Congenital heart disease (CHD) is the most common congenital anomaly worldwide and accounts for nearly one-third of all congenital birth defects (1). The Global Burden of Diseases (GBD) study estimated that 13.3 million people globally lived with CHD, and in 2019 there were 2305.2 congenital heart disease per 100,000 live births (2). Over the past 20 years, the overall mortality of CHD has declined by 60.4%, from 7.1 per 100,000 in 1990 to 2.8 per 100,000 in 2019 (2). However, this rate remains relatively high in low and middle-income countries. In China, the incidence of congenital heart disease has increased by a factor of 4.3, from 3.3 per 1,000 perinatal cases (including stillbirths and live births) in 2010 to 17.3 per 1,000 perinatal cases in 2020 (3). Another large prospective multicenter screening study in China reported 8.98 cases of CHD per 1,000 live births (4). The global healthcare burden of congenital heart disease is increasing, particularly in economically underdeveloped areas. It has become a global and severe public health problem.

Advancements in cardiovascular medicine and surgery for CHD have significantly improved survival rates, enabling nearly most patients to reach adulthood (5–7). However, these medical strides have escalated treatment costs, imposing substantial economic burdens on families affected by CHD and society. A National Health Interview Survey (NHIS) in the US revealed that around half of families with CHD children faced financial challenges due to medical expenses (8). Additionally, analysis of Healthcare Cost and Utilization Project (HCUP) data indicated that CHD patients incurred a total cost of approximately USD 6.1 billion, constituting 26.6% of birth defects-related expenses (9). Despite China currently holding the highest number of CHD patients globally (10, 11), studies on the CHD economic burden, especially in economically underdeveloped areas, are limited. Economically underdeveloped areas are defined by lower levels of economic development, indicated by factors such as low per capita income, high poverty rates, limited access to basic services and infrastructure, high unemployment rates, and a less diversified economy (12).

To grasp the economic burden of congenital heart disease (CHD) in economically underdeveloped regions, we studied Gansu Province in northwestern China—a region with a resident population of 25.01 million and a GDP of 901.67 billion Chinese yuan, ranking fifth lowest in China (13). In Gansu province, urban and rural resident medical insurance has a RMB5000 deductible and a 60% to 80% reimbursement rate (14). The level of care varies among hospital types, with general hospitals providing more comprehensive cardiologist teams and higher-level diagnosis and treatment compared to primary medical institutions. This study aimed to describe the composition and changing trends of CHD inpatient costs within Gansu Province between 2015 and 2020. Additionally, we explored the factors influencing the average inpatient cost per time and daily inpatient cost for patients with CHD and their significance. Based on these results, we discussed potential solutions for reducing the economic burden of CHD and informing future health policy development and practice.

This study is the first to systemically report the trends and factors influencing inpatient costs of CHD patients in economically underdeveloped areas of northwestern China, thus providing substantial insights into the economic burden of congenital heart disease in China. We found that adults over the age of 18 between 2015 and 2020 accounted for the largest patient group, but infants younger than 1 year had the highest inpatient costs. This may be attributed to advancements in diagnosis and treatment during infancy and childhood, resulting in higher survival rates for patients with CHD (24, 25). Consequently, the increasing number of adults with congenital heart disease (ACHD), outnumber the population of children living with CHD (26). Additionally, this may also be related to the delayed healthcare-seeking behavior of congenital heart disease patients due to medical resources and lower educational levels in Gansu Province. Our study revealed that the average length of stay was 10.09 ± 9.16 days, which was longer than those in other reports (27, 28). It is worth noting that almost half of the patients in this study underwent cardiac procedures, which could have contributed to their prolonged length of stay. A previous study has indicated that patients with congenital heart disease require intensive care unit (ICU) admission post-surgery, which further extends their length of stay, and it is important to consider that the longer the ICU stay, the more healthcare resources and associated costs are utilized (29). In our study, the observed proportion of patients with CCHD was comparatively lower than reported in other studies (17, 30). This discrepancy may be associated with the constrained medical resources and inadequate advanced diagnostic and therapeutic capabilities within Gansu Province. Under such circumstances, patients with CCHD may demonstrate a tendency to seek medical attention in provinces with more sophisticated medical facilities. Moreover, our study has observed higher inpatient costs for patients with CCHD and congenital heart surgery. This is consistent with the findings of other similar CHD studies (28, 30, 31).

In our study, the average inpatient costs per time of CHD patients in Gansu Province from 2015 to 2020 was CNY 22,586.68 (USD 3,274.57), which was higher compared with a similar study conducted on adults with congenital heart disease in Hong Kong, China (32). In contrast, inpatient costs in Gansu Province were significantly lower than the findings of the National Center for Cardiovascular Disease (33). Moreover, compared to other high-income countries the inpatient costs of congenital heart disease are significantly lower in Gansu Province. For instance, a study from Canada revealed that for children in their 1^st year of life, the median (IQR) cost per child, excluding drug costs, was $224,324 ($127,596–$312,077) (34). A study conducted in Arkansas found that the median per-patient hospital costs for all hospitalizations were $28,482 (interquartile range [IQR]: $10,899, $53,530) (26). Another study on the costs of congenital heart defects in American adolescents showed median (IQR) costs and costs per admission of $27,304 ($47,448) and $10,720 ($18,246), respectively (24). The difference in cost between our study with others might be related to various factors, such as the year of the study, the economic level of the countries, the method of treatment utilized, and the criteria for inclusion and exclusion. Additionally, it is worth noting that the use of ICD-9 codes in US studies and ICD-10 codes in ours could also play a role in the differences observed. Despite the lower inpatient costs observed in Gansu Province compared to developed countries, compared to the national economic data, the total expenditures exceed the per capita disposable income of CNY 20,335 in the province in 2020, indicating a significant financial burden for CHD patients and their families.

Treatment, examination, medication, and surgery accounted for a high proportion of inpatient costs, with these four items accounting for more than 80% of the total costs, similar to other reports (32, 35). The examination costs are considerably high, possibly attributed to using costly technologies such as color Doppler ultrasound, spiral CT, magnetic resonance imaging, and cardiac catheterization to diagnose CHD. In Gansu Province, the average inpatient costs per time and daily inpatient costs of CHD patients showed a generally rising trend from 2015 to 2020. However, an abnormal downward trend was observed in 2017, which could be attributed to the zero-markup policy (ZMP) for essential medicines in Gansu Province. This policy eliminated the 15% profit margin previously allowed for drug sales at public hospitals. A previous study (36) on the impacts of ZMP on medical expenditures found that the policy led to a short-term decrease in total inpatient costs and medicine expenses per patient in pilot hospitals. However, the difference disappeared over the long term. Moreover, we found that out-of-pocket costs per time for patients with CHD decreased after 2017, with an average growth rate of −20.02%. This trend seems related to the continuous improvement of the national health insurance system and the gradual increase of reimbursement rates in recent years.

The results of the quantile regression analysis and the random forest regression tree model indicated that among the variables considered, the length of stay, cardiac procedure, the proportion of medications, age, and hospital level were the main factors influencing inpatient costs. Prior studies (28, 37, 38) have established that length of stay, surgical procedures, and age play a significant role in determining the cost of hospitalization. Our results add to the literature by showing that medication proportion and hospital level were critical factors impacting inpatient costs. As such, interventions targeting these variables should be prioritized to reduce the economic burden of cardiac disease. Specifically, efforts to decrease the length of stay and optimize medication proportion likely yield the most significant impact. Children, especially infants, had significantly higher inpatient costs. Therefore, more attention should be paid to this population, and a multidisciplinary program is needed to obtain better outcomes. Hospital level as a significant influence on inpatient costs also corresponds to the “Two-Eight Rule” by the 2021 Medical Quality Report of Cardiovascular Diseases in China (39), meaning that 20% of the large provincial and municipal hospitals implement 80% of the treatment. This principle results in the regionalization of medical resources. Medical institutions that offer higher levels of medical specialization and better equipment tend to charge more for their services. This is particularly evident in provincial and municipal institutions, where a higher percentage of patients (89.96%) undergo cardiac surgery due to their advanced medical capabilities and specialized services. As a result, patients in such institutions may face higher medical costs. Consequently, it is necessary to promote the equitable allocation of medical resources across different areas and strengthen the development of primary medical institutions to address this issue.

Several limitations should be addressed for this study. First, only the inpatient costs of patients with the first diagnosis of CHD were analyzed. The costs of patients with CHD who were admitted for other reasons, as well as indirect costs, were not included. Second, the data for the study came from the hospital information system. Thus, the variables included have limitations and cannot include other variables, such as the type of admission that may affect the cost of hospitalization, and the purpose of the indexed hospitalization of the included patients. Third, we have not adequately considered the potential impact of major changes in policies on the trend of inpatient costs. Lastly, our study only reflected the costs of patients with CHD in Northwest China. However, special attention should be given to the fact that this study represents the first systematic report on trends and influencing factors related to inpatient costs for CHD patients in China. Therefore, our findings might help further understand the financial burden caused by congenital heart disease surgery and facilitate the adjustment of health insurance policies.

This is the first report on the changing trend and influencing factors study of CHD patients in economically underdeveloped areas of northwestern China. Our study has identified that the length of stay, cardiac procedure, the proportion of medications, age, and hospital level were the main factors influencing inpatient costs. Furthermore, it showed that CHD causes a significant economic burden on both families and society. Therefore, to further reduce the patient's financial burden, the length of stay should be reasonably reduced, and the rational distribution of medical resources should be continuously promoted to ensure equitable access to healthcare services.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

SZ: Data curation, Methodology, Writing – original draft, Investigation. YY: Data curation, Investigation, Validation, Writing – review & editing. LW: Writing – review & editing, Data curation, Investigation, Validation. HL: Data curation, Investigation, Validation, Writing – review & editing. XW: Data curation, Investigation, Validation, Writing – review & editing. CO: Data curation, Investigation, Validation, Writing – review & editing. JP: Data curation, Investigation, Validation, Writing – review & editing. XH: Resources, Supervision, Writing – review & editing.