Abstract 1779: The Negative Impact of Diagnostic Testing Performed Prior to Adult Congenital Heart Disease Referral - Financial Burden and Cost to the Patient
Adult congenital heart disease (ACHD) patients (pts) are an underserved, complex, rapidly expanding population and, despite surpassing the volume of pediatric CHD pts, neither IM or pediatric cardiology fellowship fully prepares physicians to care for this group. The diagnostic studies recommended, technical skills required, and unique data interpretation requires specialized training in both disciplines. Therefore, we sought to determine whether pts referred to our ACHD program underwent appropriate and complete testing prior to referral and evaluated the financial impact of unnecessary and repeat testing.
Methods: We reviewed diagnostic testing before and after referral to the ACHD program for consecutive new pts (>18 yo). All cardiovascular testing prior to referral and subsequent testing were recorded. Unnecessary testing was defined as those performed outside of guidelines or inappropriate for their CHD. Incomplete testing was defined as that which required repeating. Financial cost of unnecessary and repeat testing was estimated based on usual insurance billing practice.
Results: From 2/06 to 4/07, 200 new pts were referred to the ACHD program, mean age 33.2 ± 12.7 yrs (range 18.1–72.9 yrs). Common diagnoses included ASD (17%), TOF (14%), bicuspid aortic valve (11%) and COA (10%) with 81% classified as moderate or complex CHD. Unnecessary testing consisted of 35 stress studies (25 nuclear and 10 echo), 5 TEEs, and 14 cardiac caths. Repeat studies for incomplete testing were necessary in 65/81 TTEs (80%), 9/39 TEEs (23%), 0/5 cardiac CTs, 8/12 CMRs (67%) and 16/31 caths (51%). Overall,105/200 pts (52%) endured unnecessary or repeat testing carrying a conservative financial burden of $456,980; 916 patient hours: and 114 patient work days lost.
Conclusions: Diagnostic testing in ACHD requires specialized training from technician to physician. Repeat testing was necessary in 58% of studies, and 52% of the pts were affected by unnecessary or repeat testing. Therefore, ACHD pts frequently endure unnecessary and repeat testing which carries a financial burden to the patient and health care system and medical risk to the patient. Adults with moderate and complex CHD should be referred to appropriately trained ACHD providers prior to diagnostic testing.