHIS database includes
PHIS database included payer type (government, private,
coding consensus meetings, consistency reviews, and
and other) and total hospital charges. As described pre-
quarterly data quality reports. Linking these datasets
viously, costs were estimated using hospital and
enabled us to capitalize on the strengths of both datasets,
department-specific cost-to-charge ratios, adjusted for
including the detailed clinical information and data on
regional differences using the Centers for Medicare and
postoperative morbidities in the STS-CHS database and
Medicaid Services price and wage index, and indexed to
resource utilization information in the PHIS database [6].
2010 dollars [4]. Of note, professional fees are not
This study was not considered human subjects research
included in most administrative datasets, including the
by the Duke Institutional Review Board in accordance
PHIS database, and thus were not included in this
with the Common Rule (45 CFR 46.102(f)).
analysis.

Study Population Analysis

As described previously, hospitals participating in both Study population characteristics were described using
the STS-CHS and PHIS databases from 2006 to 2010 were standard summary statistics. Unadjusted rates of com-
eligible for inclusion (n ¼ 33 hospitals) [4]. Hospitals that plications, median LOS, and total hospital costs were also
did not report resource utilization data (n ¼ 1 hospital) described for the 9 operations. In our evaluation of
and those with greater than 15% missing data for any adjusted excess costs associated with complications and
preoperative variables or outcomes and cost data prolonged LOS, we fitted procedure-specific negative
described below (n ¼ 5 hospitals) were excluded. From binomial models (with log-link functions to account for
the remaining 27 hospitals, patients undergoing 9 oper- the skewed cost distribution). We evaluated both those
ations of varying complexity were included. These with any complication and those with major complica-
included the STS benchmark operations; ventricular tions (versus no complications) and the LOS data were
septal defect (VSD) repair, tetralogy of Fallot repair divided into 5 groups for the purposes of analysis; less
(excluding pulmonary atresia or absent pulmonary valve, than or equal to procedure-specific median LOS,
or atrioventricular canal repair), complete atrioventricular and þ1, þ2–3, þ4–7, þ8 or more days above the median
canal repair, arterial switch operation (ASO)  VSD LOS. The method of generalized estimating equations
repair, Fontan operation (including lateral tunnel and with robust standard error estimates was used in order to
extracardiac conduit  fenestration; excluding Fontan account for within-center clustering. All models were
revision), truncus arteriosus repair (excluding concomi- adjusted for important patient characteristics including
tant truncal valve repair or replacement or interrupted age, weight, sex, race, prematurity, the presence of any
aortic arch repair), and the Norwood operation (including noncardiac or genetic abnormality or STS-defined pre-
either systemic-to-pulmonary artery shunt or right operative risk factor, previous cardiothoracic surgery,
ventricle-to-pulmonary artery conduit) [8]. In addition to payer type, and year of surgery. VSD repair was also
these benchmark operations we also included atrial septal included in the ASO models and the presence of con-
defect (ASD) repair and bidirectional Glenn/hemi- current atrioventricular valvuloplasty was included in the
Fontan. Of the 13,013 eligible patients, those with models for Fontan and bidirectional Glenn/hemi-Fontan.
missing data for any of the outcomes described below Adjusted ratios of cost in those with and without compli-
were excluded (n ¼ 295 patients). For the purposes of cations and in those in the various LOS groups versus those
this study we included all patients regardless of survival with median LOS or less were calculated as the expo-
status, as our previous work has demonstrated that nentials of the estimated regression coefficients. Adjusted
complications can be associated with higher costs both procedure-specific excess cost associated with prolonged
on a patient and hospital level regardless of survival to LOS or complications was then defined as the follow-
discharge [4]. ing: adjusted excess cost ¼ median procedure-specific
 1662 PASQUALI ET AL Ann Thorac Surg
EXCESS COSTS AFTER CONGENITAL HEART SURGERY 2014;98:1660–6

cost * (adjusted ratio of cost – 1). For the purposes of this Table 1. Study Population Characteristics
analysis, the LOS and complication variables were added
Variable n ¼ 12,718 (27 centers)
in to separate models and evaluated individually. In
addition, we also evaluated costs associated with specific Age 4.4 months (77 days–2.1 years)
CONGENITAL HEART

complications of interest. These models were adjusted for Weight (kg) 6.1 (4.1–11.0)
the same variables described above, and the estimates Sex, female 5,777 (45.4%)
represent cost in those patients with a particular com- Race/ethnicity
plication versus those without (regardless of other com- Non-Hispanic white 6,636 (52.2%)
plications which may have occurred). This approach was Other 6,082 (47.8%)
taken as we felt it was difficult clinically to justify Prematurity 863 (6.8%)
“adjusting away” the impact of other likely interrelated Any STS preoperative factor 2,595 (20.4%)
complications. For the LOS data we also performed a Any non-cardiac/genetic 3,720 (29.2%)
sensitivity analysis, including adjustment for complica- abnormality
tions within these models, in an attempt to better assess Previous cardiothoracic surgery 3,457 (27.2%)
the impact of prolonged LOS alone on costs. Payer type
Finally, we estimated the potential cost savings over the Government 5,620 (44.2%)
study period that might be achieved with in the study Private 4,526 (35.6%)
cohort through reducing complications or LOS, taking Other 2,572 (20.2%)
into account the prevalence of the operation, the preva- Operation type
lence of complication or prolonged LOS, and the point
ASD repair 1,581 (12.4%)
estimates for excess cost from our models described
VSD repair 2,669 (21.0%)
above. For complications we estimated the potential cost
TOF repair 1,560 (12.3%)
savings for each operation if major complications were
Fontan 1,542 (12.1%)
reduced by 10%. For LOS we estimated the potential cost
BDG/Hemi-Fontan 1,692 (13.3%)
savings if those with a LOS þ1 to 3 days above the median
were reduced to the average LOS in those with the me- CAVC repair 1,150 (9.0%)
dian LOS or less, as we hypothesized that these cases may ASO 1,128 (8.9%)
be more amenable to intervention rather than those with Truncus repair 226 (1.8%)
substantially prolonged LOS, which may be more related Norwood 1,170 (9.2%)
to comorbidities that are less modifiable [10]. All analyses Data are presented as median (interquartile range), or n (%).
were performed using SAS version 9.3 (SAS Institute Inc,
ASD ¼ atrial septal defect; ASO ¼ arterial switch operation; BDG ¼
Cary, NC). A p value less than 0.05 was considered sta- bidirectional Glenn; CAVC ¼ complete atrioventricular ca-
tistically significant. nal; STS ¼ The Society of Thoracic Surgeons; TOF ¼ tetralogy of
Fallot; VSD ¼ ventricular septal defect.

Results
Study Population Characteristics ranged from $16,097 (ASD repair) to $146,571 (truncus
arteriosus repair). The average excess cost per case
A total of 12,718 patients from 27 centers were included.
associated with major complications was higher
Study population characteristics are displayed in Table 1.
($132,483), ranging from $52,127 (VSD repair) to $261,188
Compared with the overall national cohort of hospitals
(truncus arteriosus repair).
participating in the STS-CHS database during the study
Costs associated with specific types of complications
period (n ¼ 108), the 27 included hospitals had a higher
are displayed in Table 4. Complications associated with
average annual surgical volume (360 vs 175 cases/year)
the highest excess cost per case were tracheostomy, me-
and included more centers in the Midwest (37% vs 22%).
chanical circulatory support, respiratory complications,
Complication rates, median postoperative LOS, and
renal failure, and unplanned re-operation/intervention.
median cost per case for each of the 9 operations are
displayed in Table 2. As expected each of these increased
with operation complexity, from a major complication Excess Cost Associated With Prolonged Postoperative
rate of 0.6%, median LOS of 3 days, and median total Length of Stay
hospital cost per case of $25,499 for ASD repair to 32.2%, The excess cost per case associated with prolonged LOS
29 days, and $165,168, respectively, for the Norwood for each operation is displayed in Table 5. Across opera-
operation. The overall rate of complications was 43% and tions, the average excess cost per cases in those with an
overall rate of major complications was 9%. additional day of LOS above the median versus those
with a LOS equal to or less than the median was $19,273,
Excess Cost Associated With Complications ranging from $1,912 (ASD repair) to $51,597 (truncus
The excess cost per case associated with postoperative arteriosus repair). The average excess cost associated with
complications for each operation is displayed in Table 3. a LOS 4 to 7 additional days above the median was
Across operations the average excess cost per case in $40,688, and $181,043 on average for greater than 7 days
patients with any postoperative complication compared above the median. In a sensitivity analysis where the LOS
with those without a complication was $56,584 and models were adjusted for complications (in order to
Ann Thorac Surg PASQUALI ET AL 1663
2014;98:1660–6 EXCESS COSTS AFTER CONGENITAL HEART SURGERY

Table 2. Overall Complication Rates, Length of Stay, and Cost by Operation

Operation Any Complications Major Complications Postoperative LOS (days) Cost/Case

ASD repair 211 (13.3%) 10 (0.6%) 3 (3–4) $25,499 (20,645–30,962)

CONGENITAL HEART
VSD repair 757 (28.4%) 68 (2.5%) 5 (4–8) $33,679 (26,915–47,381)
TOF repair 660 (42.3%) 88 (5.6%) 7 (5–10) $44,318 (34,743–63,808)
Fontan 869 (56.4%) 144 (9.3%) 9 (7–14) $51,464 (39,976–74,640)
BDG/hemi-Fontan 673 (39.8%) 121 (7.2%) 7 (5–12) $44,893 (33,695–69,400)
CAVC repair 603 (52.4%) 89 (7.7%) 8 (6–16) $49,445 (36,293–80,545)
ASO 597 (52.9%) 145 (12.9%) 17 (13–24) $94,902 (70,357–129,984)
Truncus repair 150 (66.4%) 53 (23.5%) 25 (14–47) $133,006 (90,189–204,006)
Norwood 887 (75.8%) 377 (32.2%) 29 (19–49) $165,168 (110,446–257,980)

Data are presented as median (interquartile range), or n (%).

ASD ¼ atrial septal defect; ASO ¼ arterial switch operation; BDG ¼ bidirectional Glenn; CAVC ¼ complete atrioventricular canal; LOS ¼
length of stay; TOF ¼ tetralogy of Fallot; VSD ¼ ventricular septal defect.

better assess the impact of LOS alone), values for cost with a LOS 1 to 3 days above the median to the median
associated with prolonged LOS were slightly lower across LOS or less. Similar potential cost savings were seen for
operations. For example, the average excess cost per case the Norwood operation and many commonly performed
in those with an additional day of LOS above the median moderate and lower complexity operations. Potential
was $17,836 (compared with $19,273 in the original savings for truncus arteriosus repair were relatively low
models as noted above), ranging from $1,959 (ASD repair) compared with other operations given the relative infre-
to $50,573 (truncus arteriosus repair). quency with which this operation is performed.

Estimates of Cost Savings

Comment
Finally, we estimated the potential cost savings over the
study period (in the cohort of included hospitals) that This large multicenter analysis describes costs associated
might be achieved through reducing complications or with complications and prolonged LOS across the spec-
postoperative LOS, based on both the prevalence of the trum of congenital heart surgery. Although it is known
operation, the prevalence of complications and prolonged that the surgical treatment of congenital heart disease is
LOS, and the cost estimates derived from our models costly, there has been limited information available to
described above. The estimated cost savings in the study policy makers, hospitals, and providers regarding which
cohort that might be achieved through reducing major areas may be targeted to achieve the greatest improve-
complications by 10% was greatest for the Norwood ment in both the domains of quality and cost in order to
operation ($7,944,128) [Table 6]. However, potential cost optimize “value” [1–3]. We previously demonstrated that
savings were also substantial for some of the more the wide variation in costs across hospitals performing
moderate complexity but frequently performed opera- congenital heart surgery is driven to a large extent by
tions. In our evaluation of LOS, we assessed the potential differences in the rate of postoperative complications, and
cost savings achieved through reducing LOS in those average LOS [4]. For example, high cost (versus low cost)

Table 3. Adjusted Excess Cost per Case Associated With Complications

Any Lower Upper Major Lower Upper
Operation Complication 95% CI 95% CI Complication 95% CI 95% CI

ASD repair $16,097 $7,029 $27,691 $76,319 $21,354 $195,764

VSD repair $19,902 $14,784 $25,559 $52,127 $34,284 $74,654
TOF repair $26,886 $20,006 $34,503 $75,161 $42,516 $120,080
Fontan $33,065 $24,156 $43,023 $104,485 $73,768 $142,737
BDG/hemi-Fontan $46,844 $30,009 $67,463 $134,202 $85,041 $201,962
CAVC repair $46,795 $36,592 $58,207 $135,263 $99,314 $179,900
ASO $53,790 $35,335 $74,860 $142,736 $109,643 $181,183
Truncus repair $146,571 $103,521 $197,455 $261,188 $184,575 $356,282
Norwood $119,303 $81,948 $162,306 $210,865 $154,452 $277,234

Data represent cost per case in those with any or major complications versus no complications.
ASD ¼ atrial septal defect; ASO ¼ arterial switch operation; CAVC ¼ complete atrioventricular canal; CI ¼ confidence interval; TOF ¼
tetralogy of Fallot; VSD ¼ ventricular septal defect.
 1664 PASQUALI ET AL Ann Thorac Surg
EXCESS COSTS AFTER CONGENITAL HEART SURGERY 2014;98:1660–6

Table 4. Adjusted Excess Cost per Case Associated With Specific Complications
Complication n (%) Excess Cost/Case Lower 95% CI Upper 95% CI

Tracheostomy 29 (0.2%) $179,350 $132,958 $237,769

CONGENITAL HEART

Mechanical circulatory support 263 (2.1%) $68,964 $53,020 $87,475

Respiratory 953 (7.5%) $67,149 $53,720 $82,386
Renal failure 138 (1.15) $65,042 $45,232 $89,152
Reoperation/reintervention 662 (5.2%) $57,137 $47,419 $67,866
Neurologic 209 (1.6%) $50,649 $29,498 $77,724
Infectious 511 (4.0%) $49,968 $41,464 $59,298
Cardiac arrest 246 (1.9%) $42,366 $29,271 $57,739
Phrenic/recurrent laryngeal nerve injury 241 (1.9%) $37,271 $23,370 $53,958
Pleural effusion/chylothorax 959 (7.5%) $30,356 $24,132 $37,132

Top 10 high cost complications listed.

Certain individual complications were grouped for the purposes of analysis: respiratory complications (respiratory insufficiency requiring mechanical
ventilator support >7 days or reintubation), renal failure (requiring temporary or permanent dialysis), reoperation or reintervention (reoperation due to
bleeding or unplanned cardiac reoperation or interventional cardiac catheterization), neurologic (transient or persistent neurologic deficit, seizure, or
stroke), infectious (mediastinitis, wound infection, pneumonia, sepsis, or endocarditis).

CI ¼ confidence interval.

hospitals had a major complication rate after the Nor- previous single-center study evaluating children under-
wood operation of 50% versus 25% and an average going ASD and VSD repair demonstrated that LOS (and
postoperative LOS of 50.8 days versus 31.8 days [4]. associated hospital costs) could be reduced by standard-
Benavidez and colleagues [11] utilized a large adminis- ization of care involving practices aimed at early extu-
trative dataset to evaluate hospital charges associated bation and mobilization [15]. Thus, it appears that LOS
with complications among 10,602 children undergoing can be reduced through other mechanisms aside from
heart surgery, and reported that complications were indirect improvements through reducing complications.
associated with higher charges. In adult surgical subspecialties, multicenter quality
The present analysis leverages a unique linked dataset improvement collaboratives have proven to be successful
consisting of merged clinical registry and administrative models for sharing best practices across hospitals and
data in order to perform a detailed evaluation of costs reducing variation in outcomes and cost [16, 17]. For
associated with specific postoperative morbidities across example, a statewide collaborative in Michigan is esti-
the spectrum congenital heart surgery. This approach mated to reduce complications after general and vascular
helps to overcome limitations associated with the use of surgery in approximately 2,500 patients each year,
administrative data alone, which include issues related to resulting in an annual savings of approximately $20
accurate case ascertainment, appropriate adjustment for million [16]. New initiatives in the field of pediatric car-
case mix and patient characteristics, and accurate diology and cardiac surgery, such as those sponsored by
assessment of postoperative complications [12–14]. In our the Pediatric Heart Network and the Pediatric Cardiac
merged dataset, the detailed information available in the Critical Care Consortium (PC4), aim to employ similar
clinical registry data allow a precise evaluation of specific approaches involving implementation of data-driven best
congenital heart operations and postoperative complica- practices across centers and subsequent evaluation of
tions, as well as more detailed adjustment for patient risk outcomes and resource utilization [18]. It should be noted
factors, while the administrative data provide valuable that participating in these initiatives can also often
resource utilization data. involve a cost to the institution, most often including an
The results of our study suggest that quality improve- annual fee on the order of $5,000 to $10,000, and salary
ment efforts aimed at reducing postoperative complica- associated with data entry personnel. The present study
tions and LOS may have the potential to reduce costs. and data from the adult collaboratives suggest that these
Even modest reductions in major complication rates costs may be offset if participation leads to successful
(w10%) and LOS (1 to 3 days) were estimated to be reduction in complications or LOS in even a handful of
associated with substantial savings. Finally, our findings patients each year [16, 17].
also indicate that while potential cost savings are highest
for the Norwood operation, initiatives focused on lower Limitations
complexity but commonly performed operations may Our analysis was limited to centers participating in both
also result in significant savings. the STS-CHS and PHIS databases during the study
Although these data may provide useful information period and thus may not be generalizable to all US pe-
regarding where to best focus efforts aimed at improving diatric heart programs. Ongoing expansion of linkages
both quality and cost further investigation is needed to between clinical registry and administrative data will
understand practical strategies to achieve these goals. A facilitate the inclusion of additional centers in the future.
Ann Thorac Surg PASQUALI ET AL 1665
2014;98:1660–6 EXCESS COSTS AFTER CONGENITAL HEART SURGERY

Table 5. Adjusted Excess Cost per Case Associated With Table 6. Estimated Cost Savings
Prolonged Length of Stay
Estimated Cost Savings During the
Additional Study Perioda
Days Excess Lower Upper
> Median If Major If Those With

CONGENITAL HEART
Operation Cost/Case 95% CI 95% CI
Complications LOS þ1 to 3 Days
ASD repair þ1 $1,912 $2,007 $6,484 Operation Reduced by 10% Reduced to  Median
þ2–3 $5,723 $1,014 $11,268
ASD repair $72,396 $1,550,529
þ4–7 $17,203 $9,212 $27,034
VSD repair $347,817 $3,862,510
>7 $123,896 $79,100 $187,877
TOF repair $656,606 $3,753,565
VSD repair þ1 $5,476 $2,092 $9,180
Fontan $1,498,377 $3,638,318
þ2–3 $10,661 $6,010 $15,857
BDG/hemi-Fontan $1,634,902 $3,628,331
þ4–7 $22,783 $18,553 $27,355
CAVC repair $1,197,753 $3,185,342
>7 $101,246 $86,279 $118,081
ASO $2,076,980 $4,198,048
TOF repair þ1 $12,130 $6,045 $18,951
Truncus repair $1,387,169 $795,235
þ2–3 $16,469 $10,629 $22,930
Norwood $7,944,128 $3,929,351
þ4–7 $33,004 $26,832 $39,711
a
>7 $134,040 $105,467 $168,062 In the hospitals included in the study cohort.
Fontan þ1 $11,096 $6,904 $15,588 ASD ¼ atrial septal defect; ASO ¼ arterial switch operation; BDG ¼
þ2–3 $16,062 $11,152 $21,357 bidirectional Glenn; CAVC ¼ complete atrioventricular canal; LOS ¼
length of stay; TOF ¼ tetralogy of Fallot; VSD ¼ ventricular septal
þ4–7 $26,845 $18,788 $35,827 defect.
>7 $112,903 $93,718 $134,623
BDG/ þ1 $11,543 $7,524 $15,870
hemi-Fontan þ2–3 $17,919 $13,378 $22,813 operations, and of outpatient resource utilization will also
þ4–7 $32,759 $27,922 $37,917 be necessary. Finally, further development of methods
>7 $160,597 $127,862 $199,534 that standardize line item costs may allow better delin-
CAVC repair þ1 $16,904 $10,474 $24,023
eation of true resource use through further removing
interinstitutional variability in item costs, and future
þ2–3 $25,534 $20,709 $30,691
study of payments or reimbursements from large payer
þ4–7 $35,073 $28,809 $41,839
datasets may allow further analysis from the insurer or
>7 $178,721 $152,682 $208,114
consumer’s perspective [2, 5].
ASO þ1 $19,007 $9,905 $28,899
þ2–3 $39,090 $31,162 $47,515
Conclusions
þ4–7 $57,517 $46,172 $69,775
This multicenter analysis suggests that initiatives able to
>7 $189,085 $153,923 $229,216
achieve even modest reductions in complication rates and
Truncus repair þ1 $51,597 $8,245 $108,255
postoperative LOS may lead to reductions in costs for
þ2–3 $54,637 $22,981 $92,717
both high complexity operations such as the Norwood
þ4–7 $61,825 $30,748 $98,800
operation as well as lower complexity but more
>7 $340,298 $268,188 $425,369 commonly performed surgeries. Further investigation is
Norwood þ1 $43,789 $9,783 $84,405 needed to evaluate whether standardization of care,
þ2–3 $77,795 $38,108 $125,230 adoption of data-driven best practices across institutions,
þ4–7 $79,185 $46,383 $117,072 and other strategies commonly employed by quality
>7 $288,601 $235,308 $348,987 improvement initiatives to reduce postoperative mor-
bidities and costs in other fields are also effective in the
ASD ¼ atrial septal defect; ASO ¼ arterial switch operation; BDG ¼
bidirectional Glenn; CAVC ¼ complete atrioventricular canal; CI ¼ congenital heart surgery population and can offset the
confidence interval; TOF ¼ tetralogy of Fallot; VSD ¼ ventricular cost of participating in these initiatives.
septal defect.

Funding sources: National Heart, Lung, and Blood Institute

(K08HL103631, PI: S.K. Pasquali; RC1HL099941, co-PIs: J.P.
While our estimates suggest that reductions in compli- Jacobs, J.S. Li).
cation rates and LOS may result in decreased resource
utilization, prospective studies are necessary to confirm
whether this is the case, and whether standardization of
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Notice From the American Board of

Thoracic Surgery
The 2014 Part I (written) examination will be held A candidate applying for admission to the certi-
on Monday, November 17, 2014, at multiple sites fying examination must fulfill all the requirements of
throughout the United States using an electronic the Board in force at the time the application is
format. The closing date for registration was August 15, received.
2014. Those wishing to be considered for examination Please address all communications to the American
must apply online at www.abts.org. To be admissible to Board of Thoracic Surgery, 633 N St. Clair St, Suite
the Part II (oral) examination, a candidate must have 2320, Chicago, IL 60611; telephone: (312) 202-5900;
successfully completed the Part I (written) examination. fax: (312) 202-5960; e-mail: [email protected].

Ó 2014 by The Society of Thoracic Surgeons Ann Thorac Surg 2014;98:1666  0003-4975/$36.00
Published by Elsevier

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