RESUMO
The pediatric appropriate use criteria (AUC) were applied to transthoracic echocardiograms (TTE) ordered by primary care providers (PCPs) and pediatric cardiologists for the diagnosis of syncope to compare appropriateness ratings and cost-effectiveness. Included were patients ≤18 years of age from October 2016 to October 2018 with syncope who underwent initial outpatient pediatric TTE ordered by a PCP or were seen in Pediatric Cardiology clinic. Ordering rate of TTE by pediatric cardiologists, AUC classification, and TTE findings were obtained. PCPs ordered significantly more TTEs than pediatric cardiologists for "rarely appropriate" indications (61.5% vs 7.5%, P < .001). Cardiologists ordered TTEs at 17.2% of visits. Using appropriateness as a marker of effect, with the incremental cost-effectiveness ratio, it was more cost-effective ($543.33 per patient) to refer to a pediatric cardiologist than to order the TTE alone. This suggests that improved PCP education of the AUC and appropriate indications of TTEs for syncope may improve cost-effectiveness when using order appropriateness as a marker of effectiveness.
Assuntos
Cardiologistas/educação , Ecocardiografia/economia , Padrões de Prática Médica/economia , Síncope/diagnóstico , Assistência Ambulatorial/economia , Criança , Análise Custo-Benefício , Fidelidade a Diretrizes , HumanosAssuntos
Cateterismo Cardíaco , Coração Fetal/cirurgia , Comunicação Interatrial/cirurgia , Síndrome do Coração Esquerdo Hipoplásico/cirurgia , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/instrumentação , Cateterismo Cardíaco/mortalidade , Coração Fetal/anormalidades , Coração Fetal/fisiopatologia , Comunicação Interatrial/embriologia , Comunicação Interatrial/mortalidade , Comunicação Interatrial/fisiopatologia , Mortalidade Hospitalar , Humanos , Síndrome do Coração Esquerdo Hipoplásico/embriologia , Síndrome do Coração Esquerdo Hipoplásico/mortalidade , Síndrome do Coração Esquerdo Hipoplásico/fisiopatologia , Lactente , Mortalidade Infantil , Nascido Vivo , Sistema de Registros , Medição de Risco , Fatores de Risco , Stents , Natimorto , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: The term "borderline left ventricle" describes a small left heart that may be inadequate to provide systemic cardiac output and implies the potential need for a single-ventricle palliation. The aim of this study was to identify foetal echocardiographic features that help discriminate which infants will undergo single-ventricle palliation versus biventricular repair to aid in prenatal counselling. METHODS: The foetal database at our institution was searched to identify all foetuses with borderline left ventricle, as determined subjectively by a foetal cardiologist, from 2000 to 2011. The foetal images were retrospectively analysed for morphologic and physiologic features to determine which best predicted the postnatal surgical choice. RESULTS: Of 39 foetuses identified with borderline left ventricle, 15 were planned for a univentricular approach, and 24 were planned for a biventricular approach. There were significant differences between the two outcome groups in the Z-scores of the mitral valve annulus, left ventricular end-diastolic dimension, aortic valve annulus, and ascending aorta diameter (p<0.05). With respect to discriminating univentricular outcomes, cut-offs of mitral valve Z-score ⩽-1.9 and tricuspid:mitral valve ratio ⩾1.5 were extremely sensitive (100%), whereas a right:left ventricular end-diastolic dimension ratio ⩾2.1 provided the highest specificity (95.8%). CONCLUSION: In foetuses with borderline left ventricle, a mitral valve Z-score ⩾-1.9 or a tricuspid:mitral valve ratio ⩽1.5 suggests a high probability of biventricular repair, whereas a right:left ventricular end-diastolic dimension ratio ⩾2.1 confers a likelihood of single-ventricle palliation.
Assuntos
Ecocardiografia , Cardiopatias Congênitas/diagnóstico por imagem , Ventrículos do Coração/anormalidades , Ventrículos do Coração/diagnóstico por imagem , Ultrassonografia Pré-Natal , Diagnóstico Diferencial , Feminino , Humanos , Valor Preditivo dos Testes , Gravidez , Estudos Retrospectivos , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: Resource utilization in congenital heart surgery is typically assessed using administrative data sets. Recent analyses have called into question the accuracy of coding of cases in administrative data; however, it is unclear whether miscoding impacts assessment of associated resource use. METHODS: We merged data coded within both an administrative data set and clinical registry on children undergoing heart surgery (2004-2010) at 33 hospitals. The impact of differences in coding of operations between data sets on reporting of postoperative length of stay (PLOS) and total hospital costs associated with these operations was assessed. RESULTS: For each of the eight operations of varying complexity evaluated (total n = 57,797), there were differences in coding between data sets, which translated into differences in the reporting of associated resource utilization for the cases coded in either data set. There were statistically significant differences in PLOS and cost for seven of the eight operations, although most PLOS differences were relatively small with the exception of the Norwood operation and truncus repair (differences of two days, P < .001). For cost, there was a >5% difference for three of the eight operations and >10% difference for truncus repair (US$10,570; P < .01). Grouping of operations into categories of similar risk appeared to mitigate many of these differences. CONCLUSION: Differences in coding of cases in administrative versus clinical registry data can translate into differences in assessment of associated PLOS and cost for certain operations. This may be minimized through evaluating larger groups of operations when using administrative data or using clinical registry data to accurately identify operations of interest.
Assuntos
Procedimentos Cirúrgicos Cardíacos/economia , Recursos em Saúde/estatística & dados numéricos , Cardiopatias Congênitas/cirurgia , Custos Hospitalares , Sistema de Registros , Adolescente , Criança , Pré-Escolar , Bases de Dados Factuais , Feminino , Cardiopatias Congênitas/economia , Humanos , Lactente , Recém-Nascido , Tempo de Internação/economia , Masculino , Período Pós-OperatórioRESUMO
BACKGROUND: Patent ductus arteriosus (PDA) is a common cardiac problem in neonates and infants, but determination of its hemodynamic significance can be challenging. We hypothesized that combined left (LA) and right atrial (RA) volumes physiologically best reflect hemodynamically significant patent ductus arteriosus (HSPDA), and utilized two-dimensional echocardiography (2DE) derived atrial volumes to test this hypothesis. METHODS: 2DE examinations with good-quality images in 138 neonates <3 months corrected gestational age with PDA, and 50 normal neonates without PDA were selected. Measurements of LA, RA, and combined atrial volumes were performed, in addition to transductal diameters, left atrial to aortic dimension (LA:Ao), and left ventricular end-diastolic to aortic dimension ratios. An experienced cardiologist, blinded to 2DE images of atria and ventricles and to the above measurements, independently assessed HSPDA based only on images and Doppler data of the ductus itself, thus identifying each PDA as of low hemodynamic significance or HSPDA. RESULTS: Receiver operating characteristic (ROC) curves showed indexed LA volumes and LA/RA volume ratios to have moderate power to discriminate HSPDA from low hemodynamic burden PDA. Classic LA:Ao ratio, combined atrial volumes, and RA volumes yielded ROC areas that appeared less promising as discriminators for HSPDA. CONCLUSION: Atrial volume measurements in neonates and infants have a linear association with body surface area and show acceptable inter- and intraobserver agreement. Indexed LA volume and LA/RA volume ratio are potentially useful markers for HSPDA. RA dilation due to left to right shunting through the patent foramen ovale as quantified by RA volume measurements does not appear to be an important marker for HSPDA.