Fast-track extubation after cardiac surgery in infants: Tug-of-war between performance and reimbursement?

J Thorac Cardiovasc Surg. 2021 Aug;162(2):435-443. doi: 10.1016/j.jtcvs.2020.09.123. Epub 2020 Oct 8.

Abstract

Objectives: To compare the safety and resource-efficacy of the fast-track (FT) concept (extubation ≤8 hours after surgery) versus the conventional approach (non-FT, >8 hours postoperatively) in infants undergoing open-heart surgery.

Methods: Infants <7 kg operated on cardiopulmonary bypass between 2014 and 2018 were analyzed. Propensity score matching (1:1) was performed for group comparison (FT vs non-FT). Intensive care unit (ICU) personnel use and unit performance were evaluated. Postoperative outcome and reimbursement based on German diagnosis-related groups were compared.

Results: Of 717 infants (median age: 4 months, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery mortality score: 0.1-4), FT extubation was achieved in 182 infants (25%). After matching, 123 pairs (FT vs non-FT) were formed without significant differences in baseline characteristics. FT versus non-FT showed a significantly shorter ICU stay (in days): 1.8 (0.9-2.8) versus 4.2 (1.9-6.4), P < .01, and postoperative length of stay (in days): 7 (6-10) versus 10 (7-15.5), P < .01; significantly lower postoperative transfusion rates: 61.3% versus 77%, P < .01; and tendency toward lower early mortality: 0% versus 2.8%, P = .08. Reintubation rate did not differ between the groups (P = .7). Despite a decrease in personnel capacity (2014 vs 2018), the unit performance was maintained. The mean case-mix-index of FT versus non-FT was 8.56 ± 6.08 versus 11.77 ± 12.10 (P < .01), resulting in 27% less reimbursement in the FT group.

Conclusions: FT concept can be performed safely and resource-effectively in infants undergoing open-heart surgery. Since German diagnosis-related group systems reimburse costs, not performance, there is little incentive to avoid prolonged mechanical ventilation. Greater ICU turnover rates and excellent postoperative outcomes are not rewarded adequately.

Keywords: case-mix-index; congenital heart defects; diagnosis-related groups; early extubation; fast-track; postoperative management; reimbursement; unit performance.

Publication types

  • Comparative Study
  • Observational Study
  • Video-Audio Media

MeSH terms

  • Airway Extubation / adverse effects
  • Airway Extubation / economics*
  • Airway Extubation / mortality
  • Cardiac Surgical Procedures / adverse effects
  • Cardiac Surgical Procedures / economics*
  • Cardiac Surgical Procedures / mortality
  • Female
  • Health Care Costs*
  • Heart Defects, Congenital / diagnosis
  • Heart Defects, Congenital / economics
  • Heart Defects, Congenital / mortality
  • Heart Defects, Congenital / surgery*
  • Hospital Mortality
  • Humans
  • Infant
  • Infant, Newborn
  • Insurance, Health, Reimbursement / economics*
  • Length of Stay
  • Male
  • Postoperative Complications / economics*
  • Postoperative Complications / mortality
  • Quality Indicators, Health Care / economics
  • Respiration, Artificial / adverse effects
  • Respiration, Artificial / economics*
  • Respiration, Artificial / mortality
  • Retrospective Studies
  • Risk Assessment
  • Risk Factors
  • Time Factors
  • Treatment Outcome