title: Neonatal hypoplastic left heart syndrome: effects of bloodstream infections on outcomes and costs.
abstract: BACKGROUND
  Hypoplastic left heart syndrome (HLHS) is not only a devastating disease, but also the most expensive birth defect managed in the US. Nosocomial bloodstream infections (NBIs) are common in neonates with HLHS. We examined the effects of NBIs on in-hospital mortality, length of stay, and costs for late preterm and term infants with HLHS undergoing stage 1 palliation, at both individual patient and hospital levels.
  
  
  METHODS
  We conducted a retrospective study of infants 35 weeks or greater gestation with HLHS, admitted to our institution January 1, 2003 to January 1, 2013. Children with other cardiac abnormalities, major comorbid conditions, or perinatal infections were excluded. Univariable and multivariable analyses were performed. To estimate the effects of reduced NBI incidence on resource utilization, predictive models were used.
  
  
  RESULTS
  One hundred forty-three children met inclusion criteria. In-hospital mortality was 9.1% (n = 13). Postoperative infection was observed in 12.6% (n = 18). Median length of stay was 23 days for survivors (IQR, 17 to 40; range, 9 to 132). Median costs were $83,000 for survivors, in 2013 dollars (IQR, $62,000 to $123,000; range, $17,000 to $517,000). NBIs were not associated with changes in mortality. In multivariable analyses, at a patient level NBIs were associated with a 74% increase in length of stay (95% confidence interval [CI], 31% to 132%, p < 0.001) and a 65% increase in costs (95% CI, 28% to 114%, p < 0.001). On a hospital level, in this cohort a 50% reduction in the incidence of NBIs would be expected to yield a 4.3% decrease in average length of stay and a 3.8% decrease in average in-patient costs.
  
  
  CONCLUSIONS
  Nosocomial bloodstream infections in neonates with HLHS are associated with large increases in lengths of stay and costs on a patient level, but not a hospital level. For hospitals without particularly high incidences, studies are needed to identify additional targets for quality improvement.
authors.affiliation: Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, New York. Electronic address: bra2113@cumc.columbia.edu.
authors.forename: Brett R
authors.initials: BR
authors.lastname: Anderson
authors.affiliation: Division of Biostatistics, Department of Child and Adolescent Psychiatry, New York University, New York, New York.
authors.forename: Adam J
authors.initials: AJ
authors.lastname: Ciarleglio
authors.affiliation: Division of Neonatology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, New York.
authors.forename: Ganga
authors.initials: G
authors.lastname: Krishnamurthy
authors.affiliation: Robert F. Wagner Graduate School of Public Service, New York University, New York, New York.
authors.forename: Sherry A
authors.initials: SA
authors.lastname: Glied
authors.affiliation: Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, New York.
authors.forename: Emile A
authors.initials: EA
authors.lastname: Bacha
mesh_terms: D016470:Bacteremia / Q000191:economics / Q000453:epidemiology* / Q000628:therapy; D003428:Cross Infection / Q000191:economics / Q000453:epidemiology* / Q000628:therapy; D005260:Female; D017721:Hospital Costs; D017052:Hospital Mortality; D006801:Humans; D018636:Hypoplastic Left Heart Syndrome / Q000150:complications / Q000191:economics* / Q000628:therapy*; D015994:Incidence; D007231:Infant, Newborn; D007902:Length of Stay; D008297:Male; D017063:Outcome Assessment, Health Care; D010166:Palliative Care / Q000191:economics*; D012189:Retrospective Studies