Invited response to: Controlling the cost of management of congenital heart disease

We appreciate the thoughtful response from Drs. Peer and Jonas¹. The number of patients who previously underwent staged management of Tetralogy of Fallot (TOF) was not evaluated in this study², as this is unlikely to influence the change in hospital costs following implementation of an early extubation clinical practice guideline.

Drs. Peer and Jonas make a valid point that the costs of two hospitalizations for a staged repair would likely result in higher costs than a single surgery for primary repair. However, a more important question is whether there is truly better value, which would require a comprehensive assessment of the costs for both inpatient and outpatient care for TOF as well as longitudinal clinical outcomes for patients who undergoing primary repair versus staged repair for TOF and adjustment for patient-level risk factors. In addition, it must be taken into consideration that the impact of one versus two stages of repair may vary among institutions³. Unfortunately, this evaluation is outside the scope of our study whose primary aim was to investigate the effect of implementation of an early extubation clinical practice guideline on hospital costs for several common infant cardiac surgeries. But we do agree this would be an interesting investigation to undertake in the future to address the question posed by Drs. Peer and Jonas.