A practical approach for calculating reliable cost estimates from observational data: application to cost analyses in maternal and child health

Professional Fees for U.S. Hospital Care, 2016-2020

BACKGROUND

The latest comprehensive diagnosis-specific estimates of hospital professional fees relative to facility fees are from 2004 to 2012.

OBJECTIVE

Update professional fee ratio (PFR) estimates to improve cost analysis opportunities with hospital discharge data sources and compare them with previous PFR estimates.

SUBJECTS

2016-2020 MarketScan inpatient admissions and emergency department (ED) treat and release claims.

MEASURES

PFR was calculated as total admission or ED visit payment divided by facility-only payment. This measure can be multiplied by hospital facility costs to yield a total cost estimate.

RESEARCH DESIGN

Generalized linear regression models controlling for selected patient and service characteristics were used to calculate adjusted mean PFR per admission or ED visit by health payer type (commercial or Medicaid) and by selected diagnostic categories representing all clinical diagnoses (Major Diagnostic Category, Diagnostic Related Group, and Clinical Classification Software Revised).

RESULTS

Mean 2016-2020 PFR was 1.224 for admissions with commercial payers (n = 6.7 million admissions) and 1.178 for Medicaid (n = 4.2 million), indicating professional payments on average increased total payments by 22.4% and 17.8%, respectively, above facility-only payments. This is a 9% and 3% decline in PFR, respectively, compared with 2004 estimates. PFR for ED visits during 2016-2020 was 1.283 for commercial payers (n = 22.2 million visits) and 1.415 for Medicaid (n = 17.7 million). This is a 12% and 5% decline in PFR, respectively, compared with 2004 estimates.

CONCLUSIONS

Professional fees comprise a declining proportion of hospital-based care costs. Adjustments for professional fees are recommended when hospital facility-only financial data are used to estimate hospital care costs.

Inpatient Hospitalization Costs Associated with Birth Defects Among Persons Aged <65 Years - United States, 2019

Changing treatments and medical costs necessitate updates to hospitalization cost estimates for birth defects. The 2019 National Inpatient Sample was used to estimate the service delivery costs of hospitalizations among patients aged <65 years for whom one or more birth defects were documented as discharge diagnoses. In 2019, the estimated cost of these birth defect-associated hospitalizations in the United States was $22.2 billion. Birth defect-associated hospitalizations bore disproportionately high costs, constituting 4.1% of all hospitalizations among persons aged <65 years and 7.7% of related inpatient medical costs. Updating estimates of hospitalization costs provides information about health care resource use associated with birth defects and the financial impact of birth defects across the life span and illustrates the need to determine the continued health care needs of persons born with birth defects to ensure optimal health for all.

The cost-effectiveness of genotyping versus sequencing for prenatal cystic fibrosis carrier screening

OBJECTIVE

We investigated the cost-effectiveness of three sequential prenatal cystic fibrosis (CF) carrier screening strategies: genotyping both partners, genotyping one partner then sequencing the second, and sequencing both partners.

METHOD

A decision-analytic model compared the strategies in a theoretical cohort of four million pregnant couples in the US population and five racial/ethnic sub-populations. Inputs were obtained from literature and varied in sensitivity analysis. Outcomes included cost per quality-adjusted life year (QALY), missed carrier couples, affected newborns, missed prenatal diagnoses, terminations, and procedure-related losses. The cost-effectiveness threshold was $100,000/QALY.

RESULTS

Sequencing both partners identified 1099 carrier couples that were missed by genotyping both partners, leading to 273 fewer missed prenatal diagnoses, 152 more terminations, and 152 fewer affected newborns. A similar trend was observed in the genotyping followed by sequencing strategy. The incremental cost-effectiveness ratio of genotyping followed by sequencing compared to genotyping both partners was $180,004/QALY and the incremental cost-effectiveness ratio of sequencing both partners compared to genotyping followed by sequencing was $17.6 million/QALY. Sequencing both partners was cost-effective below $339 per test, genotyping/sequencing between $340 and $1837, and genotyping both partners above $1838. Sequencing was not cost-effective among five racial/ethnic sub-populations.

CONCLUSION

Despite improved outcomes, sequencing for prenatal CF carrier screening was not cost-effective compared to genotyping. The clinical significance of the incremental cost-effectiveness of CF carrier screening is a matter of deliberation for public policy debate.

Maternal and infant hospitalization costs associated with hypertensive disorders of pregnancy in a California cohort. J Matern Fetal Neonatal Med 2021;35:4208-4220. [PMID: 33722149 DOI: 10.1080/14767058.2020.1849096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

BACKGROUND

The United States has higher health care costs than other developed nations. Hypertensive disorders of pregnancy are increasingly common, and longer hospital admissions and utilization of additional therapies are costly.

OBJECTIVE

We sought to estimate maternal and neonatal hospital costs in a large cohort of pregnant women with and without hypertensive disorders of pregnancy.

STUDY DESIGN

This was a retrospective cohort study of women in California with singleton, non-anomalous births with gestational ages between 23-42 weeks. Women were categorized into seven mutually exclusive groups: no hypertension, chronic hypertension (HTN), chronic HTN with superimposed preeclampsia, gestational HTN, mild preeclampsia, severe preeclampsia, and eclampsia. Hospitalization costs were estimated for women and neonates separately and included the cost for admission for delivery only. We used Chi squared and Kruskal-Wallis equality-of-populations rank tests for statistical analysis with a significance level of 0.05.

RESULTS

In a California cohort of 1,918,482 women, 16,208 (0.8%) had chronic HTN, 5,912 (0.3%) had chronic HTN with superimposed preeclampsia, 39,558 (2.1%) had gestational HTN, 33,462 (1.7%) had mild preeclampsia, 17,184 (0.9%) had severe preeclampsia and 1252 (0.1%) had eclampsia. Median hospitalization costs and length-of-stays were statistically significantly different for women in each group (p<.001). Women with eclampsia had the highest median hospitalization costs ($25,437, IQR: $16,893-$37,261) and women without any hypertensive disorder of pregnancy had the lowest ($11,720, IQR: $8019-$17,530). Costs were significantly different between groups based on gestational age and mode of delivery, and with severe maternal morbidity and neonatal intensive care unit admission status (p<.001).

CONCLUSIONS

We found that hospitalization costs of hypertensive disorders of pregnancy were significantly higher than women without hypertension in pregnancy. These results highlight the economic burden of hypertensive disorders of pregnancy.

Maternal and infant hospitalization costs associated with maternal pre-pregnancy body mass index in California, 2007-2011

BACKGROUND

In the United States, the number of pregnant women who are overweight or obese is increasing. While such individuals are at increased risk of pregnancy complications, data regarding costs associated with pre-pregnancy body mass index (BMI) and maternal and infant outcomes are lacking.

OBJECTIVE

To estimate maternal and infant costs associated with pre-pregnancy BMI in a large cohort of pregnant women.

MATERIALS AND METHODS

We conducted a retrospective cohort study of women with singleton, non-anomalous births in California from 2007 to 2011. Women with preexisting diabetes mellitus and chronic hypertension were excluded. Hospitalization costs were estimated separately for women and infants using hospital charges adjusted using a cost-to-charge ratio. These costs included hospitalization costs for admission for delivery only. We estimated the differences in median costs between seven categories of pre-pregnancy BMIs, including underweight (BMI <18.5), normal weight (BMI 18.5-24.9), overweight (BMI 25.0-29.9), class I obesity (BMI 30.0-34.9), class II obesity (BMI 35.0-39.9), class III obesity (BMI 40.0-49.9) and obesity with BMI ≥50.0. We also performed stratified analyses by mode of delivery and gestational age at delivery. We examined the length of stay for women and infants and estimated the gestational age at delivery. Analyses were conducted utilizing Kruskal-Wallis equality-of-populations rank tests with a significance cutoff of 0.05.

RESULTS

In a California cohort of 1,722,840 women, 787,790 (45.7%) had a pre-pregnancy BMI that was considered overweight or obese. The median maternal and infant costs of each pre-pregnancy BMI strata were significantly different when compared to other strata, with underweight and normal weight women having the lowest median costs ($11,581 and $11,721, respectively) and the most obese category (BMI ≥50) having the highest costs ($15,808). When stratified by mode of delivery and gestational age at delivery, this remained true. Hospitalization costs for women and infants with severe maternal morbidity were also significantly different based on maternal BMI.

COMMENT

The hospitalization costs associated with each strata of BMI were significantly different when compared to each other and when stratified by mode of delivery and prematurity. This analysis allows for a greater understanding of the health care costs associated with different maternal pre-pregnancy BMI classes.

Maternal and Neonatal Hospitalization Costs Associated With Elective Induction of Labor at Term in California, 2007-2011

OBJECTIVE

To compare hospitalization costs of pregnancies managed by elective induction of labor to those with spontaneous labor in a large cohort of pregnant women.

METHODS

We conducted a retrospective cohort study of women with singleton, nonanomalous births in California from 2007 to 2011. We excluded women with placenta previa, breech presentation, prior cesarean delivery, planned cesarean delivery, medically indicated induction of labor, gestational age less than 37 weeks or at or greater than 41 weeks, and stillbirths. We adjusted hospital charges using a cost-to-charge ratio and costs included hospitalization costs for admission for delivery only. We estimated the difference in costs between elective induction of labor (resulting in a vaginal or cesarean delivery) and spontaneous labor for both women and neonates, stratified by mode of delivery, parity, gestational age at delivery and geographic location. We conducted analyses using Kruskal-Wallis equality-of-populations rank tests with a significance level of 0.05.

RESULTS

In a California cohort of 1,278,151 women, 190,409 (15%) had an elective induction of labor. Median maternal hospitalization costs were $10,175 (interquartile range: $7,284-$14,144) with induction of labor and $9,462 (interquartile range: $6,667-$13,251) with spontaneous labor (P<.01) for women who had a vaginal delivery, and $20,294 (interquartile range: $15,367-$26,920) with induction of labor and $18,812 (interquartile range: $13,580-$25,197) with spontaneous labor (P<.01) for women who had a cesarean delivery. Maternal median hospitalization costs were significantly higher in the setting of elective induction of labor regardless of parity, mode of delivery, and gestational age at delivery. Alternatively, median hospitalization costs for neonates of women who had an elective induction of labor were significantly lower.

CONCLUSION

Further research regarding approaches to induction of labor is necessary to determine whether strategies to reduce health care costs without affecting or even improving outcomes could help curb costs associated with induction of labor.

Acute care utilization in pediatric sickle cell disease and sickle cell trait in the USA: prevalence, temporal trends, and cost

The objective of this study was to analyze acute care utilization of sickle cell disease (SCD) and sickle cell trait (SCT) in children and identify trends in emergency department (ED) visits and inpatient admissions over a 10-year period. This is a retrospective population-based study of SCD- and SCT-related ED visits and admissions from 2006 to 2015. Data were acquired from the Healthcare Cost and Utilization Project (HCUP), National Inpatient Sample (NIS), and National Emergency Department Sample (NEDS) database. Cost-to-charge and estimated professional fee ratios were applied to approximate costs. Over 80% of medical expenditure on HbSS is through ED-based admissions. There is a statistically significant increase from 2006 to 2015 in the direct hospital admissions associated with patients less than 18 years of age who have been diagnosed with SCT.Conclusion: Among patients less than 18 years of age with HbSS, inpatient admissions through the emergency department accounted for the largest medical expenditure of the SCD subtypes. What is Known: • There are currently no multi-year, nationwide analyses of acute care utilization in sickle cell disease and sickle cell trait (SCT) in the pediatric population. • SCT is more common than SCD, affecting 1.5% of all infants born in the USA. What is New: • Comprehensive annual costs of acute care utilization of patients less than 18 years of age with SCD and SCT in the USA which includes aggregated demographical patient care data and to illustrate temporal trends of acute care utilization in children less than 18 years of age with SCD and SCT • Among patients less than 18 years of age with HbSS, inpatient admissions through the emergency department accounted for the largest medical expenditure of the sickle cell disease subtypes.

Genitourinary Complications Are a Leading and Expensive Cause of Emergency Department and Inpatient Encounters for Persons With Spinal Cord Injury

OBJECTIVES

To determine the rates of emergency department (ED) visits and inpatient hospitalizations for genitourinary (GU) complications after spinal cord injury (SCI) using a national sample; to examine which patient and facility factors are associated with inhospital mortality; and to estimate direct medical costs of GU complications after SCI.

DESIGN

Retrospective cross-sectional and cost analysis of the 2006 to 2015 National Inpatient Sample and National Emergency Department Sample from the Healthcare Cost and Utilization Project.

PARTICIPANTS

SCI-related encounters using various International Classification of Disease, Ninth Edition, Clinical Modification diagnosis codes. The inpatient sample included 1,796,624 hospitalizations, and the ED sample included 618,118 treat-and-release visits.

MAIN OUTCOME MEASURES

The exposure included a GU complication, identified by International Classification of Disease, Ninth Edition, Clinical Modification codes 590-599. The outcomes then included an ED visit or hospitalization, death prior to discharge, and direct medical costs estimated from reported hospital charges.

RESULTS

For the inpatient sample, we observed a 2.5% annual increase (95% confidence interval [CI], 1.8-3.2) in the proportion of SCI-related hospitalizations with any GU complication from 2006 to 2011, and a lesser rate of increase of 0.9% (95% CI, 0.4-1.4) each year from 2011 to 2015. Age, level of injury, and payer source were correlated to inhospital mortality. The costs of GU-related health care use exceeded $4 billion over the study period.

CONCLUSIONS

This study shows the rates and economic burden of health care use associated with GU complications in persons with SCI in the United States. The need to develop strategies to effectively deliver health care to the SCI population for these conditions remains great.

Hypertensive disorders of pregnancy and postpartum readmission in the United States: national surveillance of the revolving door

OBJECTIVES

Hypertensive disorders of pregnancy (HDP) represent the most common cause of maternal-fetal morbidity and mortality. Yet, the prevalence and cost of postpartum (42-day) readmission (PPR) among HDP-complicated pregnancies in the United States remains unknown. This study provides national prevalence and cost estimates of HDP, and examine factors associated with potentially preventable PPR following HDP-complicated pregnancies.

METHOD

The 2013 and 2014 Nationwide Readmissions Databases were used to investigate HDP and PPR among delivery hospitalizations to women aged 15-49 years. PPR rates, length of stay, and costs were stratified by four HDP subtypes based on timing and severity of their condition. Survey logistic regression was employed to generate adjusted odds ratios for the association between HDP and PPR.

RESULT

In 2013 and 2014, there were 6.3 million delivery hospitalizations; 666 506 (10.6%) were complicated by HDP. Annually, HDP was responsible for higher rates of potentially preventable PPR. Among HDP-complicated pregnancies, the 42-day all-cause PPR rate ranged from 2.5% (gestational hypertension) to 4.6% (superimposed preeclampsia/eclampsia). Compared with normotensive pregnancies, HDP resulted in an excess 404 800 hospital days and inpatient care costs of $731 million. Even after controlling for patient-level and hospital-level confounders, all hypertensive subgroups continued to have at least two-fold, statistically significant, increased odds of potentially preventable PPR.

CONCLUSION

HDP is associated with increased risk of PPR and substantial medical costs. Preventive efforts should be made to identify women at increased risk of PPR during hospitalization so that transition care intervention can be initiated.

Survival and healthcare utilization of infants diagnosed with lethal congenital malformations

OBJECTIVE

We assessed survival, hospital length of stay (LOS), and costs of medical care for infants with lethal congenital malformations, and also examined the relationship between medical and surgical therapies and survival.

STUDY DESIGN

Retrospective cohort study including infants born 1998-2009 with lethal congenital malformations, identified using a longitudinally linked maternal/infant database.

RESULTS

The cohort included 786 infants: trisomy 18 (T18, n = 350), trisomy 13 (T13, n = 206), anencephaly (n = 125), bilateral renal agenesis (n = 53), thanatophoric dysplasia/achondrogenesis/lethal osteogenesis imperfecta (n = 38), and infants > 1 of the birth defects (n = 14). Compared to infants without birth defects, infants with T18, T13, bilateral renal agenesis, and skeletal dysplasias had longer survival rates, higher inpatient medical costs, and longer LOS.

CONCLUSION

Care practices and survival have changed over time for infants with T18, T13, bilateral renal agenesis, and skeletal dysplasias. This information will be useful for clinicians in counseling families and in shaping goals of care prenatally and postnatally.

Marginal Hospital Cost of Surgery-related Hospital-acquired Pressure Ulcers

BACKGROUND

Patients who develop hospital-acquired pressure ulcers (HAPUs) are more likely to die, have longer hospital stays, and are at greater risk of infections. Patients undergoing surgery are prone to developing pressure ulcers (PUs).

OBJECTIVE

To estimate the hospital marginal cost of a HAPU for adults patients who were hospitalized for major surgeries, adjusted for patient characteristics, comorbidities, procedures, and hospital characteristics.

RESEARCH DESIGN AND SUBJECTS

Data are from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases and the Medicare Patient Safety Monitoring System for 2011 and 2012. PU information was obtained using retrospective structured record review from trained MPMS data abstractors. Costs are derived using HCUP hospital-specific cost-to-charge ratios. Marginal cost estimates were made using Extended Estimating Equations. We estimated the marginal cost at the 25th, 50th, and 75th percentiles of the cost distribution using Simultaneous Quantile Regression.

RESULTS

We find that 3.5% of major surgical patients developed HAPUs and that the HAPUs added ∼$8200 to the cost of a surgical stay after adjusting for comorbidities, patient characteristics, procedures, and hospital characteristics. This is an ∼44% addition to the cost of a major surgical stay but less than half of the unadjusted cost difference. In addition, we find that for high-cost stays (75th percentile) HAPUs added ∼$12,100, whereas for low-cost stays (25th percentile) HAPUs added ∼$3900.

CONCLUSIONS

This paper suggests that HAPUs add ∼44% to the cost of major surgical hospital stays, but the amount varies depending on the total cost of the visit.

Costs, mortality, and hospital usage in relation to prenatal diagnosis in d-transposition of the great arteries

BACKGROUND

The impact of prenatal diagnosis of d-transposition of the great arteries (dTGA) on health-care usage is largely unknown. We evaluated a population-based cohort to assess costs, mortality and inpatient encounters by whether dTGA was prenatally diagnosed or not.

METHODS

The dTGA cases (born 1997-2011) identified at the Utah Birth Defect Network, which includes data on timing of diagnosis, were linked to statewide inpatient discharge data. We excluded preterm cases or cases with additional major heart defects. We evaluated hospitalizations and costs for infants (first year of life) and mothers (10 months before birth) using multivariable models adjusted for demographic and clinical risk factors.

RESULTS

Of 119 cases, 14 (12%) were prenatally diagnosed. Birth weight, surgical complexity and extracardiac defects/syndromes were similar between groups. Of 7 deaths (6%), two occurred pre-intervention in postnatally diagnosed infants. Prenatal diagnosis was associated with more in-hospital days (estimate 13 additional days, p = 0.03) and higher mean costs for mothers ($4,141 vs $12,148) and infants (90,419 vs $49,576). Prenatal diagnosis independently predicted higher adjusted costs for the overall cohort ($22,570, p = 0.045). After excluding deaths, total costs were no longer significantly different.

CONCLUSION

Mothers of prenatally diagnosed infants with dTGA had higher inpatient costs compared with those postnatally diagnosed. Costs trended higher for their infants, although were not significantly different. Linkage of population-based surveillance systems and outcome databases can be a powerful tool to further explore the complex relationship of prenatal diagnosis to costs and outcomes in other types of congenital heart diseases. Birth Defects Research 109:262-270, 2017. © 2017 Wiley Periodicals, Inc.

Pregnancy as a window to future health: maternal placental syndromes and short-term cardiovascular outcomes

BACKGROUND

Cardiovascular disease is the leading cause of death among women. Identifying risk factors for future cardiovascular disease may lead to earlier lifestyle modifications and disease prevention. Additionally, interpregnancy development of cardiovascular disease can lead to increased perinatal morbidity in subsequent pregnancies. Identification and implementation of interventions in the short term (within 5 years of first pregnancy) may decrease morbidity in subsequent pregnancies.

OBJECTIVE

We identified the short-term risk (within 5 years of first pregnancy) of cardiovascular disease among women who experienced a maternal placental syndrome, as well as preterm birth and/or delivered a small-for-gestational-age infant.

STUDY DESIGN

We conducted a retrospective cohort study using a population-based, clinically enhanced database of women in the state of Florida. Nulliparous women and girls aged 15-49 years experiencing their first delivery during the study time period with no prepregnancy history of diabetes mellitus, hypertension, or heart or renal disease were included in the study. The risk of subsequent cardiovascular disease was compared among women who did and did not experience a placental syndrome during their first pregnancy. Risk was then reassessed among women with placental syndrome and preterm birth or delivering a small-for-gestational-age infant vs those without these adverse pregnancy outcomes.

RESULTS

The final study population was 302,686 women and girls. Median follow-up time for each patient was 4.9 years. The unadjusted rate of subsequent cardiovascular disease among women and girls with any placental syndrome (11.8 per 1000 women) was 39% higher than the rate among women and girls without a placental syndrome (8.5 per 1000 women). Even after adjusting for sociodemographic factors, preexisting conditions, and clinical and behavioral conditions associated with the current pregnancy, women and girls with any placental syndrome experienced a 19% increased risk of cardiovascular disease (hazard ratio, 1.19; 95% confidence interval, 1.07-1.32). Women and girls with >1 placental syndrome had the highest cardiovascular disease risk (hazard ratio, 1.43; 95% confidence interval, 1.20-1.70), followed by those with eclampsia/preeclampsia alone (hazard ratio, 1.42; 95% confidence interval, 1.14-1.76). When placental syndrome was combined with preterm birth and/or small for gestational age, the adjusted risk of cardiovascular disease increased 45% (95% confidence interval, 1.24-1.71). Women and girls with placental syndrome who then developed cardiovascular disease experienced a 5-fold increase in health care-related costs during follow-up, compared to those who did not develop cardiovascular disease.

CONCLUSION

Women and girls experiencing placental syndromes and preterm birth or small-for-gestational-age infant are at increased risk of subsequent cardiovascular disease in short-term follow-up. Strategies to identify and improve cardiovascular disease risk in the postpartum period may improve future heart disease outcomes.

The Feto-Maternal Health Cost of Intimate Partner Violence Among Delivery-Related Discharges in the United States, 2002-2009

Our purpose was to estimate the national prevalence of intimate partner violence (IPV) among delivery-related discharges and to investigate its association with adverse feto-maternal birth outcomes and delivery-related cost. A retrospective cross-sectional analysis of delivery-related hospital discharges from 2002 to 2009 was conducted using the Nationwide Inpatient Sample (NIS). We used ICD-9-CM codes to identify IPV, covariates, and outcomes. Multivariable logistic regression modeling was used to calculate adjusted odds ratios (OR) and 95% confidence intervals (CI) for the associations between IPV and each outcome. Joinpoint regression was used for trend analysis. During the study period, 3,649 delivery-related discharges were diagnosed with IPV (11.2 per 100,000; 95% CI = [10.0, 12.4]). IPV diagnosis during delivery is associated with stillbirth (AOR = 4.12, 95% CI = [2.75, 6.17]), preterm birth (AOR = 1.97, 95% CI = [1.59, 2.44]), fetal death (AOR = 3.34, 95% CI = [1.99, 5.61]), infant with poor intrauterine growth (AOR = 1.55, 95% CI = [1.01, 2.40]), and increased inpatient hospital care cost (US$5,438.2 vs. US$4,080.1) per each discharge, incurring an additional cost of US$4,955,707 during the study period. IPV occurring during pregnancy has a significant health burden to both the mother and infant. Education about IPV; screening at periodic intervals, including during obstetric visits; and ongoing clinical care could help to reduce or eliminate adverse effects of pregnancy-related IPV. Preventing the lifelong consequences associated with IPV can have a positive effect on the overall health of all women and delivery-related health care cost.

Professional Fee Ratios for US Hospital Discharge Data

BACKGROUND

US hospital discharge datasets typically report facility charges (ie, room and board), excluding professional fees (ie, attending physicians' charges).

OBJECTIVES

We aimed to estimate professional fee ratios (PFR) by year and clinical diagnosis for use in cost analyses based on hospital discharge data.

SUBJECTS

The subjects consisted of a retrospective cohort of Truven Health MarketScan 2004-2012 inpatient admissions (n=23,594,605) and treat-and-release emergency department (ED) visits (n=70,771,576).

MEASURES

PFR per visit was assessed as total payments divided by facility-only payments.

RESEARCH DESIGN

Using ordinary least squares regression models controlling for selected characteristics (ie, patient age, comorbidities, etc.), we calculated adjusted mean PFR for admissions by health insurance type (commercial or Medicaid) per year overall and by Major Diagnostic Category (MDC), Diagnostic Related Group, Healthcare Cost and Utilization Project Clinical Classification Software, and primary International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) diagnosis, and for ED visits per year overall and by MDC and primary ICD-9-CM diagnosis.

RESULTS

Adjusted mean PFR for 2012 admissions, including preceding ED visits, was 1.264 (95% CI, 1.264, 1.265) for commercially insured admissions (n=2,614,326) and 1.177 (1.176, 1.177) for Medicaid admissions (n=816,503), indicating professional payments increased total per-admission payments by an average 26.4% and 17.7%, respectively, above facility-only payments. Adjusted mean PFR for 2012 ED visits was 1.286 (1.286, 1.286) for commercially insured visits (n=8,808,734) and 1.440 (1.439, 1.440) for Medicaid visits (n=2,994,696). Supplemental tables report 2004-2012 annual PFR estimates by clinical classifications.

CONCLUSIONS

Adjustments for professional fees are recommended when hospital facility-only financial data from US hospital discharge datasets are used to estimate health care costs.

Trends in Cervical Cancer Among Delivery-Related Discharges and its Impact on Maternal-Infant Birth Outcomes (United States, 1998-2009)

OBJECTIVES

To estimate the national prevalence of cervical cancer (CCA) in women discharged from hospital after delivery, and to examine its associations with birth outcomes.

METHODS

We did a retrospective cross-sectional analysis of maternal hospital discharges in the United States (1998-2009). We used the Nationwide Inpatient Sample (NIS) database to identify hospital stays for women who gave birth. We determined length of hospital stay, in-hospital mortality, and used ICD-9-CM codes to identify CCA and all outcomes of interest. Multivariable logistic regression modeling was used to calculate adjusted odds ratios (AOR) and 95% confidence intervals (CI) for the associations between CCA and feto-maternal outcome.

RESULTS

In the 12-year period from 1998 to 2009, there were 8,387 delivery hospitalizations with a CCA diagnosis, a prevalence rate of 1.8 per 100,000 (95% CI=1.6, 1.9). After adjusting for potential confounders, CCA was associated with increased odds of maternal morbidities including: anemia (AOR, 1.78, 95% CI, 1.54-2.06), anxiety (AOR, 1.95, 95% CI, 1.11-3.42), cesarean delivery (AOR, 1.67, 95% CI, 1.46-1.90), and prolonged hospital stay (AOR, 1.51, 95% CI, 1.30-1.76), and preterm birth (AOR, 1.69, 95% CI, 1.46-1.97).

CONCLUSION

There is a recent increase in the prevalence of CCA during pregnancy. CCA is associated with severe feto-maternal morbidities. Interventions that promote safer sexual practice and regular screening for CCA should be promoted widely among women of reproductive age to effectively reduce the prevalence of CCA during pregnancy and its impact on the health of mother and baby.

Additive effects of Pre-pregnancy body mass index and gestational diabetes on health outcomes and costs

OBJECTIVE

Pre-pregnancy obesity and gestational diabetes mellitus (GDM) are increasingly prevalent independent risk factors for maternal and infant morbidities. However, there is a paucity of information on their joint effects on health outcomes and healthcare costs.

METHODS

A population-based retrospective cohort study was conducted in Florida using a validated statewide database covering 1,057,647 infants born between 2004 and 2009. Using generalized linear modeling, joint associations between levels of pre-pregnancy body mass index (BMI) and GDM and maternal complications of pregnancy, adverse birth outcomes, and healthcare costs were examined. The relative excess risk due to interaction was used to describe the direction and magnitude of the BMI-GDM interaction on the additive scale.

RESULTS

Increasing pre-pregnancy BMI conferred increasing odds of adverse consequences, as did GDM, and the BMI-GDM interaction was greater than additive for 9 of 14 outcomes. The cost for infants born to women with GDM/obesity-III was 34% higher during the first year compared with those born to women with normal BMI and without GDM. The costs of maternal and infant inpatient care associated with overweight/obesity and GDM totaled over $351 million.

CONCLUSIONS

These findings provide further evidence of the importance of lifestyle modifications to decrease rates of obesity and risk factors from GDM.

Transformative Use of an Improved All-Payer Hospital Discharge Data Infrastructure for Community-Based Participatory Research: A Sustainability Pathway

OBJECTIVE

To describe the use of a clinically enhanced maternal and child health (MCH) database to strengthen community-engaged research activities, and to support the sustainability of data infrastructure initiatives.

DATA SOURCES/STUDY SETTING

Population-based, longitudinal database covering over 2.3 million mother-infant dyads during a 12-year period (1998-2009) in Florida.

SETTING

A community-based participatory research (CBPR) project in a socioeconomically disadvantaged community in central Tampa, Florida.

STUDY DESIGN

Case study of the use of an enhanced state database for supporting CBPR activities.

PRINCIPAL FINDINGS

A federal data infrastructure award resulted in the creation of an MCH database in which over 92 percent of all birth certificate records for infants born between 1998 and 2009 were linked to maternal and infant hospital encounter-level data. The population-based, longitudinal database was used to supplement data collected from focus groups and community surveys with epidemiological and health care cost data on important MCH disparity issues in the target community. Data were used to facilitate a community-driven, decision-making process in which the most important priorities for intervention were identified.

CONCLUSIONS

Integrating statewide all-payer, hospital-based databases into CBPR can empower underserved communities with a reliable source of health data, and it can promote the sustainability of newly developed data systems.

Industry-Related Injuries in the United States From 1998 to 2011: Characteristics, Trends, and Associated Health Care Costs

OBJECTIVE

To describe the trends, correlates, and healthcare costs associated with industry-related injuries across the United States between 1998 and 2011.

METHODS

A retrospective, cross-sectional analysis of hospital discharges was conducted using the National Inpatient Sample. We used the International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify accidents occurring in industrial settings. Joinpoint regression modeling was used to analyze trends.

RESULTS

Most of the 357,716 inpatient hospitalizations were admissions from the emergency department (55%). Fractures were the most prevalent injuries (48.1%), whereas the lower and upper extremities were the most common injury sites (51.7%). The mean per admission cost of direct medical care was $12,849, with an overall downward trend in injuries during the study period.

CONCLUSIONS

A comprehensive trend analysis of industry-related injuries is valuable to policymakers in formulating targeted strategies and allocating resources to address disparities at various levels.

How much does a diabetes out-patient appointment actually cost? An argument for PLICS

Purpose

– The national tariff system for clinical processes and procedures aims to put a discrete unit cost on clinical activity. Calculating such costs can be subject to a great deal of local variation and interpretation. Given the rising costs of diabetes the purpose of this paper is to ask the question what does a diabetes outpatient appointment in the UK NHS actually cost? This is important in a time of financial austerity and healthcare rationing because it can be difficult to decipher the attribution of costs within the acute hospital setting.

Design/methodology/approach

– Exploring this question, the author considers the present cost model and analyse in terms of the language of unit model cost; the basic tariff system and how it works in diabetes and looking at internal cost information the author attempts to unbundle the cost to provide a more accurate value for the cost object.

Findings

– One major finding is that costs and overheads are divided arbitrarily as opposed to being distributed on the basis of measured relative consumption. Alternative costing methods are appraised to demonstrate that a patient level episodic costing approach such as patient level information and costing system (PLICS) which incorporates aspects of activity-based costing (ABC) would be far more appropriate. Using time driven ABC (TDABC), a new patient appointment costs £162 for 30 minutes and a follow-up appointment costs £81 for 15 minutes.

Practical implications

– PLICS has the added benefit of greater financial and clinical transparency and this goes some way towards the holy grail of greater engagement with the doctors delivering clinical care.

Social implications

– It would appear that there are different purposes of different costing systems. One can argue that a costing system is there to both contain costs and divide overheads and demonstrate activity. Depending on how data are interpreted costing information can be an agent of enlightenment and behavioural modification for healthcare professionals to show them their direct and indirect costs, their capacity and productivity.

Originality/value

– Clinicians and health service managers can see from this practical example how the distribution of costs and resources are unfair and can impede the delivery of a service. By using alternative costing methodologies such as ABC not only do the author gets a better reflection of the true cost of the finished consultant episode but is also able to engage clinicians in understanding how costs are generated.

Perinatal outcomes and hospital costs in gastroschisis based on gestational age at delivery

OBJECTIVE

To investigate the association between gestational age at delivery and perinatal outcomes among gastroschisis-affected pregnancies that result in live birth.

METHODS

We conducted a retrospective cohort study using a linked maternal-infant database for more than 2.3 million liveborn neonates in Florida from 1998 to 2009. Cases were identified using a combination of International Classification of Diseases, 9th Edition, Clinical Modification, diagnosis and procedure codes indicative of gastroschisis. We restricted our analyses to singleton cases without another major birth defect or medical conditions that would justify early elective delivery. We categorized cases based on gestational age in weeks and compared perinatal outcomes.

RESULTS

Among 1,005 neonates with gastroschisis, 324 (32.3%) were isolated, singleton cases without an additional indication for early delivery. We observed decreased rates of adverse pregnancy outcomes among those neonates delivered in the early term period (37-38 weeks of gestation) compared with preterm (less than 34 weeks of gestation); specifically, jaundice (18.5% compared with 42.3%, P=.01) and respiratory distress syndrome (5.9% compared with 23.1%, P≤.01). As the gestational age at birth increased, we observed fewer mean number of days spent in the hospital (less than 34 weeks of gestation: 55.9, P<.01; 34-36 weeks of gestation: 51.9, P=.02; 37-38 weeks of gestation: 36.9 [reference]) and lower direct inpatient medical costs (in thousands, U.S. dollars; less than 34 weeks of gestation: 79, P=.01; 34-36 weeks of gestation: 71, P=.04; 37-38 weeks of gestation: 51 [reference]) per infant in the first year of life.

CONCLUSION

In pregnancies complicated by gastroschisis, and with no other known major indications, birth at early term or later term gestation, when compared with delivery before 37 weeks of gestation, is associated with improved perinatal outcomes and lower medical costs.

LEVEL OF EVIDENCE

II.

Maternal opioid drug use during pregnancy and its impact on perinatal morbidity, mortality, and the costs of medical care in the United States

OBJECTIVE

To identify factors associated with opioid use during pregnancy and to compare perinatal morbidity, mortality, and healthcare costs between opioid users and nonusers.

METHODS

We conducted a cross-sectional analysis of pregnancy-related discharges from 1998 to 2009 using the largest publicly available all-payer inpatient database in the United States. We scanned ICD-9-CM codes for opioid use and perinatal outcomes. Costs of care were estimated from hospital charges. Survey logistic regression was used to assess the association between maternal opioid use and each outcome; generalized linear modeling was used to compare hospitalization costs by opioid use status.

RESULTS

Women who used opioids during pregnancy experienced higher rates of depression, anxiety, and chronic medical conditions. After adjusting for confounders, opioid use was associated with increased odds of threatened preterm labor, early onset delivery, poor fetal growth, and stillbirth. Users were four times as likely to have a prolonged hospital stay and were almost four times more likely to die before discharge. The mean per-hospitalization cost of a woman who used opioids during pregnancy was $5,616 (95% CI: $5,166-$6,067), compared to $4,084 (95% CI: $4,002-$4,166) for nonusers.

CONCLUSION

Opioid use during pregnancy is associated with adverse perinatal outcomes and increased healthcare costs.

Hospitalizations and associated costs in a population-based study of children with Down syndrome born in Florida

BACKGROUND

Our objective was to examine differences in hospital resource usage for children with Down syndrome by age and the presence of other birth defects, particularly severe and nonsevere congenital heart defects (CHDs).

METHODS

This was a retrospective, population-based, statewide study of children with Down syndrome born 1998 to 2007, identified by the Florida Birth Defects Registry (FBDR) and linked to hospital discharge records for 1 to 10 years after birth. To evaluate hospital resource usage, descriptive statistics on number of hospitalized days and hospital costs were calculated. Results were stratified by isolated Down syndrome (no other coded major birth defect); presence of severe and nonsevere CHDs; and presence of major FBDR-eligible birth defects without CHDs.

RESULTS

For 2552 children with Down syndrome, there were 6856 inpatient admissions, of which 68.9% occurred during the first year of life (infancy). Of the 2552 children, 31.7% (n = 808) had isolated Down syndrome, 24.0% (n = 612) had severe CHDs, 36.3% (n = 927) had nonsevere CHDs, and 8.0% (n = 205) had a major FBDR-eligible birth defect in the absence of CHD. Infants in all three nonisolated DS groups had significantly higher hospital costs compared with those with isolated Down syndrome. From infancy through age 4, children with severe CHDs had the highest inpatient costs compared with children in the other sub-groups.

CONCLUSION

Results support findings that for children with Down syndrome the presence of other anomalies influences hospital use and costs, and children with severe CHDs have greater hospital resource usage than children with other CHDs or major birth defects without CHDs.