THE COSTS AND BENEFITS OF OUTPATIENT SURVEILLANCE OF CONGENITAL HEART-DISEASE AFTER REPAIR

Regular outpatient re-evaluation in hopes of recognizing treatable post-operative problems is common practice after repair of congenital heart disease. The purpose of this investigation is to audit resource utilization in the care of outpatients after repair of congenital heart disease and to determine what relationship, if any, this utilization may have to active medical management. A chart review of a population of outpatients after surgical repair of secundum or sinus venosus atrial septal defect, surgical or catheter mediated relief of pulmonic stenosis, surgical repair of coarctation of the aorta, repair of tetralogy of Fallot, and Mustard operation for transposition of the great arteries yielded 1252 patient-years of follow-up between 1987 and 1993. Each patient-year was analyzed for management changes and for utilization of outpatient services. Cost of these services was translated to 1994 dollars. More complicated forms of congenital heart disease were associated with more management changes and more outpatient services. Atrial septal defect had no management changes in 254 patient-years of follow-up. Costs per patient-year varied over 6-fold ($237 for atrial septal defect to $1485 for tetralogy of Fallot). Lesion by lesion variation in types of resources utilized in surveillance of repaired congenital heart disease reflected the variation in lesion-specific anticipated late complications. Distribution of costs and management changes were highly skewed within individual forms of repaired heart disease, concentrating 44% of cost and 45% of management changes in the costliest 10% of patient-years within each diagnosis. Outpatient surveillance of repaired congenital heart disease is presently a high technology undertaking, with large expenditures for echocardiography and 24-h ambulatory electrocardiography. Resource allocation decisions that may be mandated in times of austerity must be made in light of the heterogeneity of risk for late complications across and within forms of repaired congenital heart disease.