Standardizing care delivery for infants and children with common congenital cardiac lesions

The emergence of managed care is influencing the practices of pediatric cardiology and cardiac surgery. The need for efficiencies brought about by standardizing care whenever possible has led to the development of care guidelines and clinical pathways. Care guidelines are general algorithms mapping the care of a specific problem. They are patient oriented and cover all aspects of care from diagnosis onward. National task forces have recently published guidelines for the care of children with specific congenital cardiac defects, and some of these are reviewed. Clinical pathways are more specific to an episode of inpatient or outpatient care. They consist of expected defined outcomes of care, including all tests, monitoring, and intervention. In other fields, clinical pathways have been developed for specific diagnoses or procedures. However, in pediatric cardiac surgery, the variety of conditions and operations is so great that two different methods of acuity-based, rather than disease-based, clinical pathway methodologies were developed that have been shown to decrease lengths of stay and hospital charges. Refinement of the system will require more sophisticated data, including the delineation of actual costs rather than charges, along with refinement and standardization of outcomes measurements. With fundamental changes in the delivery system, the roles of the specialist and the primary care physician have undergone changes that will continue to evolve. Vigilance on the part of all providers will be necessary to assure quality of care in this new milieu.