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Family and Society ■ Missed work days for parents and family during hospitalizations and doctor visits ■ Additional costs during hospitalizations (food, parking, etc.) ■ Time spent with paperwork (insurance claims, individual educational plan maintenance, etc.) ■ Daycare and other costs for siblings of children with CHD during hospitalizations and outpatient care ■ Lost opportunity costs for improved income and job satisfaction if changing employment is limited by insurance tied to job (United States) ■ Higher insurance premiums (United States) ■ Lifelong supportive care These costs and their implications are not limited to childhood, however As children with CHD become adults with CHD, new challenges arise First, the severity of the CHD, any neurodevelopmental challenges associated with the CHD, and surgical intervention (see also Chapter 76) may affect employment opportunities for adults with CHD.50–52 Some types of employment that require intense physical activity may be advised against or even prohibited.53 For example, in the United States, people with CHD (except for those with a patent arterial duct or bicuspid aortic valve) are typically excluded from military service.54 These limitations in the job market may have important financial ramifications Second, there may be challenges in applying for medical insurance, life insurance, travel insurance, or even home mortgages among individuals with CHD, including those with mild CHD.50–52, 55–58 For those who are able to obtain these products, their rates are often higher than those of healthy controls With all of these burdens in mind, society must plan appropriately to meet the needs of this growing population For instance, schools and educational systems must prepare to meet the academic and special educational needs that many children with CHD may require.59–61 Additional research and evaluation would help to identify the programs and interventions that could be implemented at a society level to help individuals with CHD succeed Nonfinancial Costs It is beyond the scope of this chapter to discuss the psychosocial impact of CHD for patients and families; although this is well described, it is difficult to quantitate (Box 14.2) The reader is referred to several references on the topic, as well as Chapters 12, 76, 77, 83, and 85 in this text Box 14.2 Potential Psychosocial Costs of Congenital Heart Disease to the Patient and Family Patient ■ Poor body image ■ Posttraumatic stress disorder ■ Increased anxiety, depression, and other mental illness ■ Infertility and/or increased risks of pregnancy ■ Difficulties with forming social relationships Family ■ Loss of “normalcy” ■ Less traveling, evenings out, hobbies ■ Marital discord ■ Posttraumatic stress disorder ■ Fear of unknown and lifelong outcomes ■ Increased rates of antisocial behavior in siblings Annotated References Arth AC, et al Inpatient hospitalization costs associated with birth defects among persons of all ages: United States, 2013 MMWR Morb Mortal Wkly Rep 2017;66(2):41–46 This landmark article from Centers for Disease Control examines the hospitalization costs for a variety of birth defects across the life span Pasquali SK, et al Variation in congenital heart surgery costs across hospitals Pediatrics 2014;133(3):e553–e560 Combining data from the Society of Thoracic Surgeons database and the Pediatric Hospital Information Systems databases, Pasquali and colleagues examine the differences in the cost of congenital heart disease surgery across various children's hospitals and provide benchmarks for common operations in the United States Shin AY, et al Exploring value in congenital heart disease: an evaluation of inpatient admissions Congenit Heart Dis 2015;10(6):E278–E287 Dr Shin and colleagues identify opportunities to target quality improvement and resource allocation efforts in order to maximize value in congenital heart disease management ... Variation in congenital heart surgery costs across hospitals Pediatrics 2014;133(3):e553–e560 Combining data from the Society of Thoracic Surgeons database and the Pediatric Hospital Information Systems databases, Pasquali and