O1004: What Are the Trends in Procedure Choice, Cost and Outcome in Infants Undergoing Stage 1 Palliation for Hypoplastic Left Heart Syndrome over Time?

Background: Management of infants with hypoplastic left heart syndrome (HLHS) is resource intensive. Trends in initial stage-1 palliation procedure choice and associated hospital cost and outcomes for infants with HLHS over time are unknown. Understanding how initial palliation choice is associated with outcomes and cost is beneficial in optimizing patient care. We utilized the Pediatric Health Information System (PHIS) to analyze rates of stage-1 palliation procedure choice, in-hospital mortality, and hospital cost among infants with HLHS who underwent stage-1 procedure between 2004-2022.

Methods: This retrospective cohort of infants < 30 days of age (2004-22) with HLHS were categorized by the initial stage-1 palliation procedure: 1) Norwood with modified Blalock-Taussig (NmBT) shunt, 2) Norwood with right ventricle to pulmonary artery (NRV-PA) conduit, or 3) hybrid procedure. The cohort and procedures were identified by ICD-9/10 and CPT codes. Patients with primary heart transplantation, more than one stage-1 procedure on the same day, or with a qualifying procedure later than the 30th service day were excluded. Demographics, estimated hospital cost, and mortality rates were pooled across years, summarized by procedure type, and compared with χ2 tests for categorical variables and Kruskal-Wallis tests for continuous variables. Trends over time were evaluated with Cochran-Armitage and Mann-Kendall tests.

Results: Among 45 PHIS hospitals, 7701 infants met eligibility criteria. During the study period, 67.5% (n=5194), 22.1% (n=1699), and 10.5% (n=808) of patients underwent NmBT shunt, NRV-PA conduit, and hybrid procedures respectively. More than 60% of all patients in each group were male. In-hospital mortality differed between NmBT (16.4%), NRV-PA conduit (11.2%), and hybrid (27.2%) procedure groups (p < 0.001). Median (IQR) adjusted estimated cost also differed between groups (NmBT: $189,660 [IQR: $119,375 - $332,609); NRV-PA conduit: $292,415 [IQR: $174,805 - $503,063]; hybrid: $260,123 [IQR: $128,360 - $532,612]; p=.0001). The NmBT shunt rate decreased from 87.2% in 2004 to 29.9% in 2022 (p <.001 for trend), while the NRV-PA conduit rate of 53.6% surpassed the NmBT shunt rate in 2017. The sharpest observed decline in NmBT shunt rate occurred between 2014 and 2017 [Figure 1]. An increase in median estimated hospitalization cost was observed across time for all procedure types (p <.0001) [Figure 2]. There were no observed trends in mortality over time (p>.05 for all procedure types).

Conclusion: Norwood with RV-PA conduit procedure has become the preferred stage-1 palliation. Patients who underwent this procedure had the lowest in-hospital mortality. The estimated hospitalization cost for NRV-PA conduit was higher compared to other procedures during its adoption. However, it has been the most cost-effective option since 2014. Over time, all stage-1 palliation options have become more expensive and there has not been a significant change in mortality.