oa Cardiovascular Journal of Africa - Payment and practice variation in congenital heart disease - an international study
Cost-effectiveness analyses suggest that if outcomes are approximately similar, examination of practice and price variation provides potential targets for improvement in quality and/or reduction in cost. We examined variations in practice patterns and price with regard to congenital heart disease in nine countries. Standardised descriptionptions of 5 typical patients, 1 each with aortic stenosis, pulmonary stenosis, atrioventricular septal defect, tetralogy of Fallot and tricuspid atresia were provided to the investigators who quantitated a typical course (from birth to 21 years of age) for each patient in terms of: clinic visits, outpatient echocardiogram, outpatient Holter, diagnostic catheterisation, therapeutic catheterisation, medical hospitalisation, surgical hospitalization and years on medication. Payments for each service in the public and private system were based on data from each country. We found that in respect of practice patterns, there was an average of 400% variation, with the greatest variation in clinic, outpatient echocardiogram, outpatient Holter and medical hospitalization costs. The overall use of services was lowest in Australian and Japan and highest in Canada and Italy. Pricewise, there was a 380% variation, with the greatest variation in the prices ofï¿½ medication and inpatient services. In the private sector in particular, prices were highest in Japan, the USA and Germany, and lowest in South Africa and France; in the public sector, prices were highest in Canada, Japan and Germany, and lowest in South Africa and Australia. Overall, the average worldwide payments for congenital heart disease from birth to 21 years of age were as follows: mild aortic stenosis $3 851; mild pulmonary stenosis $7 319; tetralogy of Fallot $36 456; atrioventricular septal defect $39 772; tricuspid atresia $74 940. The mean was $32 968. Payments were highest in the USA, Japan and Italy, and lowest in Australia and South Africa. In conclusion: (l) there is significant practice and price variation in paediatric cardiology services. throughout the world; and (il) further study of the need for services in which there is high variation (outpatient echocardiogram, Holter and medical admissions) is warranted, since significant reduction in these services may be possible with considerable savings and no reduction in quality.
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