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.
Highlights
Post-operative complete atrio-ventricular heart block (CAVB) occurs after 1% - 4% of pediatric cardiac operations
Post-op day (POD) 4 is the day that results in the lowest total cost of permanent pacemaker (PPM) implantation for persistent post-op CAVB, which results in $17,422 of savings per patient in this cohort with a PPM is implanted on POD 4 versus waiting until POD 10 (Table 1)
Implantation on POD 4 confers a 26% chance of inserting a PPM in a patient who may have otherwise recovered their native AV conduction, and this results in approximately 1 extra device-related infection (0.322 extra superficial infections and 0.686 deep infections), with the excess cost to each patient in the cohort totaling $2512. This excess cost due to unnecessary PPM implantation and risk of infection reduces the total savings per patient in the cohort from $17,422 to $14,910 (14%) when the PPM implantation occurs on POD 4
Summary
Post-operative (post-op) complete atrio-ventricular heart block (CAVB) occurs after 1% - 4% of pediatric cardiac operations. 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. 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. Secondary analyses sought to establish excess costs related to probability of unnecessary PPM implantation and probability of post-operative superficial or deep pocket infection within the immediate post-op period. While there have been previously published reports on the costs related to post-operative CAVB in patients with CHD in the US [1], this study is the first to describe the cost-efficiency of earlier PPM implantation in pediatric patients with post-op CAVB
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