Congenital heart disease is one of the most common forms of major birth defects. The problem which plagues this spectrum of disease is the difficulty in access to diagnostic facilities and its treatment which is quite expensive and complicated and therefore, it affects individuals, families, healthcare systems and national productivity. This is the first documented study on the cost of care for congenital heart defects in Pakistan. The focus of this study was to compare the outcome and resource utilization. The costs that we thought to contribute mainly to the care for CHD patients were included in the study.
On average, a child in group A and group B has to undergo Rs. 346019.60 and Rs. 473558.89, respectively at the time of surgical admission. This figure highlights two very important points. Firstly, the direct cost for cardiac surgical intervention is higher in the older age group (Group B). This does not include the cost of additional admissions due to other causes, especially respiratory problems. Secondly, even though the cost is lower when the intervention is done early, it still is large enough to be borne by families belonging to poor socioeconomic class. If we look at the interventions performed at government hospitals only, there is an added burden on the economics, especially in a country where 48% of the households have income ranges between Rs.5,001 - 20,000. .
The cost of hospital admissions, preoperatively and post operatively showed no significant difference between the two groups. However, the number of outpatient visits due to non-cardiac causes was higher in the older age group, preoperatively. Delay in seeking intervention puts these children at a greater risk for infections and organ dysfunction. As a result, they are more likely to develop problems, in addition to their cardiac defect and end up visiting several different doctors before an actual diagnosis is made, immensely increasing the cost of visits until reaching the final diagnosis, as evident in our study. Similarly, outpatient visits postoperatively due to cardio-pulmonary problems were also higher in the older age group. This can be attributed to the chronic harmful effects on the physiology of these children by the delayed intervention of CHD such that even though the defect was repaired, their organ systems took time to adapt.
Even though, there was no difference in the emergency room visits among the two groups, pre operatively and postoperatively; we strongly believe that if the study was conducted on a much larger basis, the difference would have been surely evident.
Only intra- and postoperative complications were recorded as outcomes for the study. Our results indicate that although the number of complications in the younger group was higher there was no significant difference in mortality between the two groups. Moreover, there was no significant difference when greater than one complication was looked at. The length of PICU stay in group A was found to be around 8 days where as in group B it was 5.6 days. The difference in post op PICU stay was statistically significant but this finding was not surprising as infants are expected to have longer PICU stay. A similar trend was hence obtained in the length of hospital stay.
None of the families that came to us had insurances to cover the cost of their children's health care. All of it was paid by parents. On several occasions, the families were supported by the hospital's welfare system. In such part of the world, where there is no social support system and expenses are out of pocket , there is a strong need for health insurance schemes, especially for the lower socioeconomic class, so that interventions can be taken at an earlier stage and complications can be reduced.
Management of congenital cardiac defects with appropriate surgeries at proper time in developing countries is a major challenge. Nowadays, it is preferred to choose a procedure that ensures maximum palliation at lower cost and at times priority is given to one-staged corrective procedures although it increases the risk of complications . Although corrective cardiac surgeries in very ill patients and low birth weight children has a higher mortality, improvements in peri-operative, anesthetic, surgical, and postoperative management have lowered the overall surgical mortality . The advantages of early corrective surgeries have been widely proven over palliative surgeries although the latter still plays an important role, especially in the staged treatment of severe complex heart malformations.
On the other hand, our study has some limitations. It is a single centre based study, so a lot has to be taken into consideration before the results can be generalized. Other aspects of resource utilization have not been looked into, especially the time spent on care for the patient, amount of hours lost from the job by the parents, effect on salary, on household expenditure and so on. Lastly, a little information obtained through the telephone was based on an estimate rather than actual figures on the paper and this bring in, to some extent, a recall bias in estimating the total postoperative cost of CHD patients.