Center Volume and Cost-Effectiveness in the Treatment of Congenital Diaphragmatic Hernia.

Abstract

The care of patients with congenital diaphragmatic hernia (CDH) is expensive, yet little is known about variability in cost-of-care for these patients. The purpose of this study was to examine the cost-effectiveness of CDH treatment, comparing high- versus low-volume centers. This is a retrospective study of neonatal patients with CDH at U.S. hospitals using data from the Pediatric Health Information System database (2015-2018). Centers were considered high-volume if they had ≥10 patients with CDH for≥2y. Cost-effectiveness analysis was performed with cost per survivor as the outcome measure, and probabilistic sensitivity analysis was performed. A total of 1687 patients were included in the study. Overall mortality was 24.4%. Patients at high-volume centers had a longer mean length of stay (64d versus 48d for low-volume centers, P=0.0001) and higher extracorporeal life support (ECLS) rates (32% versus 24%, P=0.002). Risk-adjusted mortality did not differ between high- and low-volume centers (23.9% versus 25.9%, P=0.39), except when ECLS was involved (42% versus 56%, P=0.011). Costs were significantly higher at high-volume centers ($395,291±508,351 versus $255,074±308,802, P<0.0001). Survival status, ECLS use, operative repair, length of stay, high-volume status, and gestational age were identified as independent drivers of cost. On cost-effectiveness analysis, low-volume hospitals were more cost-effective in 95% of simulations. High-volume centers have substantially higher costs without an associated survival benefit and are less cost-effective than low-volume centers. Standardization of care is necessary to minimize the delivery of low-value care.