CLINICAL
NEWS JACC in a FLASH
Featured topics in the current and recent
issues of the JACC family of journals
Pediatric Congenital Heart
Disease: A Total Population Story
Use of pediatric cardiology specialty
care centers has increased dramatically
over the last few decades, according
to a new study in JACC examining regionalized care for pediatric congenital
heart disease (CHD) in California.
Advancements in treatment have
improved the outcomes for children
born with CHD, leading to an increasing number of patients who need
ongoing care. Additionally, addressing
disparities in care for these patients is
a priority—access to care for CHD patients has been shown to vary between
white and non-white patients, as well as
between different types of insurance.
Lisa J. Chamberlain, MD, MPH, and
colleagues examined how the utilization of regional care center for pediatric
cardiac care has evolved over the last 30
years. During this time, there has been
growth of public insurance programs and
the introduction of managed care models.
The authors examined regional
pediatric cardiology specialty care
center (PCSCCs) in California between
1983 and 2011. The analysis included
164,310 pediatric CHD discharges
from these centers, with 70% of discharges being associated with a surgical
procedure and 30% associated with
hospitalization without surgery.
During the study period, regionalization of pediatric CHD care increased—58% of discharges in 1983
were from a PCSCC, while that number
jumped to 88% in 2011. Regionalization
of surgical cases also grew from 61% in
1983 to 96% in 2011. For non-surgical
cases, regionalization grew from 48%
in 1983 to 71% in 2011. However, in
2002, rates of regionalization for both
surgical and non-surgical discharges
plateaued. The researchers also found an
increased demand on inpatient care for
CHD patients with bed days increasing
from 35,753 at the start of the study
period to 71,278 at the end—a 199%
increase. This change was seen even
when adjusted for child population
ACC.org/CSWN
growth. However, PCSCC bed day increased from 22,949 in 1983 to 65,189
in 2011, while bed days in non-specialty
care centers declined from 12,804 to
6,089 during the same period.
During this time, there was also a
shift in payer status. In 1983, there was
an equal split between public and private
payers in both specialty and non-specialty sites. In 2011, however, 66% of all
pediatric CHD bed days were covered by
public programs and 96% of those were
cared for in specialty hospitals.
Finally, death rates from CHD
decreased by 45% during this period.
In 1983, 70% of death occurred during
surgery, while that number fell to 57%
in 2011. According to the authors, “As
outcomes for pediatric patients with
CHD are improved in high volume
centers, further work needs to explore
policy opportunities to recapture the
upward trend of regionalized care.”
Increased survivorship of pediatric
CHD patients has contributed to the
increased utilization of PCSCCs.
“The advances and emerging epidemiology of congenital heart disease have
engendered new demands on systems of
care, requiring increased specialization
across a wide range of multidisciplinary
teams found in regionalized centers,
where volume leads to improved quality,” the authors write. “With these shifts
have emerged other patterns: in California, deaths are increasingly associated
with medical versus surgical admissions,
echoing the literature describing that
survivors succumb more often to medical conditions that surgical problems,
and elevating the concerns that regionalized care lags for non-surgical admissions compared to surgical admissions.”
Over the study period, California
PCSCCs increased in both volume and
financial instability. With more children
covered by Medicaid, PCSCCs are seeing an increased number of bed days
covered by public payers. PCSCCs are
therefore more dependent on public
reimbursement rates and funding for
PCSCCs have become increasingly
vulnerable to policy shifts.
In an accompanying editorial comment, Roberta G. Williams, MD, writes
that the work by Dr. Chamberlain and
her colleagues is a step forward in understanding demographic and environmental changes in the CHD population and
planning future resource requirements.
“As each decade has brought innovation
that has increased survival of the marginally viable, it is likely that the pattern
of health service utilization will be quite
different when today’s child with CHD
becomes an adult,” she said. “Recent
cohorts of CHD patients will require
increasingly more services throughout
their lives… [We must] strive to find the
most efficient and low-cost strategies to
provide the best value for the patient and
to society.” She adds that a continuing
effort must be made to provide the best
health outcomes over a lifetime and to
innovating new strategies that simplify
care and its cost.
Chamberlain LJ, Fernandes SM, Saynina O, et
al. J Am Coll Cardiol. 2015;66(1):37-44.
Lipid-Lowering
After ACS: How to
IMPROVE It
Despite the established benefits of
statin therapy for secondary prevention after acute coronary syndromes
(ACS), registry data shows substantial
underutilization of and non-adherence
to prescriptions, according to a new
review paper published July 6 in JACC.
In the review, the authors led by
Laurence S. Sperling, MD, examined data demonstrating the lack of
optimal statin use despite the proven
benefits. In the recently published IMPROVE-IT trial, up to 40% of patients
discontinued statins prematurel H[