Regional Variation in Standardized Costs of Care at Children's Hospitals

Impact of Diagnosis-Related-Group (DRG) payment on variation in hospitalization expenditure: evidence from China

BACKGROUND

Diagnosis-Related-Group (DRG) payment is considered a crucial means of addressing the rapid increases of medical cost and variation in cost. This paper analyzes the impact of DRG payment on variation in hospitalization expenditure in China.

METHOD

Patients with chronic obstructive pulmonary disease (COPD), acute myocardial infarction (AMI) and cerebral infarction (CI) in a Chinese City Z were selected. Patients in the fee-for-service (FFS) payment group and the DRG payment group were used as the control group and intervention group, respectively, and propensity-score-matching (PSM) was conducted. Interquartile distance (IQR), standard deviation (SD) and concentration index were used to analyze variation and trends in terms of hospitalization expenditure across the different groups.

RESULTS

After DRG payment reform, the SD of hospitalization expenditure in respect of the COPD, AMI and CI patients in City Z decreased by 11,094, 4,833 and 4,987 CNY, respectively. The concentration indices of hospitalization expenditures for three diseases are all below 0 (statistically significant), with the absolute value tending to increase year by year.

CONCLUSION

DRG payment can be seen to guide medical service providers to provide effective treatment that can improve the consistency of medical care services, bringing the cost of medical care closer to its true clinical value.

Association between pharmacologic treatment and hospital utilization at birth among neonatal opioid withdrawal syndrome mother-infant dyads

OBJECTIVE

We linked mother-baby dyads to explore associations between maternal medication-assisted therapy (MAT) and infants' pharmacologic treatment on birth hospital utilization for infants with NOWS.

METHODS

We extracted singleton infant and maternal delivery discharges from PHIS hospitals with large volumes of deliveries for 2016-2019. We matched newborns with NOWS to maternal delivery discharges by hospital, day of birth, mode of delivery, and ZIP code. We examined the association between maternal MAT, infants' pharmacologic treatment, and hospital utilization at birth.

RESULTS

We included N = 146 mother-baby dyads from six hospitals (74% match rate). Among matched dyads, 51% received maternal MAT, 60% pharmacotherapy (37% both). Infants treated non-pharmacologically and born to mothers receiving MAT had the shortest stays vs. infants without pharmacotherapy or MAT (RR = 0.29; 95% CI: 0.25-0.35).

CONCLUSIONS

These findings underscore the importance of adequate perinatal treatment for opioid use disorder to improve outcomes for mothers and infants with opioid exposure.

Cost analysis of hospitals performing continuous albuterol in non-intensive care settings

OBJECTIVE

To compare hospital costs and resource utilization for pediatric asthma admissions based on the hospitals' availability of continuous albuterol aerosolization administration (CAA) in non-intensive care unit (ICU) settings.

METHODS

We conducted a retrospective cohort study of children ages 2-17 years admitted in 2019 with a principal diagnosis of asthma using the Pediatric Health Information System. Hospitals and hospitalizations were categorized based on location of CAA administration, ICU-only versus general inpatient floors. Hospitals preforming CAA in an intermediate care unit were excluded. We calculated total cost, standardized unit costs and rates of interventions. Groups were compared using Chi-Square, t-test and Wilcoxon rank-sum test as indicated. A log linear mixed model was created to evaluate potential confounders.

RESULTS

Twenty-one hospitals (7084 hospitalizations) allowed CAA on the floor.Twenty-four hospitals (6100 hospitalizations) allowed CAA in the ICU-only. Median total cost was $4639 (Interquartile Range (IQR) $3060-$7512) for the floor group and $5478 (IQR $3444-$8539) for the ICU-only group (p < 0.001) (mean cost difference of $775 per patient). Hospitalization costs were $4,726,829 (95% CI $3,459,920-$5,993,860) greater for the children treated at hospitals restricting CAA to the ICU. We observed higher standardized laboratory, imaging, clinical and other unit costs, along with higher use of interventions in the ICU-only group. After adjustment, we found that ICU stay and hospital LOS were the main drivers of cost difference between the groups.

CONCLUSIONS

There was cost savings and decreased resource utilization for hospitals that performed CAA on the floor. Further studies exploring variations in asthma management are warranted.

Prevalence, Cost, and Variation in Cost of Pediatric Hospitalizations in Ontario, Canada

IMPORTANCE

Identifying conditions that could be prioritized for research based on health care system burden is important for developing a research agenda for the care of hospitalized children. However, existing prioritization studies are decades old or do not include data from both pediatric and general hospitals.

OBJECTIVE

To assess the prevalence, cost, and variation in cost of pediatric hospitalizations at all general and pediatric hospitals in Ontario, Canada, with the aim of identifying conditions that could be prioritized for future research.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cross-sectional study used health administrative data from 165 general and pediatric hospitals in Ontario, Canada. Children younger than 18 years with an inpatient hospital encounter between April 1, 2014, and March 31, 2019, were included.

MAIN OUTCOMES AND MEASURES

Condition-specific prevalence, cost of pediatric hospitalizations, and condition-specific variation in cost per inpatient encounter across hospitals. Variation in cost was evaluated using (1) intraclass correlation coefficient (ICC) and (2) number of outlier hospitals. Costs were adjusted for inflation to 2018 US dollars.

RESULTS

Overall, 627 314 inpatient hospital encounters (44.8% among children younger than 30 days and 53.0% among boys) at 165 hospitals (157 general and 8 pediatric) costing $3.3 billion were identified. A total of 408 003 hospitalizations (65.0%) and $1.4 billion (43.8%) in total costs occurred at general hospitals. Among the 50 most prevalent and 50 most costly conditions (of 68 total conditions), the top 10 highest-cost conditions accounted for 55.5% of all costs and 48.6% of all encounters. The conditions with highest prevalence and cost included low birth weight (86.2 per 1000 encounters; $676.3 million), preterm newborn (38.0 per 1000 encounters; $137.4 million), major depressive disorder (20.7 per 1000 encounters; $78.3 million), pneumonia (27.3 per 1000 encounters; $71.6 million), other perinatal conditions (68.0 per 1000 encounters; $65.8 million), bronchiolitis (25.4 per 1000 encounters; $54.6 million), and neonatal hyperbilirubinemia (47.9 per 1000 encounters; $46.7 million). The highest variation in cost per encounter among the most costly medical conditions was observed for 2 mental health conditions (other mental health disorders [ICC, 0.28] and anxiety disorders [ICC, 0.19]) and 3 newborn conditions (intrauterine hypoxia and birth asphyxia [ICC, 0.27], other perinatal conditions [ICC, 0.17], and surfactant deficiency disorder [ICC, 0.17]).

CONCLUSIONS AND RELEVANCE

This population-based cross-sectional study of hospitalized children identified several newborn and mental health conditions as having the highest prevalence, cost, and variation in cost across hospitals. Findings of this study can be used to develop a research agenda for the care of hospitalized children that includes general hospitals and to ultimately build a more substantial evidence base and improve patient outcomes.

Pediatric Hospital Readmissions for Infants With Neonatal Opioid Withdrawal Syndrome, 2016-2019

BACKGROUND AND OBJECTIVES

Neonatal opioid withdrawal syndrome (NOWS) is associated with long and costly birth hospitalization and increased readmission risk. Our objective was to examine readmissions in the first year of life for infants diagnosed with NOWS compared with infants without NOWS, adjusting for sociodemographic and clinical factors, and to describe use during readmissions in this population.

METHODS

Using data from the Pediatric Health Information System, we identified singleton term infants with NOWS and without NOWS or other major condition (by diagnosis codes and All Patient Refined Diagnosis Related Groups coding, respectively) discharged from 2016 to 2019. We predicted time to first readmission within the first year of life using Cox regression analysis. Predictors included NOWS diagnosis, sociodemographic factors, birth NICU use, and birth weight.

RESULTS

We included 155 885 birth discharges from 17 hospitals (n = 1467 NOWS) with 10 087 readmissions. Unadjusted 1-year readmission rates were 9.9% among NOWS infants versus 6.2% among those without NOWS. The adjusted hazard ratio for readmission within the first year was 1.76 (95% confidence interval: 1.40-2.22) for infants with NOWS versus those without. Readmissions for infants with NOWS were longer and costlier and more likely to require intensive care and mechanical ventilation. Readmissions among infants without NOWS were most commonly for jaundice and respiratory and other infections, whereas respiratory infections were the leading cause of readmissions among NOWS infants.

CONCLUSIONS

Infants with a NOWS diagnosis were more likely to be readmitted within the first year of life. In future work, researchers should explore potential interventions to prevent readmissions and provide resources to families affected by opioid dependence.

Identifying Conditions With High Prevalence, Cost, and Variation in Cost in US Children's Hospitals

IMPORTANCE

Identifying high priority pediatric conditions is important for setting a research agenda in hospital pediatrics that will benefit families, clinicians, and the health care system. However, the last such prioritization study was conducted more than a decade ago and used International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes.

OBJECTIVES

To identify conditions that should be prioritized for comparative effectiveness research based on prevalence, cost, and variation in cost of hospitalizations using contemporary data at US children's hospitals.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study of children with hospital encounters used data from the Pediatric Health Information System database. Children younger than 18 years with inpatient hospital encounters at 45 tertiary care US children's hospitals between January 1, 2016, and December 31, 2019, were included. Data were analyzed from March 2020 to April 2021.

MAIN OUTCOMES AND MEASURES

The condition-specific prevalence and total standardized cost, the corresponding prevalence and cost ranks, and the variation in standardized cost per encounter across hospitals were analyzed. The variation in cost was assessed using the number of outlier hospitals and intraclass correlation coefficient.

RESULTS

There were 2 882 490 inpatient hospital encounters (median [interquartile range] age, 4 [1-12] years; 1 554 024 [53.9%] boys) included. Among the 50 most prevalent and 50 most costly conditions (total, 74 conditions), 49 (66.2%) were medical, 15 (20.3%) were surgical, and 10 (13.5%) were medical/surgical. The top 10 conditions by cost accounted for $12.4 billion of $33.4 billion total costs (37.4%) and 592 815 encounters (33.8% of all encounters). Of 74 conditions, 4 conditions had an intraclass correlation coefficient (ICC) of 0.30 or higher (ie, major depressive disorder: ICC, 0.49; type 1 diabetes with complications: ICC, 0.36; diabetic ketoacidosis: ICC, 0.33; acute appendicitis without peritonitis: ICC, 0.30), and 9 conditions had an ICC higher than 0.20 (scoliosis: ICC, 0.27; hypertrophy of tonsils and adenoids: ICC, 0.26; supracondylar fracture of humerus: ICC, 0.25; cleft lip and palate: ICC, 0.24; acute appendicitis with peritonitis: ICC, 0.21). Examples of conditions high in prevalence, cost, and variation in cost included major depressive disorder (cost rank, 19; prevalence rank, 10; ICC, 0.49), scoliosis (cost rank, 6; prevalence rank, 38; ICC, 0.27), acute appendicitis with peritonitis (cost rank, 13; prevalence rank, 11; ICC, 0.21), asthma (cost rank, 10; prevalence rank, 2; ICC, 0.17), and dehydration (cost rank, 24; prevalence rank, 8; ICC, 0.18).

CONCLUSIONS AND RELEVANCE

This cohort study found that major depressive disorder, scoliosis, acute appendicitis with peritonitis, asthma, and dehydration were high in prevalence, costs, and variation in cost. These results could help identify where future comparative effectiveness research in hospital pediatrics should be targeted to improve the care and outcomes of hospitalized children.

Room Costs for Common Pediatric Hospitalizations and Cost-Reducing Quality Initiatives

BACKGROUND

Improvement initiatives promote safe and efficient care for hospitalized children. However, these may be associated with limited cost savings. In this article, we sought to understand the potential financial benefit yielded by improvement initiatives by describing the inpatient allocation of costs for common pediatric diagnoses.

METHODS

This study is a retrospective cross-sectional analysis of pediatric patients aged 0 to 21 years from 48 children's hospitals included in the Pediatric Health Information System database from January 1, 2017, to December 31, 2017. We included hospitalizations for 8 common inpatient pediatric diagnoses (seizure, bronchiolitis, asthma, pneumonia, acute gastroenteritis, upper respiratory tract infection, other gastrointestinal diagnoses, and skin and soft tissue infection) and categorized the distribution of hospitalization costs (room, clinical, laboratory, imaging, pharmacy, supplies, and other). We summarized our findings with mean percentages and percent of total costs and used mixed-effects models to account for disease severity and to describe hospital-level variation.

RESULTS

For 195 436 hospitalizations, room costs accounted for 52.5% to 70.3% of total hospitalization costs. We observed wide hospital-level variation in nonroom costs for the same diagnoses (25%-81% for seizure, 12%-51% for bronchiolitis, 19%-63% for asthma, 19%-62% for pneumonia, 21%-78% for acute gastroenteritis, 21%-63% for upper respiratory tract infection, 28%-69% for other gastrointestinal diagnoses, and 21%-71% for skin and soft tissue infection). However, to achieve a cost reduction equal to 10% of room costs, large, often unattainable reductions (>100%) in nonroom cost categories are needed.

CONCLUSIONS

Inconsistencies in nonroom costs for similar diagnoses suggest hospital-level treatment variation and improvement opportunities. However, individual improvement initiatives may not result in significant cost savings without specifically addressing room costs.

The cost of treating diabetic ketoacidosis in an adolescent population in the UK: a national survey of hospital resource use

AIMS

Adolescents with Type 1 diabetes commonly experience episodes of ketoacidosis. In 2014, we conducted a nationwide survey on the management of diabetic ketoacidosis in young people. The survey reported how individual adolescents with diabetes were managed. However, the costs of treating diabetic ketoacidosis were not reported.

METHODS

Using this mixed population sample of adolescents, we took a 'bottom-up' approach to cost analysis aiming to determine the total expense associated with treating diabetic ketoacidosis. The data were derived using the information from the national UK survey of 71 individuals, collected via questionnaires sent to specialist paediatric diabetes services in England and Wales.

RESULTS

Several assumptions had to be made when analysing the data because the initial survey collection tool was not designed with a health economic model in mind. The mean time to resolution of diabetic ketoacidosis was 15.0 h [95% confidence interval (CI) 13.2, 16.8] and the mean total length of stay was 2.4 days (95% CI 1.9, 3.0). Based on data for individuals and using the British Society of Paediatric Endocrinology and Diabetes (BSPED) guidelines, the cost analysis shows that for this cohort, the average cost for an episode of diabetic ketoacidosis was £1387 (95% CI 1120, 1653). Regression analysis showed a significant cost saving of £762 (95% CI 140, 1574; P = 0.04) among those treated using BSPED guidelines.

CONCLUSION

We have used a bottom-up approach to calculate the costs of an episode of diabetic ketoacidosis in adolescents. These data suggest that following treatment guidelines can significantly lower the costs for managing episodes of diabetic ketoacidosis.

Analysis of Healthcare Institutional Costs of Pediatric Home Parenteral Nutrition Central Line Infections

BACKGROUND

Although previous literature suggests home parenteral nutrition (HPN)-dependent children experience frequent complications like community-acquired central line-associated bloodstream infections (CLABSI), few studies have characterized the cost.

OBJECTIVE

The aim of this study was to evaluate institutional cost of community-acquired CLABSI in pediatric patients with HPN.

METHODS

This is a single-center retrospective review of institutional costs for patients with HPN with community-acquired CLABSI at a tertiary care children's hospital. Inclusion was age 18 years or less between October 2011 and April 2016. Exclusions were death during hospitalization and readmission within 2 days of discharge. Patient-level factors were compared between high-cost group and all others using Welch 2-sample t test and analysis of variance. Multivariable logistic regression was used to determine predictors of higher cost.

RESULTS

There were 176 CLABSI admissions among 68 patients during the study period (median 2 hospitalizations per patients). The mean cost and length of stay per hospital admission are $28,375 (2015 US dollars) and 8 days, and both were associated with intensive care unit admission (ICU), central venous catheter removal, private insurance, and age <2 years at admission. Nine percent of patients were classified as "super-utilizers" whose 54 hospitalizations accounted for 28% of total institutional costs.

CONCLUSIONS

Among pediatric patients with HPN, community-acquired CLABSI is associated with significant cost and length of stay. Healthcare utilization is disproportionately concentrated in a small number of patients. These study findings may help inform cost analysis for future CLABSI prevention strategies.