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cost for a Norwood operation was $165,168.18 The care after surgery has an impact on costs as well An important contributor to higher costs is the overall length of stay.19 For complex surgeries, reducing the length of stay may be difficult Interventions such as earlier extubation20 and increased resource utilization in the earlier postoperative period after the repair of a tetralogy of Fallot21 did not result in shorter length of stay in an intensive care unit Complications such as renal failure, sepsis, need for extracorporeal membrane oxygenation, and need for mechanical ventilation are all associated with increased costs.12,19,22 Similarly, hospitalizations that result in mortality typically incur the greatest costs.23 However, costs of care are not restricted to the initial surgical encounter Any efforts to reduce costs of the surgical encounter must be balanced with the impact these efforts may have on the likelihood of readmission, as readmission hospitalizations have been shown to be a key driver of increased costs for the CHD population.5,17 Variation in Costs The reported costs of care for patients with CHD vary remarkably between hospitals For some procedures, the difference in costs between centers in the United States has been as high as ninefold.18 Differences in length of stay and complications following surgery can explain some of these differences but not all For the most common and less complex surgeries, increasing the volume of cases appears to be associated with lower costs, consistent with economies of scale.24,25 Opportunities to Reduce Costs As costs have continued to increase over time, even after adjusting for inflation, hospitals and health systems have implemented efforts to contain or even reduce costs, particularly for resource-intense surgical encounters For example, countries such as Mexico have promoted the regionalization of cardiac surgical care so as to reduce both costs and mortality,26 although this model is controversial in the United States.27,28 Dating as far back as the early 1980s, hospitals have investigated ways to reduce costs, such as by minimizing laboratory tests and “surveillance catheterizations” with some success.29 It may be important to target interventions in some lower-severity but highly prevalent types of CHD, as these contribute greatly to population costs.30 For example, “fast track” programs have been developed in various countries to accelerate the postoperative period for select cardiac operations such as closure of ventricular or atrial septal defects.31–33 Such focused cost-containment efforts have been shown to reduce costs by as much as 34% without increasing mortality or readmission rates.34 However, cost reduction should not be pursued if it comes with a greater risk of adverse outcomes Although higher-volume hospitals may have lower costs and mortality, the fact remains that when other factors are controlled, higher costs may be associated with lower mortality.24,25,35 It is important to weigh the balance of any cost-containment measures with potential impacts on outcomes; a reduction in costs that is achieved by sacrificing quality and increasing adverse outcomes will diminish the value of the care delivered.36 Costs to Patients, Families, and Society (See Also Box 14.1) An often ignored but likewise important cost of care for the patient with CHD is the financial burden and time costs borne by the families of affected children and the patients themselves.37 These financial burdens are in addition to the numerous emotional, psychosocial, and psychologic aspects of growing up with CHD.38–42 Frequent doctor visits, extended hospitalizations, and intricate care needs place a financial and emotional toll on families.43–45 Many caregivers may give up employment in order to provide care for a fragile child with CHD or may add a second job in order to meet the associated financial needs.46 The greatest nonmedical costs to families of children with CHD include lost income, the costs of transportation, and the need to care for siblings.47–49 Box 14.1 Indirect Cost Considerations of Congenital Heart Disease to the Patient, Family, and Society Patient and Society ■ Neurodevelopmental care (e.g., autism, attention deficit hyperactivity disorder, disorders of executive function) ■ Speech, physical, and occupational therapy, including special education ■ Costs associated with managing conditions associated with CHD, such as premature dementia, obesity, hearing loss, and infections ■ Additional specialty care ■ Additional immunizations ■ Less financially beneficial employment opportunities for adults with CHD ■ Accommodations for disabilities