Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina.
Department of Pediatrics, Children's Healthcare of Atlanta and Emory University, Atlanta, Georgia.
Ann Thorac Surg. 2019 May;107(5):1421-1426. doi: 10.1016/j.athoracsur.2018.10.019. Epub 2018 Nov 17.
The Pediatric Heart Network Collaborative Learning Study (PHN CLS) increased early extubation rates after infant tetralogy of Fallot (TOF) and coarctation of the aorta (CoA) repair across participating sites by implementing a clinical practice guideline (CPG). The impact of the CPG on hospital costs has not been studied.
PHN CLS clinical data were linked to cost data from Children's Hospital Association by matching on indirect identifiers. Hospital costs were evaluated across active and control sites in the pre- and post-CPG periods using generalized linear mixed-effects models. A difference-in-difference approach was used to assess whether changes in cost observed in active sites were beyond secular trends in control sites.
Data were successfully linked on 410 of 428 eligible patients (96%) from four active and four control sites. Mean adjusted cost per case for TOF repair was significantly reduced in the post-CPG period at active sites ($42,833 vs $56,304, p < 0.01) and unchanged at control sites ($47,007 vs $46,476, p = 0.91), with an overall cost reduction of 27% in active versus control sites (p = 0.03). Specific categories of cost reduced in the TOF cohort included clinical (-66%, p < 0.01), pharmacy (-46%, p = 0.04), lab (-44%, p < 0.01), and imaging (-32%, p < 0.01). There was no change in costs for CoA repair at active or control sites.
The early extubation CPG was associated with a reduction in hospital costs for infants undergoing repair of TOF but not CoA. This CPG represents an opportunity to both optimize clinical outcome and reduce costs for certain infant cardiac surgeries.
儿科心脏网络协作学习研究（PHN CLS）通过实施临床实践指南（CPG），提高了婴儿法洛四联症（TOF）和主动脉缩窄（CoA）修复术后的早期拔管率，这一结果在参与的各个中心都得到了体现。然而，CPG 对医院成本的影响尚未得到研究。
通过间接标识符匹配，将 PHN CLS 临床数据与儿童医院协会的成本数据相链接。使用广义线性混合效应模型，在 CPG 实施前后的活跃和对照中心评估医院成本。采用差异法来评估在活跃中心观察到的成本变化是否超出了对照中心的季节性趋势。
成功链接了来自四个活跃中心和四个对照中心的 410 名符合条件的患者中的 428 名患者（96%）。TOF 修复术后的 CP 期，活跃中心的每例病例调整后成本显著降低（42833 美元 vs 56304 美元，p < 0.01），而对照中心的成本不变（47007 美元 vs 46476 美元，p = 0.91），活跃中心与对照中心的总成本降低了 27%（p = 0.03）。TOF 队列中降低的成本包括临床费用（-66%，p < 0.01）、药房费用（-46%，p = 0.04）、实验室费用（-44%，p < 0.01）和影像学费用（-32%，p < 0.01）。活跃或对照中心的 CoA 修复费用没有变化。
早期拔管 CPG 与婴儿接受 TOF 修复术后的医院成本降低有关，但与 CoA 修复术无关。这一 CPG 为优化某些婴儿心脏手术的临床结果和降低成本提供了机会。
