Characteristics and Health Services Utilization among Adults with Congenital Heart Malformations in Israel

Michal Benderly ^1,2 Leonard Blieden ^2,3 Jonathan Buber ⁴ Alexander Dadashev ^2,3 Ofra Kalter-Leibovici ^1,2 Avraham Lorber ⁵ Amiram Nir ⁶ Sergei Yalonetsky ⁵ Gabriel Chodick ^2,7 Dalia Weitzman ^7,8 Ran Balicer ⁹ Havi Murad ¹ Rafael Hirsch ^2,3 On behalf of the Israeli Congenital Heart Disease Research Group ¹
¹Cardiovascular Epidemiology Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat-Gan
²Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
³Adult Congenital Heart Disease Unit, Rabin Medical Center, Petach Tikva
⁴Heart Institute, Sheba Medical Center, Ramat-Gan
⁵Pediatric Cardiology and GUCH Unit, Technion Faculty of Medicine,, Rambam Health Care Campus, Haifa
⁶Department of Pediatric Cardiology, Hebrew University Medical Center, Hadassah, Jerusalem
⁷Medical Division, Maccabi Healthcare Services, Tel Aviv
⁸Faculty of Health Sciences, Ben-Gurion University of the Negev, Negev
⁹Clalit Research Institute, Clalit Health Services, Tel Aviv

Background: The number of adult congenital heart disease (ACHD) patients increased significantly due to improved pediatric care. In addition to complications of the congenital malformation and related procedures, ACHD patients often present with age related co-morbidities. As data on Israeli ACHD patients are lacking, our aim was to evaluate the size, characteristics and management of ACHD in Israel.

Methods: ACHD patients, age ≥18 years, actively insured during the data collection period (2007-2011) by MACCABI and CLALIT health services, were identified retrospectively. Disease severity was categorized based on defect type and repair/palliation, (Warnes et al JACC. 2001; 37:1170-1175).

Findings: The 15,158 patients identified, represent 19,686 ACHD patients in Israel (3.9 per 1000 adults). The congenital heart disease was complex in 4%, of moderate severity in 18%, and simple in 55% of the patients. Congenital heart disease severity couldn`t be determined in 23% of patients due to nonspecific coding or missing information. During the study period 60% of patients were followed-up by cardiologists. Arab patients had a higher prevalence of moderate or complex disease, and higher rates of emergency department visits and hospitalizations. When matched by age, sex and population groups, ACHD patients had 1.65 times more primary care visits, 2.8 times more cardiology visits and 3.3 times more hospitalizations than the general Israeli population. Patients for whom severity could not be determined had high service utilization rates (standardized hospitalization ratio [ACHD vs. general population] =3.7; 95% confidence interval: 3.40-4.05). Excessed health service utilization increased with increasing age up to 6.7 times more hospitalizations among patients ³ 65 years.

Conclusions: Israeli ACHD patients have high health services utilization rates which are expected to increase with population aging. Our findings support the need for re-organization of ACHD patient healthcare, including improving classification of the cardiac malformation and organization of care according to guidelines.