Healthcare Utilization and Spending for Constipation in Children With Versus Without Complex Chronic Conditions

Constipation: A Pristine Universal Pediatric Health Delinquent

Constipation suffered by children is a global public health problem. Functional constipation (FC) brings about deteriorating effects in the children's lives who suffer from it. The risk factors for the development of constipation include the consumption of a diet low in fiber and high in calories (such as the consumption of fast food), a sedentary lifestyle with a lack of exercise, a family history of constipation, and emotional and psychological stress endured by children in their families. It is one of the most common causes of stomachaches in children. FC may lead to fecal incontinence (FI), anal fissures, recurrent urinary tract infections (RUTI), and enuresis in children. Severe constipation may result in stool becoming rock-hard and inflexible in the rectum, which is clinically identified as fecal impaction. It is imperative to perform clinical evaluation and treatment, including pharmacological (the use of stimulant and osmotic laxatives) and non-pharmacological (education, changes in diet, intervention to promote positive behavior and address any emotional issues, toilet training, and physiotherapy for the pelvic floor) interventions. In the case of refractory patients, neuromodulation, the irrigation of the anal canal, and surgical management may be needed. It is essential to lead a healthy, stress-free lifestyle with plenty of exercise and a balanced diet rich in fiber (such as fruits and vegetables) so children can have regular bowel habits and thrive.

Impact of antegrade enema initiation on healthcare utilization in pediatric patients: A population-based cohort study

BACKGROUND

When constipation is refractory to first-line interventions, antegrade enema use may be considered. We aimed to assess the impact of this intervention on healthcare utilization.

METHODS

We conducted a population-based, quasi-experimental study with pre-post comparison of the intervention group and a non-equivalent control group using linked clinical and health administrative data from Ontario, Canada. Subjects included children (0-18 years) who underwent antegrade enema initiation from 2007 to 2020 and matched controls (4:1) from the general population. To assess the change in healthcare utilization following antegrade enema initiation, we used negative binomial generalized estimating equations with covariates selected a priori.

KEY RESULTS

One hundred thirty-eight subjects met eligibility criteria (appendicostomy = 55 (39.9%); cecostomy tube = 83 (60.1%)) and were matched to 550 controls. There was no significant difference in the change in the rate of hospitalizations (rate ratio (RR) 1.05, 95% confidence interval (CI) 0.35-1.75), outpatient visits (RR 1.05, 95% CI 0.91-1.18), or same-day surgical procedures (RR 1.51, 95% CI 0.60-2.43) across cases in 2 years following antegrade enema initiation compared with controls. Cases had an increased rate of emergency department (ED) visits, which was not observed in controls (RR 1.52, 95% CI 1.11-1.79), driven in part by device-related complications.

CONCLUSIONS AND INFERENCES

Understanding healthcare utilization patterns following antegrade enema initiation allows for effective health system planning and aids medical decision-making. The observed increase in ED visits for device-related complications speaks to the need to improve preventive management to help mitigate emergency care after initiation of antegrade enemas.

A National Study to Compare Effective Management of Constipation in Children Receiving Concurrent Versus Standard Hospice Care

Constipation is a distressing and uncomfortable symptom children experience at end of life. There is a gap in knowledge about how different approaches to hospice care delivery might improve pediatric symptom management of constipation. The purpose of this study was to evaluate the effectiveness of pediatric concurrent hospice versus standard hospice care to manage constipation. Medicaid data (2011-2013) were analyzed. Children who were younger than 21 years enrolled in hospice care and had a hospice enrollment between January 1, 2011, and December 31, 2013, were included. Instrumental variable analysis was used to test the effectiveness of concurrent versus standard hospice care. Among the 18 152 children, approximately 14% of participants were diagnosed or treated for constipation from a nonhospice provider during hospice enrollment. A higher proportion of children received nonhospice care for constipation in concurrent hospice care, compared with standard hospice (19.5% vs 13.2%), although this was not significant (β = .22, P < .05) after adjusting for covariates. The findings demonstrated that concurrent care was no more effective than standard hospice care in managing pediatric constipation. Hospice and nonhospice providers may be doing a sufficient job ordering bowel regimens before constipation becomes a serious problem for children at end of life.

A Scoping Review of Non-Pharmacological Health Education Provided to Families of Children With Idiopathic Childhood Constipation Within Primary Health Care

Objectives:

Idiopathic childhood constipation is a prevalent condition that initially brings the child under the care of the primary health care team. Although it is acknowledged that health education is crucial to reducing chronicity, the range of evidenced-based non-pharmacological health education provided to families has not previously been reviewed. For this scoping review, 4 research questions sought to identify papers that provide information on the utilization of guidelines, the range of health education, who provides it, and whether any gaps exist.

Methods:

Following a registered protocol and using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews, searches of 10 online databases, reference lists, Google Scholar, and book chapter references were made. Eligible papers were original research published in English between January 2000 and December 2022.

Results:

Twelve worldwide studies (2 qualitative and 10 quantitative) reported that: evidence-based guidelines are not consistently used by primary care providers; the range of non-pharmacological health education provided is inconsistent; the non-pharmacological health education is provided by doctors, nurses, and pharmacists; and that gaps exist in non-pharmacological health education provision.

Conclusion:

This review demonstrates that rather than a lack of guideline-awareness, decreased specific idiopathic childhood constipation knowledge (and possibly time) may be responsible for inconsistent non-pharmacological health education. Inappropriate treatment and management of some children escalates risk for chronicity. Improving health education provision however, may be achieved through: increased collaboration; better utilization of nurses; and through developing the child’s health literacy by involving both child and family in all aspects of health education and decision-making.

Preoperative depression, lumbar fusion, and opioid use: an assessment of postoperative prescription, quality, and economic outcomes

OBJECTIVE Preoperative depression has been linked to a variety of adverse outcomes following lumbar fusion, including increased pain, disability, and 30-day readmission rates. The goal of the present study was to determine whether preoperative depression is associated with increased narcotic use following lumbar fusion. Moreover, the authors examined the association between preoperative depression and a variety of secondary quality indicator and economic outcomes, including complications, 30-day readmissions, revision surgeries, likelihood of discharge home, and 1- and 2-year costs. METHODS A retrospective analysis was conducted using a national longitudinal administrative database (MarketScan) containing diagnostic and reimbursement data on patients with a variety of private insurance providers and Medicare for the period from 2007 to 2014. Multivariable logistic and negative binomial regressions were performed to assess the relationship between preoperative depression and the primary postoperative opioid use outcomes while controlling for demographic, comorbidity, and preoperative prescription drug-use variables. Logistic and log-linear regressions were also used to evaluate the association between depression and the secondary outcomes of complications, 30-day readmissions, revisions, likelihood of discharge home, and 1- and 2-year costs. RESULTS The authors identified 60,597 patients who had undergone lumbar fusion and met the study inclusion criteria, 4985 of whom also had a preoperative diagnosis of depression and 21,905 of whom had a diagnosis of spondylolisthesis at the time of surgery. A preoperative depression diagnosis was associated with increased cumulative opioid use (β = 0.25, p < 0.001), an increased risk of chronic use (OR 1.28, 95% CI 1.17-1.40), and a decreased probability of opioid cessation (OR 0.96, 95% CI 0.95-0.98) following lumbar fusion. In terms of secondary outcomes, preoperative depression was also associated with a slightly increased risk of complications (OR 1.14, 95% CI 1.03-1.25), revision fusions (OR 1.15, 95% CI 1.05-1.26), and 30-day readmissions (OR 1.19, 95% CI 1.04-1.36), although it was not significantly associated with the probability of discharge to home (OR 0.92, 95% CI 0.84-1.01). Preoperative depression also resulted in increased costs at 1 (β = 0.06, p < 0.001) and 2 (β = 0.09, p < 0.001) years postoperatively. CONCLUSIONS Although these findings must be interpreted in the context of the limitations inherent to retrospective studies utilizing administrative data, they provide additional evidence for the link between a preoperative diagnosis of depression and adverse outcomes, particularly increased opioid use, following lumbar fusion.

Pediatric Complex Chronic Conditions: Does the Classification System Work for Infants?

BACKGROUND

One widely accepted approach to identify children with life-limiting health problems is the complex chronic conditions (CCCs) classification system. Although considered the "gold standard" for classifying children with serious illness, little is known about its performance, especially among infants.

OBJECTIVE/HYPOTHESIS

This research examined the prevalence of CCCs and the infant characteristics related to a CCC classification.

METHODS

Multivariate regression analysis was conducted with 2012 Kids' Inpatient Database, Healthcare Cost and Utilization Project data files, using a national sample of infant decedents less than 1 year.

RESULTS

Our findings showed that 40% of the infants were classified with a CCC. African Americans were negatively associated with a CCC classification (adjusted odds ratio [aOR] = 0.63; 95% confidence interval [CI] = 0.543-0.731). When infants had other insurance coverage, they were less likely (aOR = 0.63; 95% CI = 0.537-0.748) to have a CCC classification. Infants who resided in nonurban areas (aOR = 1.21; 95% CI =1.034-1.415) and had comorbidities (aOR = 38.19; 95% CI = 33.12-44.04) had greater odds of having a CCC classification.

CONCLUSIONS

The findings suggested that the infants are not commonly classified with a CCC and highlighted the significant variation in race with African American infants exhibiting different CCC classifications than Caucasian infants. Given the importance of reducing disparities in palliative care, critical attention to using CCC classifications in research is warranted.

Understanding the Constipation Conundrum: Predictors of Obtaining an Abdominal Radiograph During the Emergency Department Evaluation of Pediatric Constipation

OBJECTIVES

Many children with constipation who are evaluated in emergency departments (EDs) receive an abdominal radiograph (AR) despite evidence-based guidelines discouraging imaging. The objectives of this study were to identify predictors associated with obtaining an AR and to determine if ARs were associated with a longer length of stay (LOS) among children with constipation evaluated in the ED.

METHODS

A review of billing and electronic health records was conducted in an academic pediatric ED for children ages 0 to 17 years who had a primary discharge diagnosis of constipation from July 2013 to June 2014. Logistic regression was used to identify predictors for obtaining an AR. Differences in mean LOS were analyzed using linear regression.

RESULTS

In total, 326 children met inclusion criteria, and 60% of the children received an AR. In logistic regression, significant predictors included age (odds ratio [OR] = 1.1/year of age, P = 0.004), presenting with abdominal pain as chief complaint compared with constipation (OR = 4.4, P < 0.0001), and history of emesis (OR = 2.8, P = 0.001) after controlling for provider type and previous constipation medication use. In linear regression, the adjusted mean LOS for those with an AR was 163 minutes compared with 117 minutes for those without after controlling for age, provider type, and history of constipation medication use (P < 0.0001).

CONCLUSIONS

Abdominal radiographs were used frequently in the ED diagnosis and management of constipation, particularly in older children and those with abdominal pain and emesis. Abdominal radiographs were associated with increased LOS.

Patterns of Electrolyte Testing at Children's Hospitals for Common Inpatient Diagnoses

BACKGROUND

Overuse of laboratory testing contributes substantially to health care waste, downstream resource use, and patient harm. Understanding patterns of variation in hospital-level testing across common inpatient diagnoses could identify outliers and inform waste-reduction efforts.

METHODS

We conducted a multicenter retrospective cohort study of pediatric inpatients at 41 children's hospitals using administrative data from 2010 to 2016. Initial electrolyte testing was defined as testing occurring within the first 2 days of an encounter, and repeat testing was defined as subsequent testing within an encounter in which initial testing occurred. To examine if testing rates correlated across diagnoses at the hospital level, we compared risk-adjusted rates for gastroenteritis with a weighted average of risk-adjusted rates in other diagnosis cohorts. For each diagnosis, linear regression was performed to compare initial and subsequent testing.

RESULTS

In 497 719 patient encounters, wide variation was observed across hospitals in adjusted, initial, and repeat testing rates. Hospital-specific rates of testing in gastroenteritis were moderately to strongly correlated with the weighted average of testing in other conditions (initial: r = 0.63; repeat r = 0.83). Within diagnoses, higher hospital-level initial testing rates were associated with significantly increased rates of subsequent testing for all diagnoses except gastroenteritis.

CONCLUSIONS

Among children's hospitals, rates of initial and repeat electrolyte testing vary widely across 8 common inpatient diagnoses. For most diagnoses, hospital-level rates of initial testing were associated with rates of subsequent testing. Consistent rates of testing across multiple diagnoses suggest that hospital-level factors, such as institutional culture, may influence decisions for electrolyte testing.

Epidemiology of Children With Multiple Complex Chronic Conditions in a Mixed Urban-Rural US Community

OBJECTIVES

Children with multiple complex chronic conditions (MCCs) represent a small fraction of our communities but a disproportionate amount of health care cost and mortality. Because the temporal trends of children with MCCs within a geographically well-defined US pediatric population has not been previously assessed, health care planning and policy for this vulnerable population is limited.

METHODS

In this population-based, repeated cross-sectional study, we identified and enrolled all eligible children residing in Olmsted County, Minnesota, through the Rochester Epidemiology Project, a medical record linkage system of Olmsted County residents. The pediatric complex chronic conditions classification system version 2 was used to identify children with MCCs. Five-year period prevalence and incidence rates were calculated during the study period (1999-2014) and characterized by age, sex, ethnicity, and socioeconomic status (SES) by using the housing-based index of socioeconomic status, a validated individual housing-based SES index. Age-, sex-, and ethnicity-adjusted prevalence and incidence rates were calculated, adjusting to the 2010 US total pediatric population.

RESULTS

Five-year prevalence and incidence rates of children with MCCs in Olmsted County increased from 1200 to 1938 per 100 000 persons and from 256 to 335 per 100 000 person-years, respectively, during the study period. MCCs tend to be slightly more prevalent among children with a lower SES and with a racial minority background.

CONCLUSIONS

Both 5-year prevalence and incidence rates of children with MCCs have significantly increased over time, and health disparities are present among these children. The clinical and financial outcomes of children with MCCs need to be assessed for formulating suitable health care planning given limited resources.

Encopresis Plus?

Dexter is a 12-year-old boy who presents with his maternal grandmother for follow-up to primary care for secondary encopresis. Dexter presented, 18 months ago, with a 3-month history of secondary encopresis. At that time, a comprehensive assessment revealed functional constipation resulting in encopresis. Dexter's symptoms resolved with a combination of medication management and behavioral strategies; laxatives were discontinued 12 months ago.Dexter's grandmother reports that for the past 6 months, her grandson developed encopresis once again. However, she notes that, although Dexter had small-volume episodes of soiling in the past, he is now passing fully formed stools into his underwear. These episodes usually occur once a day, either at home or at school. Frustrated, Dexter's grandmother has transitioned him to adult diapers.Dexter denies hematochezia, pain, dysuria, hematuria, urinary incontinence, dietary changes, or weight loss. He passes soft stool in his underwear once daily without blood or pain. When interviewed alone, Dexter denies drug use, depression, or significant social stressors. Surprisingly, he seems unconcerned about depression, drugs and social stress, and frequently laughs when discussing them. His physical examination, including a rectal examination, is normal.Dexter's medical history is notable for attention-deficit hyperactivity disorder, treated with stimulant medication. He was toilet trained at 3 years without any difficulty. He lives with his grandmother, who is his legal guardian; his mother has chronic mental health problems and substance abuse. Dexter maintains regular contact with his mother and reports that their relationship is positive.Dexter's grandmother is extremely distressed by his current presentation and notably, Dexter is not. What would you do next?

Reducing hospital admissions of healthy children with functional constipation: a quality initiative

Functional constipation (FC) is a common medical problem in children, with minimal risk of long-term complications. We determined that a large number of children were being admitted to our children’s hospital for FC in which there was no neurological or anatomical cause. Our hospital experienced a patient complication in which a patient died after inpatient treatment of FC. Subsequently, we developed a standardised approach to determine when paediatric patients needed hospitalisation for FC, as well as to develop a regimented outpatient therapeutic approach for such children to prevent hospitalisation. Our quality improvement initiative resulted in a large decrease in the number of children with FC admitted into the hospital as well as a decrease in the number of children needing faecal disimpaction in the operating room. Our quality improvement process can be used to decrease hospitalisations, decrease healthcare costs and improve patient care for paediatric FC.

Constipation-Related Health Care Utilization in Children Before and After Hospitalization for Constipation

We studied constipation-related health care among children before and after constipation admission. Index admissions for constipation in 2010-2011 were identified in the Truven Marketscan Database, which includes children receiving Medicaid in 10 states. We measured number of and spending for outpatient constipation visits 12 months before and after index hospitalizations. We also measured spending for constipation hospitalizations and rehospitalization rate. There were 780 index constipation admissions. The median number of outpatient constipation visits was 1 (interquartile range [IQR] = 0, 3) in the 12 months before and 2 (IQR [0, 4]) after admission ( P = .001). Median outpatient spending for constipation was $110 (IQR [0, 429]) before and $132 (IQR [0, 431]) after admission ( P = .2). Median spending for index constipation admissions was $5295 (IQR [2756, 8267]); 78 children (10%) were rehospitalized for constipation within 12 months. Constipation-related health care utilization increased after constipation admission. Median spending for one constipation admission was 50 times the median spending for 12 months of outpatient constipation visits.

Constipation-Related Emergency Department Use, and Associated Office Visits and Payments Among Commercially Insured Children

OBJECTIVE

Pediatric constipation is common, costly, and often managed in the Emergency Department (ED). The objectives of this study were to determine the frequency of constipation-related ED visits in a large commercially insured population, the frequency of an office visit in the month before and after these visits, demographic characteristics associated with these office visits, and the ED-associated payments.

METHODS

Data were extracted from the Truven MarketScan database for commercially insured children from 2012 to 2013. Data on the presence and timing of clinic visits within 30 days before and after an ED constipation visit and demographic variables were extracted. Logistic regression was used to predict an outcome of presence of a visit with independent variables of age, sex, and region of the country.

RESULTS

In a population of 17 million children aged 0 to 17 years, 448,440 (2.6%) were identified with constipation in at least 1 setting, with 65,163 (14.5%) having an ED visit for constipation. Of all children with a constipation-related ED visit, 45% had no office visit in the 30 days before or after the ED visit. Increasing age was associated with absence of an office visit. The median payment by insurance for an ED constipation visit was $523, the median out-of-pocket payment was $100, for a total of $623 per visit.

CONCLUSION

One in 7 children with constipation in this commercially insured population received ED care for constipation, many without an outpatient visit in the month before or after. Efforts to improve primary care utilization for this condition should be encouraged.

Hospital-Level Variation in Practice Patterns and Patient Outcomes for Pediatric Patients Hospitalized With Functional Constipation

BACKGROUND AND OBJECTIVE

Constipation is a common pediatric condition with a prevalence of 3% to 5% in children aged 4 to 17 years. Currently, there are no evidence-based guidelines for the management of pediatric patients hospitalized with constipation. The primary objective was to evaluate practice patterns and patient outcomes for the hospital management of functional constipation in US children's hospitals.

METHODS

We conducted a multicenter, retrospective cohort study of children aged 0 to 18 years hospitalized for functional constipation from 2012 to 2014 by using the Pediatric Health Information System. Patients were included by using constipation and other related diagnoses as classified by International Classification of Diseases, Ninth Revision. Patients with complex chronic conditions were excluded. Outcome measures included percentage of hospitalizations due to functional constipation, therapies used, length of stay, and 90-day readmission rates. Statistical analysis included means with 95% confidence intervals for individual hospital outcomes.

RESULTS

A total of 14 243 hospitalizations were included, representing 12 804 unique patients. The overall percentage of hospitalizations due to functional constipation was 0.65% (range: 0.19%-1.41%, P < .0001). The percentage of patients receiving the following treatment during their hospitalization included: electrolyte laxatives: 40% to 96%; sodium phosphate enema: 0% to 64%; mineral oil enema: 0% to 61%; glycerin suppository: 0% to 37%; bisacodyl 0% to 47%; senna: 0% to 23%; and docusate 0% to 11%. Mean length of stay was 1.97 days (range: 1.31-2.73 days, P < .0001). Mean 90-day readmission rate was 3.78% (range: 0.95%-7.53%, P < .0001).

CONCLUSIONS

There is significant variation in practice patterns and clinical outcomes for pediatric patients hospitalized with functional constipation across US children's hospitals. Collaborative initiatives to adopt evidence-based best practices guidelines could help standardize the hospital management of pediatric functional constipation.