Congenital Heart Disease in Syrian Refugee Children: The Experience at a Tertiary Care Center in a Developing Country.

The influx of Syrian refugees to Lebanon that began in 2012 created new health-care and financial stressors on the country with an increase in communicable and non-communicable diseases. This study aims to describe the presentations, diagnoses, management, financial burden, and outcomes among Syrian refugees with congenital heart disease (CHD) in Lebanon. This is a retrospective study that was conducted through reviewing the charts of all Syrian pediatric patients referred to the Children's Heart Center at the American University of Beirut Medical Center for evaluation between the years 2012 and 2017. We reviewed the charts of 439 patients. The mean age at presentation was 3.97 years, and 205 patients (46.7%) were females. 99 Patients (22.6%) were found to have no heart disease, 69 (15.7%) had simple, 146 (33.3%) had moderate, and 125 (28.5%) had complex heart diseases. 176 (40.1%) Patients underwent interventional procedures, with a surgical mortality rate of 10.1%, compared to a rate of 2.9% among non-Syrian children. The average cost per surgical procedure was $15,160. CHD poses a significant health and financial burden on the Syrian refugee population in Lebanon, a small country with very limited resources. The Syrian cohort had a higher frequency of complex cardiac lesions, presented late with additional comorbidities, and had a strikingly elevated surgical mortality rate. Securing appropriate funds can improve the lives of this population, ease the financial burden on the hosting country, provide adequate health-care services, and improve morbidity and mortality.

Concomitant Left Atrial Appendage Closure Outcomes and Cost: A Multi-institutional Cohort Analysis.

BACKGROUND: Left atrial appendage closure (LAAC) is frequently performed during cardiac operations, but the impact of LAAC on patient outcomes is not fully known. We hypothesized that the addition of LAAC would increase morbidity and resource utilization. METHODS: All patients undergoing cardiac surgery from a multi-institutional Society of Thoracic Surgeons database from 2011 to 2016 were stratified by LAAC. The effect of LAAC on risk-adjusted outcomes was assessed by hierarchical regression modeling accounting for preoperative risk factors, planned surgical procedure, hospital, and year. RESULTS: Concomitant LAAC was performed on 2384 of 28,311 patients (9.3%), who were older, with a greater burden of preoperative atrial fibrillation and heart failure. Although the addition of LAAC increased the risk of new-onset postoperative atrial fibrillation (OR 1.69, P < 0.01), it did not increase rates of major morbidity (OR 1.00, P = 0.970), stroke (OR 0.92, P = 0.787), or mortality (OR 0.93, P = 0.684). Although cardiopulmonary bypass time was not significantly increased by LAAC, patients' total hospitalization costs were $3035 higher (P = 0.018). CONCLUSIONS: Although concomitant LAAC was not associated with major complications, there were higher risk-adjusted rates of new-onset postoperative atrial fibrillation. Furthermore, LAAC added approximately $3000 to a patient's total hospital cost. These short-term risks and costs should be weighed against potential long-term benefits of left atrial appendage closure.

Invasive Cardiac Procedures in Interstage Single Ventricle Patients in Emergent Hospitalizations.

Single ventricle congenital heart disease (SV CHD) patients are at risk of morbidity and mortality between the first and second palliative surgical procedures (interstage). When these patients present acutely they often require invasive intervention. This study sought to compare the outcomes and costs of elective and emergent invasive cardiac procedures for interstage patients. Retrospective review of discharge data from The Vizient Clinical Data Base/Resource Manager™, a national health care analytics platform. The database was queried for admissions from 10/2014 to 12/2017 for children 1-6 months old with ICD-9 or ICD-10 codes for SV CHD who underwent invasive cardiac procedures. Demographics, length of stay (LOS), complication rate, in-hospital mortality and direct costs were compared between elective and emergent admissions using t test or χ2, as appropriate. The three most frequently performed procedures were also compared. 871 admissions identified, with 141 (16%) emergent. Age of emergent admission was younger than elective (2.9 vs. 4 months p < 0.001). Emergent admissions including cardiac catheterization or superior cavo-pulmonary anastomosis had longer LOS (58.7 vs. 25.8 day, p < 0.001 and 54.8 vs .22.6 days, p < 0.001) and higher costs ($134,774 vs. $84,253, p = 0.013 and $158,679 vs. $81,899, p = 0.017). Emergent admissions for interstage SV CHD patients undergoing cardiac catheterization or superior cavo-pulmonary anastomosis are associated with longer LOS and higher direct costs, but with no differences in complications or mortality. These findings support aggressive interstage monitoring to minimize the need for emergent interventions for this fragile patient population.

Effect of comorbid neuropsychiatric disorders on children and adolescents undergoing surgery for moderate and severe congenital heart disease.

BACKGROUND: Children and adolescents with congenital heart disease (CHD) are at an increased risk of neuropsychiatric disorders (NPDs). The purpose of this study is to determine how a comorbid NPD affects hospital outcomes and costs for CHD patients undergoing cardiac surgery. METHODS: Retrospective review of the 2000-2012 Healthcare Cost and Utilization Project Kids' Inpatient Databases for admissions 10 to 21 years old with an ICD-9 code for moderate or severe CHD and a procedure code for cardiopulmonary bypass as a marker for cardiac surgery; admissions with syndromes that could be associated with NPD were excluded. Demographics, hospital outcomes, and charges were compared between admissions with and without NPD ICD-9 codes using analysis of variance, independent samples Kruskal-Wallis, and χ2 , as appropriate. RESULTS: There were 4768 admissions with CHD and cardiac surgery: 4285 (90%) with no NPD, 93 (2%) with cognitive deficits, 390 (8%) with mood/behavior deficits. Patients with NPD had a longer length of stay and higher mean charges (P < .001 for both). Patients with mood/behavior deficits were older and patients with cognitive deficits were more likely female (P < .001 for both). CONCLUSIONS: Children and adolescents with moderate or severe CHD and NPD who undergo cardiac surgery incur longer hospital stays and higher charges. Recognizing and addressing the underlying NPDs may be important to improve postoperative progression for children and adolescents with CHD hospitalized for cardiac surgery.

Intraoperative Transesophageal Echocardiography During Cardiovascular Surgery in China.

OBJECTIVE: To perform a comprehensive nationwide survey of more than 90% of all cardiovascular hospitals in China to assess the current 2018 status of transesophageal echocardiography (TEE) equipment, operating physicians, education, impact on surgery, and reimbursement. DESIGN: In this nationwide survey, 716 cardiovascular hospitals in mainland China were included. A 15-question electronic survey was sent to these hospitals and the data were received directly from the questionnaire website for analysis. SETTING: Cardiovascular hospitals in mainland China. PARTICIPANTS: Departments of anesthesiology in cardiovascular hospitals in mainland China. INTERVENTIONS: Answer a 15-question survey. MEASUREMENTS AND MAIN RESULTS: About 90% of hospitals have acquired machines to perform TEEs with most of the machines controlled by the ultrasound department. Anesthesiologists performed intraoperative TEEs in 45% of the hospitals, but only 15% of the hospitals have anesthesiologists who have met the basic TEE training requirements. Most anesthesiologists (68%) believed TEE significantly contributed to patient care during cardiovascular surgeries. The overwhelming majority of surveyed hospital staff (93%) stated that they were planning to continue or start intraoperative TEE examinations in the future. CONCLUSION: Many hospitals in China have acquired equipment to perform intraoperative TEE examinations during cardiovascular surgeries. However, the number of anesthesiologists who can perform TEEs independently still is not adequate. Standardized trainings, a formal certification process, and governmental payment model changes must be provided to ensure high-quality TEE services and better surgical outcomes in China.

Quality Assessment of Reporting of Economic Evaluation in Cardiac Sugery: Has it Improved?

OBJECTIVES: Cardiac surgery has seen substantial scientific progress over recent decades. Health economic evaluations have become important tools for decision makers to prioritize scarce health resources. The present study aimed to identify and critically appraise the reporting quality of health economic evaluations conducted in the field of cardiac surgery. METHODS: A literature search was performed to identify health economic evaluations in cardiac surgery. The consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement was used to assess the quality of reporting of studies. RESULTS: A total 4,705 articles published between 1981 and 2016 were identified; sixty-nine studies fulfilled the inclusion criteria. There was a trend toward a greater number of publications and reporting quality over time. Six (8.7 percent) studies were conducted between 1981 and 1990, nine (13 percent) between 1991 and 2000, twenty-four (34.8 percent) between 2001 and 2010, and thirty (43.5 percent) after 2011. The mean CHEERS score of all articles was 16.7/24; for those published between 1980 and 1990 the mean (SD) score was 10.2 (±1.4), for those published between 1991 and 2000 it was 11.2 (±2.4), between 2001 and 2010 it was 15.3 (±4.8), and after 2011 it was 19.9 (±2.9). The quality of reporting was still insufficient for several studies after 2000, especially concerning items "characterizing heterogeneity," "assumptions," and "choice of model." CONCLUSIONS: The present study suggests that, even if the quantity and the quality of health economics evaluation in cardiac surgery has increased, there remains a need for improvement in several reporting criteria to ensure greater transparency.

Predictors of increased costs following index adult cardiac operations: Insights from a statewide publicly reported registry.

BACKGROUND: The aim of this study was to identify hospital-level predictors of increased cost following index adult cardiac operations in a statewide registry. METHODS: The Pennsylvania Health Care Cost Containment Council (PHC4) database was queried for isolated coronary artery bypass grafting (CABG), isolated valve surgery, or CABG plus valve surgery performed between 2014 and 2016. Charge-to-cost ratios for each individual hospital were used to estimate cost. Expected (predicted) operative mortality and 30-day readmission were evaluated using multivariable risk models and linear regression analysis was utilized to evaluate the risk-adjusted impact of multiple hospital-level characteristics on costs. RESULTS: During the study period, 29 578 patients underwent isolated CABG (n = 16,641), isolated valve surgery (n = 8618), or CABG plus valve surgery (n = 4319) at 60 hospitals. The median cost of CABG was $61 573 (interquartile range [IQR] $50 780 to $77 482). The median cost of isolated valve surgery was $68,835 (IQR $56 039 to $89 465) and CABG plus valve surgery $83 574 (IQR $69 806 to $114 407). Hospital-level predictors of increasing costs in isolated CABG included higher predicted mortality rates, higher observed-to-expected (OE) mortality ratios, and nonteaching status. No hospital-level independent predictors of increased costs were identified for isolated valve or CABG plus valve surgery. CONCLUSIONS: Hospitals that performed higher risk cases and had higher OE ratios for operative mortality in isolated CABG were found to have increased costs. These data collectively suggest that attention to risk assessment and outcome optimization efforts in isolated CABG would likely result in programmatic advantages not only from a clinical standpoint but also economic.

Postoperative Inhaled Nitric Oxide Does Not Decrease Length of Stay in Pediatric Cardiac Surgery Admissions.

Pulmonary hypertension is one of the most challenging complications in congenital heart surgery. The purpose of this study was to characterize inhaled nitric oxide administration in children with and without pulmonary hypertension who underwent congenital heart surgery and to describe the effect of nitric oxide administration on admission outcomes. This is a cross-sectional study utilizing data from the Pediatric Health Information System (PHIS) and PHIS + databases from 2004 to 2015. Pediatric patients with a congenital heart disease diagnosis were included and divided into groups with pulmonary hypertension that received and not received inhaled nitric oxide and patients without diagnosis of pulmonary hypertension who received and did not receive inhaled nitric oxide. For all admissions, the following were captured: age of admission, gender, year of admission, length of stay, billed charges, inpatient mortality, the presence of specific congenital malformations of the heart, specific cardiac surgeries, and comorbidities. Comparisons between groups were completed using a Mann-Whitney-U test and Fisher's exact test. Outcomes evaluation was completed using univariate and regression analyses. A total of 40,194 pediatric cardiac surgical admissions without pulmonary hypertension were identified. Of these, 726 (1.8%) received inhaled nitric oxide. Regression analyses demonstrated that inhaled nitric oxide was independently associated with increased length of stay, billed charges, and inpatient mortality. A total of 1678 pediatric cardiac surgical admissions with pulmonary hypertension were identified. Of these, 195 (11.6%) received inhaled nitric oxide. Regression analyses demonstrated that inhaled nitric oxide was independently associated with a significant increase in length of stay and billed charges. There was no statistically significant association between inhaled nitric oxide and decrease mortality. Administration of inhaled nitric oxide after pediatric cardiac surgery increases length of stay and billed charges while not providing improved inpatient mortality. In fact, administration of inhaled nitric oxide was associated with increased mortality in those without pulmonary hypertension while not impacting mortality in any way in those with pulmonary hypertension.

Congenital Heart Surgical Admissions in Patients with Trisomy 13 and 18: Frequency, Morbidity, and Mortality.

Congenital heart defects are common among patients with trisomy 13 and 18; surgical repair has been controversial and rarely studied. We aimed to assess the frequency of cardiac surgery among admissions with trisomy 13 and 18, and evaluate their associations with resource use, complications, and mortality compared to admissions without these diagnoses. We evaluated congenital heart surgery admissions of ages < 18 years in the 1997, 2000, 2003, 2006, and 2009 Kids' Inpatient Database. Bivariate and multivariate analyses examined the adjusted association of trisomy 13 and 18 on resource use, complications, and inpatient death following congenital heart surgery. Among the 73,107 congenital heart surgery admissions, trisomy 13 represented 0.03% (n = 22) and trisomy 18 represented 0.08% (n = 58). Trisomy 13 and 18 admissions were longer; trisomy 13: 27 days vs. 8 days, p = 0.003; trisomy 18: 16 days vs. 8 days, p = 0.001. Hospital charges were higher for trisomy 13 and 18 admissions; trisomy 13: $160,890 vs. $87,007, p = 0.010; trisomy 18: $160,616 vs. $86,999, p < 0.001. Trisomy 18 had a higher complication rate: 52% vs. 34%, p < 0.006. For all cardiac surgery admissions, mortality was 4.5%; trisomy 13: 14% and trisomy 18: 12%. In multivariate analysis, trisomy 18 was an independent predictor of death: OR 4.16, 95% CI 1.35-12.82, p = 0.013. Patients with trisomy 13 and 18 represent 0.11% of pediatric congenital heart surgery admissions. These patients have a 2- to 3.4-fold longer hospital stay and double hospital charges. Patients with trisomy 18 have more complications and four times greater adjusted odds for inpatient death.

Public Health Costs for Northern Territory and South Australian Cardiac Surgery Patients.

BACKGROUND: The cost of performing cardiac surgery in the public health system in Australia is unclear. This paper analyses the cost of cardiac surgery performed at Flinders Medical Centre (FMC), South Australia, comparing cost by procedure, rheumatic valvular heart disease status, Aboriginality and location. METHODS: This study is a retrospective, population-based analysis of cardiac surgery data held in the Cardiac Surgery Registry cross-referenced to cost data provided by the FMC Department of Finance and Patient Travel, Accommodation and Transport Services at the Royal Darwin Hospital. Seven hundred ninety-five (795) patients who underwent cardiac surgery at FMC from 1 July 2014 to 30 June 2016 were included. RESULTS: Across all procedures, Northern Territory (NT) Aboriginal patients had a mean total cost of $78,506 which was $24,113 more than NT non-Aboriginal, $28,443 more than South Australian (SA) Aboriginal and $22,955 more than SA non-Aboriginal patients. The total cost of a patient undergoing a repeat sternotomy (reoperative procedure) was found to be significantly higher than a primary procedure ($85,797 versus $59,097). In patients undergoing valve surgery procedures, those identified with rheumatic heart disease had a higher mean total cost than those without (a difference of $25,094). Significantly, the rheumatic patient group showed a higher proportion of reoperative procedures (19% versus 5%). CONCLUSIONS: The cost of treating NT Aboriginal cardiac surgical patients remotely has a significant financial impact upon the health care delivery system, as does the impact of rheumatic heart disease. This study found that the cost for the NT Aboriginal patient group was substantially higher than the NT non-Aboriginal, SA Aboriginal and SA non-Aboriginal patient groups. The additional cost to family and dislocation of social structures is not able to be calculated, but would also clearly weigh heavily on both patient groups. These findings suggest that future health funding models should recognise Aboriginality, remoteness and rheumatic heart disease.

Resource Use and Morbidities in Pediatric Cardiac Surgery Patients with Genetic Conditions.

OBJECTIVE: To evaluate and describe resource use and perioperative morbidities among those patients with genetic conditions undergoing cardiac surgery. STUDY DESIGN: Using the Pediatric Health Information System database, we identified patients ≤18 years old with cardiac surgery classified by Risk Adjustment for Congenital Heart Surgery (RACHS) during 2003-2014. A total of 95 253 patients met study criteria and included no genetic conditions (84.6%), trisomy 21 (9.9%), trisomy 13 or 18 (0.2%), 22q11 deletion (0.8%), Turner syndrome (0.4%), and "other" genetic conditions (4.2%). We compared perioperative complications and procedures in each genetic condition with patients without genetic conditions using regression analysis. RESULTS: All groups with genetic conditions, excluding trisomy 21 RACHS 3-5, experienced increased length of stay and cost among survivors. Complications varied by genetic condition, with patients with trisomy 21 having increased odds of pulmonary hypertension and nosocomial infections. Patients with 22q11 only had increased odds of infection. Patients with Turner syndrome had increased odds of acute renal failure (OR 2.35). Patients with trisomy 13 or 18 had increased odds of pulmonary hypertension (OR 3.13), acute renal failure (OR 2.93), cardiac arrest (OR 2.84), and nosocomial infections (OR 3.53), and those with "other" genetic conditions had increased odds of all complications. CONCLUSIONS: Children with congenital heart disease and genetic conditions, except trisomy 21 RACHS 3-5, had increased costs and length of stay. Perioperative morbidities were more common and differed across genetic condition subgroups. Patient-specific risk factors are important for risk stratification, benchmarking, and counseling with families.

Right Anterolateral Minithoracotomy versus Median Sternotomy Approach for Resection of Left Atrial Myxoma.

BACKGROUND: Minimally invasive surgery has become the standard approach for several cardiac diseases. In this retrospective study, we compared right anterolateral minithoracotomy (RALT) with standard median sternotomy (SMS) for resection of left atrial myxoma (LAM). MATERIALS AND METHODS: From January 2009 to June 2015, the clinical data of patients who underwent RALT (n = 30) and SMS (n = 36) for resection of LAM in our hospital were collected. The preoperative clinical data and operative results were compared between the two groups. RESULTS: There were no significant differences in aortic cross-clamp and cardiopulmonary bypass time between the two groups. The total incision length was significantly shorter in RALT group compared with SMS group (p < 0.001). For RALT and SMS groups, respectively, the intensive care unit length of stay was 29.2 ± 6.5 versus 43.5 ± 6.9 hours (p < 0.001), and the postoperative hospital length of stay was 5 days (interquartile range [IQR]: 4-6) versus 8 days (IQR: 7-10) (p < 0.001). The total cost in RALT group was 27,000 RMB (IQR: 25,000-29,000) versus 33,000 RMB (IQR: 31,000-35,000) in SMS group (p < 0.001). There were no significant differences in mortality and postoperative complications between the two groups. CONCLUSION: RALT approach for LAM resection can be performed safely with favorable cosmetic outcome, accepted clinical results, and lower cost. It should be considered as a promising alternative to SMS and merit additional study.

Defining Value-Based Care in Cardiac and Vascular Anesthesiology: The Past, Present, and Future of Perioperative Cardiovascular Care.

Health care reimbursement models are transitioning from volume-based to value-based models. Value-based models focus on patient outcomes both during the hospital admission and postdischarge. These models place emphasis on cost, quality of care, and coordination of multidisciplinary services. Perioperative physicians are challenged to evaluate traditional practices to ensure coordinated, cost-effective, and evidence-based care. With the Centers for Medicare and Medicaid Services planned introduction of bundled payments for coronary artery bypass graft surgery, cardiovascular anesthesiologists are financially responsible for postdischarge outcomes. In order to meet these patient outcomes, multidisciplinary care pathways must be designed, implemented, and sustained, a process that is challenging at best. This review (1) provides a historical perspective of health care reimbursement; (2) defines value as it pertains to quality, service, and cost; (3) reviews the history of value-based care for cardiac surgery; (4) describes the drive toward optimization for vascular surgery patients; and (5) discusses how programs like Enhanced Recovery After Surgery assist with the delivery of value-based care.

The impact of obesity on cardiac surgery outcomes.

BACKGROUND: A survival benefit for obese patients has been observed in various medical and surgical populations. We examined the effect of obesity on outcomes after cardiac surgery from a large national database. METHODS: A total of 6 648 334 adult patients were identified from the Nationwide Inpatient Sample who underwent cardiac surgery between 1998 and 2011, of who 598 450 were obese. Multivariable regression analysis and propensity score matching were used for comparisons of outcomes and costs. RESULTS: In-hospital mortality was 2.0% for obese patients versus 2.3% for non-obese patients (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.84, 0.94). Obese patients were at increased risk for acute renal failure (OR, 1.20; CI, 1.16, 1.23) and wound infection (OR, 1.29; CI, 1.18, 1.40), but less likely to require blood transfusion (OR, 0.96; CI, 0.94, 0.98). Mean length of stay was the same (8.7 days), with greater mean total charges for obese patients ($103 645 vs $101 763, P < 0.001). CONCLUSION: Obesity is associated with lower in-hospital mortality rates, but a higher incidence of acute renal failure and wound infections.

The CRAC cohort model: A computerized low cost registry of interventional cardiology with daily update and long-term follow-up.

OBJECTIVES: To assess the reliability and low cost of a computerized interventional cardiology (IC) registry to prospectively and systematically collect high-quality data for all consecutive coronary patients referred for coronary angiogram or/and coronary angioplasty. BACKGROUND: Rigorous clinical practice assessment is a key factor to improve prognosis in IC. A prospective and permanent registry could achieve this goal but, presumably, at high cost and low level of data quality. One multicentric IC registry (CRAC registry), fully integrated to usual coronary activity report software, started in the centre Val-de-Loire (CVL) French region in 2014. METHODS: Quality assessment of CRAC registry was conducted on five IC CathLab of the CVL region, from January 1st to December 31st 2014. Quality of collected data was evaluated by measuring procedure exhaustivity (comparing with data from hospital information system), data completeness (quality controls) and data consistency (by checking complete medical charts as gold standard). Cost per procedure (global registry operating cost/number of collected procedures) was also estimated. RESULTS: CRAC model provided a high-quality level with 98.2% procedure completeness, 99.6% data completeness and 89% data consistency. The operating cost per procedure was €14.70 ($16.51) for data collection and quality control, including ST-segment elevation myocardial infarction (STEMI) preadmission information and one-year follow-up after angioplasty. CONCLUSIONS: This integrated computerized IC registry led to the construction of an exhaustive, reliable and costless database, including all coronary patients entering in participating IC centers in the CVL region. This solution will be developed in other French regions, setting up a national IC database for coronary patients in 2020: France PCI.

[Impact of an automated dispensing system for medical devices in cardiac surgery department]. / Impact de l'implantation d'armoires sécurisées dédiés aux dispositifs médicaux dans un service de chirurgie cardiaque.

To secure medical devices' management, the implementation of automated dispensing system in surgical service has been realized. The objective of this study was to evaluate security, organizational and economic impact of installing automated dispensing system for medical devices (ASDM). The implementation took place in a cardiac surgery department. Security impact was assessed by comparing traceability rate of implantable medical devices one year before and one year after installation. Questionnaire on nurses' perception and satisfaction completed this survey. Resupplying costs, stocks' evolution and investments for the implementation of ASDM were the subject of cost-benefit study. After one year, traceability rate is excellent (100%). Nursing staffs were satisfied with 87.5% by this new system. The introduction of ASDM allowed a qualitative and quantitative decrease in stocks, with a reduction of 30% for purchased medical devices and 15% for implantable medical devices in deposit-consignment. Cost-benefit analysis shows a rapid return on investment. Real stock decrease (purchased medical devices) is equivalent to 46.6% of investment. Implementation of ASDM allows to secure storage and dispensing of medical devices. This system has also an important economic impact and appreciated by users.

Implementing a protocol to optimize blood use in a cardiac surgery service: results of a pre-post analysis and the impact of high-volume blood users.

BACKGROUND: Blood transfusions are a common and costly intervention for cardiac surgery patients. Evidence suggests that a more restrictive transfusion strategy may reduce costs and transfusion-related complications without increasing perioperative morbidity and mortality. STUDY DESIGN AND METHODS: A transfusion-limiting protocol was developed and implemented in a cardiovascular surgery unit. Over a 5-year period, data were collected on patient characteristics, procedures, utilization of blood products, morbidity, and mortality, and these were compared before and after the protocol was implemented. RESULTS: After the protocol was put in place, fewer patients required transfusions (38.2% vs. 45.5%, p = 0.004), with the greatest reduction observed in postoperative blood use (29.1% vs. 37.2%, p = 0.001). In-hospital morbidity and mortality did not increase. When patients who received transfusions were stratified by procedure, the protocol was most effective in reducing transfusions for patients undergoing isolated coronary artery bypass grafting (CABG; 4.09 units vs. 2.51 units, p = 0.009) and CABG plus valve surgery (10.32 units vs. 4.77 units, p = 0.014). A small group of patients were disproportionate recipients of transfusions, with approximately 6% of all patients receiving approximately half of the blood products. CONCLUSION: A protocol to limit transfusions decreased the proportion of cardiothoracic surgery patients who received blood products. A very small group of patients received a large number of transfusions, and within that group the observed mortality was significantly higher than in the general patient population. Current protocols cannot possibly account for these patients, and this should be considered when analyzing the performance of protocols designed to reduce unnecessary transfusions.

Process Improvement Initiative for the Perioperative Management of Patients With a Cardiovascular Implantable Electronic Device.

BACKGROUND: Economic, personnel, and procedural challenges often complicate and interfere with efficient and safe perioperative care of patients with cardiovascular implantable electronic devices (CIEDs). In the context of a process improvement initiative, we created and implemented a comprehensive anesthesiologist-run perioperative CIED service to respond to all routine requests for perioperative CIED consultations at a large academic medical center. This study was designed to determine whether this new care model was associated with improved operating room efficiency, reduced institutional cost, and adequate patient safety. METHODS: We included patients with a CIED and a concurrent cohort of patients with the same eligibility criteria but without a CIED who underwent first-case-of-the-day surgery during the periods between February 1, 2008, and August 17, 2010 (preintervention) and between March 4, 2012, and August 1, 2014 (postintervention). The primary end point was delay in first-case-of-the day start time. We used multiple linear regression to compare delays in start times during the preintervention and postintervention periods and to adjust for potential confounders. A patient safety database was queried for CIED-related complications. Cost analysis was based on labor minutes saved and was calculated using nationally published administrative estimates. RESULTS: A total of 18,148 first-case surgical procedures were performed in 15,100 patients (preintervention period-7293 patients and postintervention period-7807 patients). Of those, 151 (2.1%) patients had a CIED in the preintervention period, and 146 (1.9%) had a CIED in the postintervention period. After adjustment for imbalances in baseline characteristics (age, American Society of Anesthesiologists physical status, and surgical specialty), the difference in mean first-case start delay between the postintervention and preintervention periods in the cohort of patients with a CIED was -16.7 minutes (95% confidence interval [CI], -26.1 to -7.2). The difference in mean delay between the postintervention and preintervention periods in the cohort without a CIED was -4.7 minutes (95% CI, -5.4 to -3.9). There were 3 CIED-related adverse events during the preintervention period and none during the postintervention period. Based on reduction in first-case start delay, the intervention was associated with cost savings (estimated institutional savings $14,102 annually, or $94.06 per CIED patient), with a return on investment ratio of 2.18 over the course of the postintervention period. CONCLUSIONS: Based on our experience, specially trained anesthesiologists can provide efficient and safe perioperative care for patients with CIEDs. Other centers may consider implementing a similar strategy as our specialty adopts the perioperative surgical home model.

Outcomes and Costs of Cardiac Surgery in Adults with Congenital Heart Disease.

Advances in pediatric cardiac surgical and medical care have led to increased survival of patients with congenital heart disease (CHD). Consequently, many CHD patients survive long enough to require cardiac surgery as adults. Using the 2013 Nationwide Inpatient Sample (NIS) database, we compared costs and outcomes for adult patients undergoing surgery for treatment of CHD to a reference population of adults undergoing CABG. Patients were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 CM) procedure codes. We recorded the demographic characteristics, gender, ethnicity, hospital bed size, hospital length of stay, in-hospital mortality, and comorbidities. Patients with ACHD have higher incidences of in-hospital mortality (2.6 vs. 1.8%), and complication rates including neurologic complications (2.6 vs. 0.9%), thromboembolic complications (3.9 vs. 1.4%), arrhythmias (51.6 vs. 29.8%), hepatic failure (4.44 vs. 2.03%), and sepsis (7.24 vs. 4.61%) (all p < 0.001). In addition, cost is higher in patients with CHD (Coefficient = 0.116, 95% CI, 0.105-0.128; p < 0.001), Elixhauser score ≥ 7 (Coefficient = 0.114, 95% CI, 0.108-0.121; p < 0.001), neurologic complications (Coefficient = 0.169, 95% CI, 0.143-0.196; p < 0.001), thrombotic complications (Coefficient = 0.243, 95% CI, 0.222-0.265; p < 0.001), sepsis (Coefficient = 0.198, 95% CI, 0.185-0.211; p < 0.001), acute kidney injury (Coefficient = 0.056, 95% CI, 0.041-0.063; p < 0.001), elective cases (Coefficient = 0.047, 95% CI, 0.041-0.053; p < 0.001), and length of stay > 6 days (Coefficient = 0.703, 95% CI, 0.697-0.710; p < 0.001). This study shows that ACHD patients undergoing cardiac surgery experience higher hospital costs and poorer outcomes than a reference population of adult CABG patients. Recognition and treatment of comorbidities in ACHD patients undergoing cardiac surgery may provide an opportunity to improve perioperative outcomes in this growing patient population.

Lower Hospital Charges and Societal Costs for Catheter Device Closure of Atrial Septal Defects.

Atrial septal defects (ASD) are among the most common congenital heart defects. As more ASDs are corrected by interventional catheterization instead of surgery, it is critical to understand the associated clinical and societal costs. The goal of this study was to use a national U.S. database to describe hospital charges and societal costs for surgical and catheter-based (ASD) closure. Retrospective review of hospital discharge data from the Kids' Inpatient Database from January 2010 to December 2012. The database was queried for admissions for <21 years old with ICD-9 procedure codes for surgical (35.51 or 35.61) or catheter (35.52) ASD closure; those with other cardiac conditions and/or additional cardiac procedures were excluded. Age, length of stay (LOS), and hospital charges and lost parental wages (societal costs) were compared between groups using t test or Mann-Whitney U test, as appropriate. Four hundred and eighty-six surgical and 305 catheter ASD closures were identified. LOS, hospital charges, and total societal costs were higher in surgical ASD compared to catheter ASD admissions (3.6 vs. 1.3 days, p < 0.001, $87,465 vs. $64,109, p < 0.001, and $90,000 vs. $64,966, p < 0.001, respectively). In this review of a large national inpatient database, we found that hospital and societal costs for surgical ASD closure are significantly higher than catheter ASD closure in the United States in the current era. Factors that likely contribute to this include longer LOS and longer post-operative recovery. Using "real-world" data, this study demonstrates a substantial cost advantage for catheter ASD closure compared to surgical.