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Tytuł:
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Fast-track extubation after cardiac surgery in infants: Tug-of-war between performance and reimbursement?
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Autorzy:
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Murin P; Department of Congenital Heart Surgery-Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany. Electronic address: .
Weixler VHM; Department of Congenital Heart Surgery-Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany.
Romanchenko O; Department of Congenital Heart Surgery-Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany.
Schulz A; Department of Congenital Heart Surgery-Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany.
Redlin M; Department of Anesthesiology, German Heart Center Berlin, Berlin, Germany.
Cho MY; Department of Congenital Heart Surgery-Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany.
Sinzobahamvya N; Department of Congenital Heart Surgery-Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany.
Miera O; Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany.
Kuppe H; Department of Anesthesiology, German Heart Center Berlin, Berlin, Germany.
Berger F; Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany.
Photiadis J; Department of Congenital Heart Surgery-Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany.
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Źródło:
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The Journal of thoracic and cardiovascular surgery [J Thorac Cardiovasc Surg] 2021 Aug; Vol. 162 (2), pp. 435-443. Date of Electronic Publication: 2020 Oct 08.
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Typ publikacji:
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Comparative Study; Journal Article; Observational Study; Video-Audio Media
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Język:
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English
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Imprint Name(s):
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Publication: St. Louis, MO : Mosby
Original Publication: St. Louis.
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MeSH Terms:
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Health Care Costs*
Airway Extubation/*economics
Cardiac Surgical Procedures/*economics
Heart Defects, Congenital/*surgery
Insurance, Health, Reimbursement/*economics
Postoperative Complications/*economics
Respiration, Artificial/*economics
Airway Extubation/adverse effects ; Airway Extubation/mortality ; Cardiac Surgical Procedures/adverse effects ; Cardiac Surgical Procedures/mortality ; Female ; Heart Defects, Congenital/diagnosis ; Heart Defects, Congenital/economics ; Heart Defects, Congenital/mortality ; Hospital Mortality ; Humans ; Infant ; Infant, Newborn ; Length of Stay ; Male ; Postoperative Complications/mortality ; Quality Indicators, Health Care/economics ; Respiration, Artificial/adverse effects ; Respiration, Artificial/mortality ; Retrospective Studies ; Risk Assessment ; Risk Factors ; Time Factors ; Treatment Outcome
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Contributed Indexing:
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Keywords: case-mix-index; congenital heart defects; diagnosis-related groups; early extubation; fast-track; postoperative management; reimbursement; unit performance
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Entry Date(s):
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Date Created: 20201109 Date Completed: 20210802 Latest Revision: 20210802
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Update Code:
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20240105
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DOI:
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10.1016/j.jtcvs.2020.09.123
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PMID:
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33162169
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Objectives: To compare the safety and resource-efficacy of the fast-track (FT) concept (extubation ≤8 hours after surgery) versus the conventional approach (non-FT, >8 hours postoperatively) in infants undergoing open-heart surgery.
Methods: Infants <7 kg operated on cardiopulmonary bypass between 2014 and 2018 were analyzed. Propensity score matching (1:1) was performed for group comparison (FT vs non-FT). Intensive care unit (ICU) personnel use and unit performance were evaluated. Postoperative outcome and reimbursement based on German diagnosis-related groups were compared.
Results: Of 717 infants (median age: 4 months, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery mortality score: 0.1-4), FT extubation was achieved in 182 infants (25%). After matching, 123 pairs (FT vs non-FT) were formed without significant differences in baseline characteristics. FT versus non-FT showed a significantly shorter ICU stay (in days): 1.8 (0.9-2.8) versus 4.2 (1.9-6.4), P < .01, and postoperative length of stay (in days): 7 (6-10) versus 10 (7-15.5), P < .01; significantly lower postoperative transfusion rates: 61.3% versus 77%, P < .01; and tendency toward lower early mortality: 0% versus 2.8%, P = .08. Reintubation rate did not differ between the groups (P = .7). Despite a decrease in personnel capacity (2014 vs 2018), the unit performance was maintained. The mean case-mix-index of FT versus non-FT was 8.56 ± 6.08 versus 11.77 ± 12.10 (P < .01), resulting in 27% less reimbursement in the FT group.
Conclusions: FT concept can be performed safely and resource-effectively in infants undergoing open-heart surgery. Since German diagnosis-related group systems reimburse costs, not performance, there is little incentive to avoid prolonged mechanical ventilation. Greater ICU turnover rates and excellent postoperative outcomes are not rewarded adequately.
(Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)
Comment in: J Thorac Cardiovasc Surg. 2021 Aug;162(2):448-450. (PMID: 33172663)
Comment in: J Thorac Cardiovasc Surg. 2021 Aug;162(2):447-448. (PMID: 33288239)
Comment in: J Thorac Cardiovasc Surg. 2021 Aug;162(2):444-445. (PMID: 33341272)
Comment in: J Thorac Cardiovasc Surg. 2021 Aug;162(2):446-447. (PMID: 33610370)
