William N. Evans, MD & Ruben J. Acherman, MD
Introduction
In contrast to postnatal oximetry screening, fetal cardiac evaluation and diagnosis is the best evidence-based method for perinatal detection of specific cardiovascular malformations.[1,2] Utilizing ongoing community-wide, general obstetric and specialized perinatal sonographer education, coupled with non-siloed fetal cardiology and perinatology care, a system of near-universal prenatal detection of critical congenital cardiovascular malformations is achievable in large, geographically diverse populations.[3,4] Organized in this manner, universal fetal echocardiography is not necessary. Rather, educationally-driven general-obstetric sonographer identification of possible fetal cardiovascular abnormalities increases the probability of a specific malformation diagnosis when referred to an integrated fetal cardiology-perinatology care system for fetal echocardiography. Previous reports have commented on or modeled possible costs of prenatal detection of congenital cardiovascular malformations.[5,6] To evaluate our program, this study analyzed estimated costs per case of a cardiovascular malformation prenatally detected in Nevada for both significant and critical malformations. To the best of our knowledge, no previous study has analyzed non-theoretically modeled cost data from a state-wide population.
Materials and Methods
The study protocol conforms with the principles of the Declaration of Helsinki of 1975, as revised in 2013. The local Sunrise Institutional Review Board approved this study and exempted consent. We accessed data for this observational, non-randomized report by inquiring our research database (Epi-InfoTM), an internal congenital cardiovascular surgery database, and our electronic health records (EHR). The Epi-Info database is maintained by the Children’s Heart Center Nevada’s research director, and data is exclusively entered from coding sheets completed by our center’s physicians from each patient encounter or procedure. No individual or other party external to our center has access to our Epi-Info database, congenital cardiovascular malformation database, or EHR. For the searchable parts of our EHR, we used Perspective Software by Lexmark International, Inc. Lexington, Kentucky. As the sole provider of prenatal and postnatal congenital cardiology services in the state, our electronic databases include information on all patients diagnosed with congenital cardiovascular malformations in Nevada. Following the database and EHR inquiry, we reviewed patient records and collated data for analysis. We used descriptive statistics to report averages, percentages, and rates, and we did not utilize statistical testing to compare values. From the inquired databases and EHR, we identified all patients born in Nevada between March 2019 and March 2020 that underwent, between zero and twelve months of age, or are likely to undergo a primary cardiovascular surgery or a neonatal emergent catheter interventional procedure rather than a surgical procedure or who have received comfort care for a complex malformation. Conditions, requiring neonatal procedures at ≤ 30 days old, were deemed as critical congenital cardiovascular malformations, and conditions requiring, or likely to require, a surgical procedure between one and twelve months of age were deemed as significant congenital cardiovascular malformations. From this cohort, we identified those mothers who received standard prenatal care that included at least one obstetric ultrasound and were referred to a maternal-fetal-medicine center for fetal risk factors or a suspected fetal cardiac abnormality to undergo a fetal-cardiologist-supervised, diagnostic-fetal echocardiogram. Similar to Pinto and associates.[5] We utilized Medicaid reimbursement figures, Table 1, as average values for fetal echocardiography and evaluation of management services performed.
For an estimate of the cost per case detected, we first determined the number of total fetal cardiac evaluations and divided that total by the number of prenatal fetal cardiovascular malformations detected to determine the number of fetal cardiac evaluations per detected malformation. The number of fetal cardiology evaluations per malformation detected was multiplied by the total cost for each fetal cardiology evaluation to calculate an estimated cost per case detected. In addition, we also analyzed the percentages of those with Medicaid, commercial insurance, or no insurance coverage separately for those prenatally diagnosed and those non-prenatally diagnosed. Beyond this, we performed no other cost analysis, such as estimated savings from reduced utilization of emergent neonatal transport services or any other prenatal or postnatal expense or savings from the diagnosis and management of congenital cardiovascular malformations.
To read the full article, please go to the October 2020 Issue of CCT.