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Fontan palliation versus heart transplantation: a comparison of charges
R J Gajarski1, J A Towbin, A Garson
1Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Texas Children's Hospital, Houston, TX 77030, USA.
Insights
Heart transplantation is more expensive than Fontan palliation initially, but Fontan palliation becomes more costly for high-risk patients due to increased morbidity and need for transplantation. Heart transplantation may offer better long-term survival and cost-effectiveness for these individuals.
Area of Science:
- Pediatric Cardiology
- Cardiovascular Surgery
- Health Economics
Background:
- Single-ventricle physiology presents complex surgical challenges.
- Current surgical options include Fontan palliation and heart transplantation.
- Cost-effectiveness data comparing these approaches are limited.
Purpose of the Study:
- To compare the expenditures associated with the Fontan procedure versus heart transplantation for single-ventricle abnormalities.
- To evaluate the long-term cost implications, including follow-up care and readmissions.
Main Methods:
- Retrospective review of 82 Fontan procedure patients and 26 heart transplant recipients (1988-1992).
- Inclusion of all costs: surgery, hospital stay, physician fees, diagnostic charges, readmissions, and outpatient evaluations.
- Expenditures estimated using 1992-1993 dollar charges.
Main Results:
- Total expenditure for heart transplantation ($96,475) significantly exceeded the Fontan procedure ($29,730).
- Transplant recipients had higher readmission rates and diagnostic test utilization.
- High-risk Fontan patients requiring subsequent transplantation incurred greater combined costs than initial transplantation.
Conclusions:
- While initial heart transplantation costs are higher, Fontan palliation for high-risk patients leads to greater long-term expenditures and morbidity.
- Heart transplantation is recommended as the initial definitive procedure for select high-risk single-ventricle patients.
- This approach may improve long-term survival and reduce overall healthcare costs.
Abstract:
Surgical approaches to single-ventricle physiologic abnormalities have included Fontan palliation or transplantation. No cost expenditures have been published. This study compared expenditures between the Fontan procedure and heart transplantation. Between 1988 and 1992, records of 82 patients who underwent the Fontan procedure and 26 who underwent transplant were retrospectively reviewed. Charges for Fontan or transplant procedures were accrued from the date of surgical admission until discharge or patient death and included hospital, physician, and diagnostic laboratory charges. Additionally, the frequency and cost of postoperative hospital readmissions, outpatient evaluations, and diagnostic procedures were recorded for each patient. Estimated expenditures for each evaluated parameter were based on 1992 to 1993 dollar charges. The total expenditure (surgery plus yearly follow-up) for transplantation exceeded that for the Fontan procedure ($96,475 vs $29,730; p < 0.001). Although both groups had similar follow-up periods and mortality rates, the number of hospital readmissions and postoperative diagnostic tests was higher among transplant recipients. Within 1 postoperative year at least four high-risk patients who had undergone a Fontan procedure required listing for transplantation; the total costs of their combined procedures (approximately $80,000 + $3,000 to $5,000 annual outpatient charges) was markedly greater than the cost of the Fontan procedure alone. Although the expenditure for heart transplantation far exceeds that for the Fontan procedure, Fontan palliation in high-risk patients is ultimately more costly and increases postoperative morbidity. In this subgroup, we recommend heart transplantation as the initial definitive procedure because it may increase long-term survival rates and minimize health care expenditures.