Emergency department visits for CHD becoming safer but more costly
Emergency department visits for children with congenital heart disease (CHD) are getting more expensive over time but mortality rates are improving, according to an analysis of more than 420,000 CHD-related trips to the ED over a nine-year period.
“With major advances in prenatal diagnosis, surgical techniques, and intraoperative and post-operative care, patients who once would have died in infancy are now surviving to childhood, adolescence, and adulthood, thus transforming once fatal lesions into new forms of chronic disease in childhood and beyond,” wrote lead author Jonathan B. Edelson, MD, a pediatric cardiologist at Children’s Hospital of Philadelphia, and colleagues in the Journal of the American College of Cardiology.
“Given the complexity and size of this population, children with CHD consume a disproportionately large share of available resources, with yearly expenditures in the United States approaching $6 billion, and notable recent increases in both institutional costs and charges to the patient.”
Despite this growing population, most current data relates to costs and outcomes of CHD patients in an inpatient setting rather than EDs, the authors said. To address this research gap, Edelson et al. used the Nationwide Emergency Department Sample to estimate resource utilization, medical complexity, hospital admission rates and mortality for CHD-related ED visits from 2006 through 2014.
Among their findings:
- CHD-related ED visits accounted for 0.17 percent of all ED visits among children under 18—or an estimated 420,452 visits during the study period.
- Compared to other pediatric patients, those with CHD were more likely to be infants (43 percent versus 13 percent) and to have at least one other complex chronic condition (35 percent versus 2 percent).
- 46 percent of CHD-related ED visits resulted in inpatient admissions, compared to 4 percent of those for non-CHD patients.
- Median ED charges were $1,266 for CHD patients and $741 for non-CHD patients, represented in 2014 U.S. dollars. Adjusted median charges for CHD-related visits increased from $1,219 to $1,630 over the nine-year period.
- Mortality decreased from 1.13 percent to 0.75 percent from 2006 to 2014.
“There is some suggestion that the devotion of extensive resources is not without benefit, as demonstrated by the concurrent decrease in mortality,” Edelson and colleagues wrote. “Although the overall CHD ED visit mortality rate demonstrated in this study may be decreasing for any number or reasons, including improved surgical technique and more refined medical therapies, it is at least equally plausible that higher resource devotion and medical attention has appropriately led to decreased mortality in this vulnerable population.”
The researchers also noted that patients with single-ventricle disease were admitted to the hospital 44.6 percent of the time and died in the ED 2.04 percent of the time. They hypothesized other factors associated with medical complexity may have played a role in both the increased resource utilization and admission rates seen in the CHD population.
“Given that visits among children with CHD were more frequently associated with acute presenting complaints such as sepsis, neurological injury, and acute kidney injury, and that they more frequently had complex (chronic conditions), it seems likely that the increased admission rate is due to both the acuity and medical complexity of the CHD group,” they wrote. “There may also be a provider influence on resource utilization based on comfort level with assessing CHD in the ED. Interestingly, the admission rate for patients with CHD has gradually but persistently decreased over the 9 years studied, while the overall number of visits remained static, perhaps due to improved care delivery in the ED.”
The authors pointed out the Nationwide Emergency Department Sample only captures hospital admissions that go through the ED, meaning it may have missed some direct admissions from patients’ homes, cardiology offices or urgent care centers.
Daniel joined TriMed’s Chicago editorial team in 2017 as a Cardiovascular Business writer. He previously worked as a writer for daily newspapers in North Dakota and Indiana.