• J. Thorac. Cardiovasc. Surg. · Aug 2021

    Comparative Study Observational Study

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

    • Peter Murin, Viktoria H M Weixler, Olga Romanchenko, Antonia Schulz, Mathias Redlin, Mi-Young Cho, Nicodeme Sinzobahamvya, Oliver Miera, Hermann Kuppe, Felix Berger, and Joachim Photiadis.
    • Department of Congenital Heart Surgery-Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany. Electronic address: murin@dhzb.de.
    • J. Thorac. Cardiovasc. Surg. 2021 Aug 1; 162 (2): 435-443.

    ObjectivesTo 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.MethodsInfants <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.ResultsOf 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.ConclusionsFT 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.Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

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