TITLE:
Pediatric Post-Operative Atrio-Ventricular Block Meets the Affordable Care Act: A New Strategy for Management
AUTHORS:
Melissa L. Morello, Joan S. Steinberg, Christopher Snyder
KEYWORDS:
Pediatric, Pacemaker, Post-Operative, Heart Block, Atrioventricular Block, Cost
JOURNAL NAME:
Open Journal of Pediatrics,
Vol.7 No.3,
August
4,
2017
ABSTRACT: Introduction: Post-operative (post-op) complete atrio-ventricular heart block
(CAVB) occurs after 1% - 4% of pediatric cardiac operations. Current practice
dictates implantation of permanent pacemaker (PPM) when post-op CAVB
persists >9 days. We propose that earlier PPM implantation may be the most
cost-effective methodology since patient costs increase with extended length
of stay (LOS). Methods: Data on the probabilities of persistent post-op CAVB
were extracted from published reports. No individual patient data were utilized
during this study. This was utilized to create a decision-making model and
a total cost analysis on post-op day 0 - 10 to determine the most cost-efficient
day to implant a PPM. Cost variables included estimates of daily cardiac ICU
care, cost of PPM implantation, LOS, cost related to possible superficial or
deep infection based on published prevalence rates (2.3% and 4.9%, respectively)
and need for explant due to deep infection or recovery of native conduction.
The model assumes 5-day minimum LOS and 1 day increase in LOS
with PPM implantation. Cost data were obtained from relevant billing codes
and manufacturer list prices for PPM and leads. A secondary analysis evaluated
probability of unnecessary PPMs implanted and excess costs. Results:
Post-op day (POD) 4 is the lowest total cost of PPM implantation for post-op
CAVB, even when accounting for possible risk of either superficial or deep
infection. A one-way sensitivity analysis accounting for variability of cardiac
ICU care costs between centers ranging from $3000 - $9000 per day consistently
replicates POD 4 as the most cost-effective day for PPM implantation.
Implant on POD 4 results in a 26% chance of unnecessary implantation. Conclusions:
The most cost-efficient day for PPM implantation for post-op
CAVB is post-op day 4, which results in a minimum total cost savings of $17,422 per patient. Added costs due to risk of superficial or deep infection
are marginal due to low prevalence of post-operative infection in this population.