Hospital Utilization Among Children With the Highest Annual Inpatient Cost

Developing a Sustainable Care Delivery Payment Model for Children With Medical Complexity

Children with medical complexity (CMC) are a small but growing population representing <1% of all children while accounting for >30% of childhood health care expenditure. Complex care is a relatively new discipline that has emerged with goals of improving CMC care, optimizing CMC family function, and reducing health care costs. The provision of care coordination services is a major function of most complex care programs. Unfortunately, most complex care programs struggle to achieve financial sustainability in a predominately fee-for-service environment. The article describes how 2 programs in Wisconsin worked with their state Medicaid payer through a Centers for Medicare and Medicaid Services Health Care Innovation Award to develop a sustainable complex care payment model, and the value the payment model is currently bringing to stakeholders. Key elements of the process included: Developing a relationship between payer and clinicians that allowed for an understanding of each's viewpoint, use of an accepted clinical service model, and an effort to measure cost of care for the service provided supported by time-study methodology.

Analysis of North Carolina Medicaid Claims Data to Simulate a Pediatric Accountable Care Organization

Importance

Despite momentum for pediatric value-based payment models, little is known about tailoring design elements to account for the unique needs and utilization patterns of children and young adults.

Objective

To simulate attribution to a hypothetical pediatric accountable care organization (ACO) and describe baseline demographic characteristics, expenditures, and utilization patterns over the subsequent year.

Design, Setting, and Participants

This retrospective cohort study used Medicaid claims data for children and young adults aged 1 to 20 years enrolled in North Carolina Medicaid at any time during 2017. Children and young adults receiving at least 50% of their primary care at a large academic medical center (AMC) in 2017 were attributed to the ACO. Data were analyzed from April 2020 to March 2021.

Main Outcomes and Measures

Primary outcomes were total cost of care and care utilization during the 2018 performance year.

Results

Among 930 266 children and young adults (377 233 children [40.6%] aged 6-12 years; 470 612 [50.6%] female) enrolled in Medicare in North Carolina in 2017, 27 290 children and young adults were attributed to the ACO. A total of 12 306 Black non-Hispanic children and young adults (45.1%), 6308 Hispanic or Latinx children and young adults (23.1%), and 6531 White non-Hispanic children and young adults (23.9%) were included. Most attributed individuals (23 133 individuals [84.7%]) had at least 1 claim in the performance year. The median (IQR) total cost of care in 2018 was $347 ($107-$1123); 272 individuals (1.0%) accounted for nearly half of total costs. Compared with children and young adults in the lowest-cost quartile, those in the highest-cost quartile were more likely to have complex medical conditions (399 individuals [6.9%] vs 3442 individuals [59.5%]) and to live farther from the AMC (median [IQR distance, 6.0 [4.6-20.3] miles vs 13.9 [4.6-30.9] miles). Total cost of care was accrued in home (43%), outpatient specialty (19%), inpatient (14%) and primary (8%) care. More than half of attributed children and young adults received care outside of the ACO; the median (IQR) cost for leaked care was $349 ($130-$1326). The costliest leaked encounters included inpatient, ancillary, and home health care, while the most frequently leaked encounters included behavioral health, emergency, and primary care.

Conclusions and Relevance

This cohort study found that while most children attributed to the hypothetical Medicaid pediatric ACO lived locally with few health care encounters, a small group of children with medical complexity traveled long distances for care and used frequent and costly home-based and outpatient specialty care. Leaked care was substantial for all attributed children, with the cost of leaked care being higher than the total cost of care. These pediatric-specific clinical and utilization profiles have implications for future pediatric ACO design choices related to attribution, accounting for children with high costs, and strategies to address leaked care.

The Impact of Non-English Language Preference on Pediatric Hospital Outcomes

OBJECTIVES

To characterize the relationship between non-English language preference (NELP) and hospital outcomes including length of stay (LOS), time of discharge, emergency department return visits, readmissions, and cost for pediatric general medicine inpatients.

METHODS

We conducted a retrospective analysis at an urban, quaternary care, free-standing children's hospital. Patients ages 0 to 18 admitted to any general medicine service between January 1, 2017, and December 31, 2019 were included. Patients were divided into 3 language preference categories: English, Spanish, and non-Spanish NELP. Single and multifactor regression analysis was used to model differences in outcome measures by language preference adjusted for technology dependence.

RESULTS

A total of 4820 patients met criteria. In adjusted models, the average LOS for English-speaking patients was 126 hours; LOS for patients who preferred Spanish was not significantly different, whereas LOS for patients with non-Spanish NELP was 50% longer (P < .001). English-speaking patients were discharged earliest in the day (mean 3:08 pm), with patients who preferred Spanish discharged 0.5 hours later and patients with non-Spanish NELP discharged 1.1 hours later than English-speaking patients (P < .001). Patients with NELP were found to be technology-dependent more frequently (P < .001) than the English preference group. Emergency department return visits, readmissions, and cost were not significantly different between groups.

CONCLUSIONS

NELP was associated with longer length of stay and discharges later in the day. The most pronounced differences occurred in patients with non-Spanish NELP who also had more frequent technology dependence and more limited access to interpreters.

Emergency Department Visits and Hospitalizations After Pediatric Tracheostomy

OBJECTIVE

To determine factors associated with frequent emergency department (ED) visits and hospitalizations after pediatric tracheostomy.

METHODS

A prospective cohort of children (<18 years) with a tracheostomy placed at a tertiary children's hospital between 2015 and 2019 were followed for 24 months after index discharge. ED visits and hospitalizations were recorded to identify risk factors for frequent utilization (≥4 visits).

RESULTS

A total of 239 children required 1285 total visits to the ED or hospital after index discharge with 112 children (47%) having ≥4 visits. Respiratory-related illness was the most common reason (N = 699, 54%) followed by gastrostomy tube issues (N = 119, 9.3%). Frequent utilization was associated with Black race (OR: 2.01, 95% CI: 1.18-3.70, p = 0.01), mechanical ventilation (OR: 2.74, 95% CI: 1.35-5.59, p = 0.006), and Spanish language (OR: 3.86, 95% CI: 1.47-10.11, p = 0.006) on regression modeling. There were no predictors of visits for tracheostomy-related complications, which accounted for 4.8% of all encounters. A sub-analysis showed that Hispanic ethnicity and gestational age predicted visits for respiratory failure.

CONCLUSION

Frequent ED visits or hospitalizations are required for 47% of children in the first 2 years after tracheostomy placement. Ventilatory support, Black race, and Spanish language increase the likelihood of high utilization. Although tracheostomy-related visits are uncommon, strategies to anticipate and decrease respiratory-related admissions may have the most impact.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

The Role of Associations in Reducing the Emotional and Financial Impact on Parents Caring for Children with Duchenne Muscular Dystrophy: A Cross-Cultural Study

Caregivers' emotions and finances are affected by the deterioration of functional capacity of patients with Duchenne muscular dystrophy (DMD), both in Mexico and Spain. Patient associations may reduce this impact on caregivers. This study aims to study the role of two models of associations, inspired by two different cultural models, in how the services they provide can help decrease the emotional and financial impact on the caregivers of children with DMD. The sample consisted of 34 caregivers from Mexico and 40 from Spain recruited from Spanish hospitals and rare disease organizations in Spain and Mexico. The instruments used consisted of a sociodemographic and socioeconomic questionnaire, the CarerQol-7D, the PHQ-15, the Zarit Caregiver's Burden Scale and the SWLS. The results showed that caregivers in Mexico are in better physical and psychological health than caregivers in Spain. They also receive more subsidies than those in Spain. Caregivers in Mexico have a greater well-being and are less affected by the economic impact of the disease due to the associations' day-to-day work and the fact that they generate a network of health services that they make available to the patient free of charge. These differences may also be attributable to cultural issues and to the fact that Mexico has a deeply established culture of support.

Access to Services for Children and Youth With Special Health Care Needs and Their Families: Concepts and Considerations for an Integrated Systems Redesign

Access to services for children and youth with special health care needs (CYSHCN) have typically emphasized coverage, service, timeliness, and capability. Yet families of CYSHCN continue to describe a fragmented health care system with significant unmet needs. For many years, the concept of access to services has focused on the services themselves, rather than starting with the needs of CYSHCN and their families. Meeting these needs should be grounded in health equity, address systemic racism and ableism, and emphasize the life course and journey of those with such needs and their families. In this paper, we start with the simple concept of asking that care is available for CYSHCN regardless of when, where, and how they need it. Access to services is built on relationships instead of a series of transactions. Opportunities for innovation include creating a single point of service entry; determining services based on need instead of diagnosis; and emphasizing service continuity, transition, and a place-based approach. The innovations reimagine access throughout the life course, centering care around a proactive, human-centered system that addresses health and all of its determinants. The landscape of antipoverty investments, cultural humility, workforce changes, technology, and human-centered thought in design have the potential to further transform the conceptual framework to improve access to services for CYSHCN and their families.

Out-of-Network Care in Commercially Insured Pediatric Patients According to Medical Complexity

BACKGROUND

Commercial health plans establish networks and require much higher cost sharing for out-of-network (OON) care. Yet, the adequacy of health plan networks for access to pediatric specialists, especially for children with medical complexity, is largely unknown.

OBJECTIVE

To examine differences in OON care and associated cost-sharing payments for commercially insured children with different levels of medical complexity.

DESIGN

Cross-sectional study using a nationwide commercial claims database.

SUBJECTS

Enrollees 0-18 years old in employer-sponsored insurance plans. The Pediatric Medical Complexity Algorithm was used to classify individuals into 3 levels of medical complexity: children with no chronic disease, children with non-complex chronic diseases, and children with complex chronic diseases.

MAIN OUTCOMES

OON care rates, cost-sharing payments for OON care and in-network care, OON cost sharing as a proportion of total health care spending, and OON cost sharing as a proportion of total cost sharing.

RESULTS

The study sample included 6,399,006 individuals with no chronic disease, 1,674,450 with noncomplex chronic diseases, and 603,237 with complex chronic diseases. Children with noncomplex chronic diseases were more likely to encounter OON care by 6.77 percentage points with higher cost-sharing by $288 for OON care, relative to those with no chronic disease. For those with complex chronic diseases, these differences rose to 16.08 percentage points and $599, respectively. Among children who saw behavioral health providers, rates of OON care were especially high.

CONCLUSIONS

Commercially insured children with medical complexity experience higher rates of OON care with higher OON cost-sharing payments compared with those with no chronic disease.

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.

Social Determinants of Health Needs and Pediatric Health Care Use

OBJECTIVE

To examine the associations between family-reported social needs in primary care settings and pediatric health care use.

STUDY DESIGN

Data were obtained for a sample of 56 253 children and youths (age 0-21 years) who received primary care at a large hospital-based pediatric institution between June 2018 and October 2019 to estimate a propensity score for the probability of being seen in a primary care clinic. Inverse probability weighted regression specifications were used to examine the associations between reported social needs and health care use. Families were asked about 4 social needs: housing, utilities, transportation, and food. Outcomes included the number of Emergency Department (ED), inpatient, social work, and well-child visits (only for those aged 0-2 years) in the 6 months before and after needs screening.

RESULTS

Overall, 12.0% of the families reported a general social need, with 28% of those needs identified as urgent. Food and transportation needs were most common. Patients with needs were more likely to have an ED or inpatient visit at 6 months prescreening and 6 months postscreening compared with those without needs. Among children aged <2 years, those with a social need were less likely to have completed a well-child visit at 6 months postscreening compared with those without a need.

CONCLUSIONS

Social needs are linked to less preventive care use and greater reliance on emergency care services. Understanding how to better assist families in need requires greater attention.

Trends in Hospital Costs and Levels of Services Provided for Children With Bronchiolitis Treated in Children's Hospitals

IMPORTANCE

Increasing hospital costs for bronchiolitis have been associated with increasing patient complexity and mechanical ventilation. However, the associations of illness severity and diagnostic coding practices with bronchiolitis hospitalization costs have not been examined.

OBJECTIVE

To investigate the association of patient complexity, illness severity, and diagnostic coding practices with bronchiolitis hospitalization costs.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cross-sectional study included 385 883 infants aged 24 months or younger who were hospitalized with bronchiolitis at 39 hospitals in the Pediatric Health Information System database from January 1, 2010, to December 31, 2019.

EXPOSURE

Hospitalization for bronchiolitis.

MAIN OUTCOMES AND MEASURES

Inflation-adjusted standardized unit cost (expressed in dollar units) per hospitalization over time. A nested subgroup analysis was performed to further examine factors associated with changes in cost.

RESULTS

A total of 385 883 bronchiolitis hospitalizations were studied; the patients had a mean (SD) age of 7.5 (6.4) months and included 227 309 of 385 883 boys (58.9%) and 253 870 of 385 883 publicly insured patients (65.8%). Among patients hospitalized with bronchiolitis, the median standardized unit cost per hospitalization increased significantly during the study period (from $5636 [95% CI, $5558-$5714] in 2010 to $6973 [95% CI, $6915-$7030] in 2019; P < .001 for trend). Similar increases in cost were observed among subgroups of patients without a complex chronic condition and without the need for mechanical ventilation. However, costs for patients without a complex chronic condition or mechanical ventilation, who received care outside the intensive care unit did not change in an economically significant manner (from $4803 [95% CI, $4752-$4853] in 2010 to $4853 [95% CI, $4811-$4895] in 2019; P < .001 for trend), suggesting that intensive care unit use was a primary factor associated with cost increases. Substantial changes in coding practices were observed. Among patients hospitalized with bronchiolitis, 1.2% (95% CI, 1.1%-1.3%) were assigned an APR-DRG (All Patient Refined Diagnosis Related Group) for respiratory failure in 2010, which increased to 21.6% (95% CI, 21.2%-21.9%) in 2019 (P < .001 for trend). Increased costs and coding intensity were not accompanied by objective evidence of worsening illness severity.

CONCLUSIONS AND RELEVANCE

This cross-sectional study suggests that hospitalized children with bronchiolitis are receiving costlier and more intensive care without objective evidence of increasing severity of illness. Changes in coding practices may complicate efforts to study trends in the use of health care resources using administrative data.

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.

A Nationwide Analysis of Cleft Palate Repair: Impact of Local Anesthesia on Operative Outcomes and Hospital Cost

BACKGROUND

This study investigates the associations between local anesthesia practice and perioperative complication, length of stay, and hospital cost for palatoplasty in the United States.

METHODS

Patients undergoing cleft palate repair between 2004 and 2015 were abstracted from the Pediatric Health Information System database. Perioperative complication, length of stay, and hospital cost were compared by local anesthesia status. Multiple logistic regressions controlled for patient demographics, comorbidities, and hospital characteristics.

RESULTS

Of 17,888 patients from 49 institutions who met selection criteria, 8631 (48 percent), 4447 (25 percent), and 2149 (12 percent) received epinephrine-containing lidocaine, epinephrine-containing bupivacaine, and bupivacaine or ropivacaine alone, respectively. The use of epinephrine-containing bupivacaine or bupivacaine or ropivacaine alone was associated with decreased perioperative complication [adjusted OR, 0.75 (95 percent CI, 0.61 to 0.91) and 0.63 (95 percent CI, 0.47 to 0.83); p = 0.004 and p = 0.001, respectively]. Only bupivacaine- or ropivacaine-alone recipients experienced a significantly reduced risk of prolonged length of stay on adjusted analysis [adjusted OR, 0.71 (95 percent CI, 0.55 to 0.90); p = 0.005]. Risk of increased cost was reduced in users of any local anesthetic (p < 0.001 for all).

CONCLUSIONS

Epinephrine-containing bupivacaine or bupivacaine or ropivacaine alone was associated with reduced perioperative complication following palatoplasty, while only the latter predicted a decreased postoperative length of stay. Uses of epinephrine-containing lidocaine, epinephrine-containing bupivacaine, and bupivacaine or ropivacaine alone were all associated with decreased hospital costs. Future prospective studies are warranted to further delineate the role of local anesthesia in palatal surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Diseases Costs and Impact of the Caring Role on Informal Carers of Children with Neuromuscular Disease

This study aims to evaluate the costs of informal care for children with neuromuscular disease and evaluate how physical and psychological health is associated with socio-demographic variables. A cross sectional design was used with a convenience sample of 110 carers that participated in this study. Participants were recruited from Spanish hospitals and rare diseases organizations. Economic costs and sociodemographic aspects were assessed using the economic costs questionnaire and the sociodemographic questionnaire. Physical and psychological health was evaluated using the CarerQol-7D, PHQ-15, Barthel Index, Zarit Overload Scale and Satisfaction with Life Scale. Carers of children with neuromuscular disease spent a large percentage of their annual income in physical therapy, psychological care and speech therapy. Informal costs differed according to the degree of dependency of the child. These were higher in those caregivers whose child under their care presented low functional independence. The loss of work productivity was related to marital status, use of professional services and the child's dependency. Finally, carers who were female, single or separated and without a job showed worse physical and psychological health. The results highlighted that carers have to face a number of high costs because of the non-existence of social protection and due to the child's diagnosis.

Point-of-Care Complexity Screening Algorithm to Identify Children With Medical Complexity

OBJECTIVES

For pediatric complex care programs to target enhanced care coordination services to the highest-risk patients, it is critical to accurately identify children with medical complexity (CMC); however, no gold standard definition exists. The aim of this study is to describe a point-of-care screening algorithm to identify CMC with high health care use, a group that may benefit the most from improved care coordination.

METHODS

From July 1, 2015, to June 30, 2016 (fiscal year 2016 [FY16]), a medical complexity screening algorithm was implemented by a pediatric complex care program at a single tertiary care center for hospitalized patients at the time of admission. Using the screening algorithm, we categorized inpatients into 1 of 3 groups: CMC, children with special health care needs (CSHCN), or previously healthy (PH) children. Inpatient resource use for FY16 and FY17 encounters was extracted for children screened in FY16.

RESULTS

We categorized 2187 inpatients in FY16 into the 3 complexity groups (CMC = 77; CSHCN = 1437; PH children = 673). CMC had more complex chronic conditions (median = 6; interquartile range [IQR] 4-11) than CSHCN (median = 1; IQR 0-2) and PH children (median = 0; IQR 0-0). CMC had greater per-patient and per-encounter hospital use than CSHCN and PH children. CMC and children with ≥4 complex chronic conditions had comparable levels of resource use.

CONCLUSIONS

By implementation of a point-of-care screening algorithm, we identified CMC with high health care use. By using this algorithm, it was feasible to identify hospitalized CMC that could benefit from care coordination by a pediatric complex care program.

Lessons Learned, Best Practices: Care Coordination for Children with Medical Complexity

Although care coordination has long been established in the health care system in the United States, too often it may compete or work at cross purposes with care teams serving patients and families. Care coordination is a team sport that requires strong clinician-family partnerships as well as adequate time and resources to be done effectively. We incorporate the latest literature to offer clarity for identifying, coordinating, and funding care for children with medical complexity (CMC), the most medically fragile, high-cost subpopulation of children and youth with special health care needs. Algorithms for identifying CMC exist. Calculation of the cost of care for CMC is confounded by cost shifting to families and the variable course of illness and aging in this heterogeneous population. Multiple studies of different sizes have reported similar care coordination team structure, staffing ratios, and cost ranges. We describe models for funding this work and how they can be tailored to individual practice environments. [Pediatr Ann. 2020;49(11):e457-e466.].

Prevalence of upper respiratory tract infections and associated factors among children in Turkey

PURPOSE

Upper respiratory tract infections (URIs) are the most common diseases observed in children aged 0-6 years in Turkey. This study was conducted to investigate URIs in 0-6 year-old children in Turkey.

DESIGN AND METHODS

Data of children aged 0-6 years who were included in the 2014 Turkey Health Survey conducted by the Turkish Statistical Institute were collected from their parents.

RESULTS

In total, 1,293 and 1,732 children with and without URIs, respectively, were identified. The weighted point prevalence of URIs was 42.23%. Compared with the uninsured and female children belonging to high-income families, insured male children belonging to low-income families were more likely to develop URIs (p < .001). Moreover, comorbidities such as communicable diseases, anemia and diarrhea, and factors like health services utilization were associated with URIs. Analysis of health services utilization highlights that URIs were reported more among the children who had not visited a hospital than among those who had visited a hospital, with an odds ratio of 1.23.

CONCLUSIONS

The results of this study provide a deeper understanding of sociodemographic, comorbid, and health services utilization factors associated with URIs. These results provide useful insights for pediatric nursing professionals to improve the quality and efficiency of pediatric respiratory nursing services.

PRACTICE IMPLICATIONS

Collaborative networks with other health professionals, parents, and public health policy-makers are essential to decrease the prevalence of URIs in Turkey. These study results provide several insights for health professionals to improve pediatric action plans for ultimately improving child health status.

Association of a Targeted Population Health Management Intervention with Hospital Admissions and Bed-Days for Medicaid-Enrolled Children

IMPORTANCE

As the proportion of children with Medicaid coverage increases, many pediatric health systems are searching for effective strategies to improve management of this high-risk population and reduce the need for inpatient resources.

OBJECTIVE

To estimate the association of a targeted population health management intervention for children eligible for Medicaid with changes in monthly hospital admissions and bed-days.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study, using difference-in-differences analysis, deployed integrated team interventions in an academic pediatric health system with 31 in-network primary care practices among children enrolled in Medicaid who received care at the health system's hospital and primary care practices. Data were collected from January 2014 to June 2017. Data analysis took place from January 2018 to June 2019.

EXPOSURES

Targeted deployment of integrated team interventions, each including electronic medical record registry development and reporting alongside a common longitudinal quality improvement framework to distribute workflow among interdisciplinary clinicians and community health workers.

MAIN OUTCOMES AND MEASURES

Trends in monthly inpatient admissions and bed-days (per 1000 beneficiaries) during the preimplementation period (ie, January 1, 2014, to June 30, 2015) compared with the postimplementation period (ie, July 1, 2015, to June 30, 2017).

RESULTS

Of 25 460 children admitted to the hospital's health system during the study period, 8418 (33.1%) (3869 [46.0%] girls; 3308 [39.3%] aged ≤1 year; 5694 [67.6%] black) were from in-network practices, and 17 042 (67.9%) (7779 [45.7%] girls; 6031 [35.4%] aged ≤1 year; 7167 [41.2%] black) were from out-of-network practices. Compared with out-of-network patients, in-network patients experienced a decrease of 0.39 (95% CI, 0.10-0.68) monthly admissions per 1000 beneficiaries (P = .009) and 2.20 (95% CI, 0.90-3.49) monthly bed-days per 1000 beneficiaries (P = .001). Accounting for disproportionate growth in the number of children with medical complexity who were in-network to the health system, this group experienced a monthly decrease in admissions of 0.54 (95% CI, 0.13-0.95) per 1000 beneficiaries (P = .01) and in bed-days of 3.25 (95% CI, 1.46-5.04) per 1000 beneficiaries (P = .001) compared with out-of-network patients. Annualized, these differences could translate to a reduction of 3600 bed-days for a population of 93 000 children eligible for Medicaid.

CONCLUSIONS AND RELEVANCE

In this quality improvement study, a population health management approach providing targeted integrated care team interventions for children with medical and social complexity being cared for in a primary care network was associated with a reduction in service utilization compared with an out-of-network comparison group. Standardizing the work of care teams with quality improvement methods and integrated information technology tools may provide a scalable strategy for health systems to mitigate risk from a growing population of children who are eligible for Medicaid.

Trends in Bronchiolitis Hospitalizations in the United States: 2000-2016

OBJECTIVES

To investigate the temporal trend in the national incidence of bronchiolitis hospitalizations, their characteristics, inpatient resource use, and hospital cost from 2000 through 2016.

METHODS

We performed a serial, cross-sectional analysis of nationally representative samples (the 2000, 2003, 2006, 2009, 2012, and 2016 Kids' Inpatient Databases) of children (age <2 years) hospitalized for bronchiolitis. We identified all children hospitalized with bronchiolitis by using International Classification of Diseases, Ninth Revision, Clinical Modification 466.1 and International Classification of Diseases, 10th Revision, Clinical Modification J21. Complex chronic conditions were defined by the pediatric complex chronic conditions classification by using inpatient data. The primary outcomes were the incidence of bronchiolitis hospitalizations, mechanical ventilation use, and hospital direct cost. We examined the trends accounting for sampling weights.

RESULTS

From 2000 to 2016, the incidence of bronchiolitis hospitalization decreased from 17.9 to 13.5 per 1000 person-years in US children (25% decrease; P trend < .001). In contrast, the proportion of bronchiolitis hospitalizations among overall hospitalizations increased from 16% to 18% (P trend < .001). There was an increase in the proportion of children with a complex chronic condition (6%-13%; 117% increase), hospitalization to children's hospital (15%-29%; 93% increase), and mechanical ventilation use (2%-5%; 184% increase; all P trend < .001). Likewise, the hospital cost increased from $449 million to $734 million (63% increase) nationally (with an increase in geometric mean of cost per hospitalization [from $3267 to $4086; 25% increase; P trend < .001] adjusted for inflation) from 2003 to 2016.

CONCLUSIONS

From 2000 through 2016, the incidence of bronchiolitis hospitalizations among US children declined. In contrast, mechanical ventilation use and nationwide hospital direct cost substantially increased.

Patterns of health care use related to respiratory conditions in early life: A birth cohort study with linked administrative data

OBJECTIVES

To identify distinctive patterns of respiratory-related health services use (HSU) between birth and 3 years of age, and to examine associated symptom and risk profiles.

METHODS

This study included 729 mother and child pairs enrolled in the Toronto site of the Canadian Healthy Infant Longitudinal Development study in 2009-2012; they were linked to Ontario health administrative databases (2009-2016). A model-based cluster analysis was performed to identify distinct groups of children who followed a similar pattern of respiratory-related HSU between birth and 3 years of age, regarding hospitalization, emergency department (ED) and physician office visits for respiratory conditions and total health care costs (2016 Canadian dollars).

RESULTS

The majority (estimated cluster weight = 0.905) showed a pattern of low and stable respiratory care use (low HSU) while the remainder (weight = 0.095) showed a pattern of high use (high HSU). From 0 to 3 years of age, the low- and high-HSU groups differed in mean trajectories of total health care costs ($783 per 6 months decreased to $114, vs $1796 to $177, respectively). Compared to low-HSU, the high-HSU group was associated with a constant risk of hospitalizations, early high ED utilization and physician visits for respiratory problems. The two groups differed significantly in the timing of wheezing (late onset in low-HSU vs early in high-HSU) and future total costs (stable vs increased).

CONCLUSIONS

One in ten children had high respiratory care use in early life. Such information can help identify high-risk young children in a large population, monitor their long-term health, and inform resource allocation.

Care coordination for children with medical complexity

PURPOSE OF REVIEW

We review the literature to help the reader better understand the latest thinking on how best to identify, coordinate and fund care for children with medical complexity, a medically fragile high-cost subpopulation of children and youth with special healthcare needs.

RECENT FINDINGS

Proprietary and public algorithms have been developed to identify children with medical complexity. Research on families and healthcare providers of children with medical complexity have identified essential components of effective care coordination. Calculation of the cost of care for this population is confounded by cost shifting to families and the variable course of illness in this heterogeneous high-cost population. Care coordination is a team sport that requires strong family partnerships, adequate time and resources to be done effectively. Multiple studies of different sizes have reported similar care coordination team structure, staffing ratios and cost ranges. Multiple options for funding this work now exist and can be tailored to individual environments.

SUMMARY

Effective care coordination can positively impact the care of children with medical complexity. Recent work resulting in a better understanding of the needs of families and providers will guide the development of new technologies and measures.

Connecting Hospital to Home: Characteristics of and Rehospitalization Rates in Hospitalized Children With Private-Duty Nursing

OBJECTIVES

Children with medical complexity are frequently hospitalized and have extensive health care needs. Private-duty nursing (PDN) is a service on which some children with medical complexity rely to live at home, but little is known about patients discharged with PDN. Our objective for this study was to describe the characteristics and longitudinal outcomes of patients with PDN who are hospitalized.

METHODS

This study was a 1-year retrospective study of patients receiving PDN who were hospitalized at a quaternary freestanding children's hospital; there was an additional 2-year follow-up. Patient characteristics, rehospitalization rates, length of stay, mortality, and hospital charges were identified. Descriptive statistics were performed to characterize trends, and a time-to-event analysis was used to characterize unplanned rehospitalization.

RESULTS

Among 8187 unique patients who were hospitalized in the initial study year (June 1, 2014 to -May 31, 2015), 188 patients (2%) used PDN. Of patients using PDN, 94% used gastrointestinal devices. The median index length of stay was 4 days (interquartile range 2-6). Two-year mortality was 12%. Cumulative all-cause rehospitalization rates were 18% by 30 days, 62% by 365 days, and 87% within 2 years; the median rehospitalization frequency was 3 per patient. The most common reasons for unplanned rehospitalization were infection (41%) and device complication (10%). During the study period, 11% of both rehospitalizations and total hospital days were attributed to patients with PDN. Unplanned rehospitalizations of patients with PDN accounted for $117 million in hospital charges.

CONCLUSIONS

One in 50 patients hospitalized at a single center were discharged with PDN, which accounted for a disproportionate level of hospital use. Future research should be used to address whether the access and quality of PDN may impact rehospitalization.

Association of Home Respiratory Equipment and Supply Use with Health Care Resource Utilization in Children

OBJECTIVE

To compare health care use and spending in children using vs not using respiratory medical equipment and supplies (RMES).

STUDY DESIGN

Cohort study of 20 352 children age 1-18 years continuously enrolled in Medicaid in 2013 from 12 states in the Truven Medicaid MarketScan Database; 7060 children using RMES were propensity score matched with 13 292 without RMES. Home RMES use was identified with Healthcare Common Procedure Coding System and International Classification of Diseases codes. RMES use was regressed on annual per-member-per-year Medicaid payments, adjusting for demographic and clinical characteristics, including underlying respiratory and other complex chronic conditions.

RESULTS

Of children requiring RMES, 47% used oxygen, 28% suction, 22% noninvasive positive-pressure ventilation, 17% tracheostomy, 8% ventilator, 5% mechanical in-exsufflator, and 4% high-frequency chest wall oscillator. Most children (93%) using RMES had a chronic condition; 26% had ≥6. The median per-member-per-year payments in matched children with vs without RMES were $24 359 vs $13 949 (P < .001). In adjusted analyses, payment increased significantly (P < .001 for all) with mechanical in-exsufflator (+$2657), tracheostomy (+$6447), suction (+$7341), chest wall oscillator (+$8925), and ventilator (+$20 530). Those increased payments were greater than the increase associated with a coded respiratory chronic condition (+$2709). Hospital and home health care were responsible for the greatest differences in payment (+$3799 and +$3320, respectively) between children with and without RMES.

CONCLUSION

The use of RMES is associated with high health care spending, especially with hospital and home health care. Population health initiatives in children may benefit from consideration of RMES in comprehensive risk assessment for health care spending.

Care Coordination for Children and Youth With Special Health Care Needs: National Survey Results

We analyzed findings from the 2009-2010 National Survey of Children with Special Health Care Needs to identify associations between families with children and youth with special health care needs (CYSHCN) reporting adequate care coordination (CC) with family-provider relations, shared decision making (SDM), and child outcomes. Eligible subjects were the 98% of families asked about CC, service use, and communication. Bivariate analysis using χ² tests were performed on binary outcome variables to determine the strength of the associations between CC and independent and dependent variables. Weighted, multivariate logistic regression models were constructed to assess independent associations of adequate CC with child outcomes and associations of SDM on adequate CC. Among families of CYSHCN asked about CC, 72% reported receiving help with CC. Of these, 55% reported receiving adequate CC. Family report of adequate CC was favorably associated with family-provider relations, child outcomes, and report of provider participation in SDM.

Trends in common surgical procedures at children's and nonchildren's hospitals between 2000 and 2009

PURPOSE

Though growth in children's surgical expenditures has been documented, procedure-specific differences in volume and costs at children's hospitals (CH) and non-hildren's hospitals (NCH) have not been explored. Our purpose was to compare trends in volume and costs of common pediatric surgical procedures between CH and NCH.

METHODS

We performed a review of the 2000-2009 Kids' Inpatient Database identifying all cases of appendectomy for uncomplicated appendicitis (AP), tonsillectomy and adenoidectomy (TA), fundoplication (FP), humeral fracture repair (HFR), pyloromyotomy (PYL), and cholecystectomy (CHOLE). Trends in case volume and costs were examined at CH versus NCH.

RESULTS

The proportion of surgical care at CH increased for all procedures from 2000 to 2009. TA and CHOLE demonstrated higher costs per case at CH. Positive growth over time in cost per case at CH was seen for AP and FP, with the cost per case of FP increasing by 21% between 2006 and 2009.

CONCLUSIONS

The proportion of surgeries performed at CH is continuing to grow alongside proportionate increases in costs, however costs for certain procedures are higher at CH than NCH. Further investigation is needed to explore cost containment at CH while still maintaining specialized, high quality surgical care.

LEVEL OF EVIDENCE

Level III.

Predicting Changes in Pediatric Medical Complexity using Large Longitudinal Health Records

Medically complex patients consume a disproportionate amount of care resources in hospitals but still often end up with sub-optimal clinical outcomes. Predicting dynamics of complexity in such patients can potentially help improve the quality of care and reduce utilization of hospital resources. In this work, we model the change prediction of medical complexity using a large dataset of 226K pediatric patients over 5 years from Children's Healthcare of Atlanta (CHOA). We compare different classification methods including logistic regression, random forest, gradient boosting trees, and multilayer perceptron in predicting whether patients will change their complexity status in the last year based on the data from previous years. We achieved an area under the ROC curve (AUC) of 88% for predicting noncomplex patients becoming complex and 74% for predicting complex patients staying complex. We also identify the factors associated with the change in complexity of patients.

Ethical Framework for Risk Stratification and Mitigation Programs for Children With Medical Complexity

Those in hospitals and health care systems, when designing clinical programs for children with medical complexity, often talk about needing to develop and implement a system of risk stratification. In this article, we use the framework of an ethical evaluation of a health care program to examine what this task of risk stratification might entail by identifying specific and detailed issues that require particular attention and making a series of recommendations to help ensure that programs for children with medical complexity avoid potentially ethically problematic situations and practices.

Potential Opportunities for Prevention or Earlier Diagnosis of Child Physical Abuse in the Inpatient Setting

OBJECTIVES

To compare rates of previous inpatient visits among children hospitalized with child physical abuse (CPA) with controls as well as between individual abuse types.

METHODS

In this study, we used the Pediatric Health Information System administrative database of 44 children's hospitals. Children <6 years of age hospitalized with CPA between January 1, 2011, and September 30, 2015, were identified by discharge codes and propensity matched to accidental injury controls. Rates for previous visit types were calculated per 10 000 months of life. χ2 and Poisson regression were used to compare proportions and rates.

RESULTS

There were 5425 children hospitalized for CPA. Of abuse and accident cases, 13.1% and 13.2% had a previous inpatient visit, respectively. At previous visits, abused children had higher rates of fractures (rate ratio [RR] = 3.0 times; P = .018), head injuries (RR = 3.5 times; P = .005), symptoms concerning for occult abusive head trauma (AHT) (eg, isolated vomiting, seizures, brief resolved unexplained events) (RR = 1.4 times; P = .054), and perinatal conditions (eg, prematurity) (RR = 1.3 times; P = .014) compared with controls. Head injuries and symptoms concerning for occult AHT also more frequently preceded cases of AHT compared with other types of abuse (both P < .001).

CONCLUSIONS

Infants hospitalized with perinatal-related conditions, symptoms concerning for occult AHT, and injuries are inpatient populations who may benefit from abuse prevention efforts and/or risk assessments. Head injuries and symptoms concerning for occult AHT (eg, isolated vomiting, seizures, and brief resolved unexplained events) may represent missed opportunities to diagnose AHT in the inpatient setting; however, this requires further study.

Effectiveness of a Comprehensive Case Management Service for Children With Medical Complexity

OBJECTIVES

To assess whether children with medical complexity (CMC) exposed to a hospital-based comprehensive case management service (CCMS) experience improved health care quality, improved functional status, reduced hospital-based utilization, and/or reduced overall health care costs.

METHODS

Eligible CMC at Seattle Children's Hospital were enrolled in a cluster randomized controlled trial between December 1, 2010, and September 29, 2014. Participating primary care providers (PCPs) were randomly assigned, and CMC either had access to an outpatient hospital-based CCMS or usual care directed by their PCP. The CCMS included visits to a multidisciplinary clinic ≥ every 6 months for 1.5 years, an individualized shared care plan, and access to CCMS providers. Differences between control and intervention groups in change from baseline to 12 months and baseline to 18 months (difference of differences) were tested.

RESULTS

Two hundred PCPs caring for 331 CMC were randomly assigned. Intervention group (n = 181) parents reported more improvement in the Consumer Assessment of Healthcare Providers and Systems version 4.0 Child Health Plan Survey global health care quality ratings than control group parents (6.7 [95% confidence interval (CI): 3.5-9.8] vs 1.3 [95% CI: 1.9-4.6] at 12 months). We did not detect significant differences in child functional status and most hospital-based utilization between groups. The difference in change of overall health care costs was higher in the intervention group (+$8233 [95% CI: $1701-$16 937]) at 18 months). CCMS clinic costs averaged $3847 per child-year.

CONCLUSIONS

Access to a CCMS generally improved health care quality, but was not associated with changes in child functional status or hospital-based utilization, and increased overall health care costs among CMC.

Health Care Expenditures and Utilization for Children With Noncomplex Chronic Disease

BACKGROUND

Pediatric health care expenditures and use vary by level of complexity and chronic illness. We sought to determine expenditures and use for children with noncomplex chronic diseases (NC-CDs).

METHODS

We performed a retrospective, cross-sectional analysis of Medicaid enrollees (ages 0-18 years) from January 1, 2012, through December 31, 2013, using administrative claims (the Truven MarketScan Medicaid Database). Patients were categorized by chronicity of illness by using 3M Health Information System's Clinical Risk Groups (CRGs) as follows: without chronic diseases (WO-CDs) (CRG 1-2), NC-CDs (CRG 3-5), and complex chronic diseases (C-CDs) (CRG 6-9). Primary outcomes were medical expenditures, including total annualized population expenditure and per-member per-year expenditure (PMPY). Secondary outcomes included the number of health care encounters over the 2-year period.

RESULTS

There were 2 424 946 children who met inclusion criteria, 53% were WO-CD; 36% had an NC-CD; and 11% had a C-CD. Children with NC-CDs accounted for 33% ($2801 PMPY) of the annual spending compared with 20% ($1151 PMPY) accounted for by children WO-CDs and 47% ($12 569 PMPY) by children with C-CDs. The median outpatient visit count by group over the 2-year period was 15 (interquartile range [IQR] 10-25) for NC-CD, 8 (IQR 5-13) WO-CD, and 34 (IQR 19-72) for C-CD.

CONCLUSIONS

Children with NC-CDs accounted for 33% of pediatric Medicaid expenditures and have significantly higher PMPY and aggregate annual expenditures than children WO-CDs. The annual aggregate expenditures of the NC-CD group represent a significant societal cost because of the high volume of children, extrapolated to ∼$34.9 billion annually in national Medicaid expenditures.

High-Expenditure Pharmaceutical Use Among Children in Medicaid

BACKGROUND AND OBJECTIVES

Medication use may be a target for quality improvement, cost containment, and research. We aimed to identify medication classes associated with the highest expenditures among pediatric Medicaid enrollees and to characterize the demographic, clinical, and health service use of children prescribed these medications.

METHODS

Retrospective, cross-sectional study of 3 271 081 Medicaid-enrolled children. Outpatient medication spending among high-expenditure medication classes, defined as the 10 most expensive among 261 mutually exclusive medication classes, was determined by using transaction prices paid to pharmacies by Medicaid agencies and managed care plans among prescriptions filled and dispensed in 2013.

RESULTS

Outpatient medications accounted for 16.6% of all Medicaid expenditures. The 10 most expensive medication classes accounted for 63.9% of all medication expenditures. Stimulants (amphetamine-type) accounted for both the highest proportion of expenditures (20.6%) and days of medication use (14.0%) among medication classes. Users of medications in the 10 highest-expenditure classes were more likely to have a chronic condition of any complexity (77.9% vs 41.6%), a mental health condition (35.7% vs 11.9%), or a complex chronic condition (9.8% vs 4.3%) than other Medicaid enrollees (all P < .001). The 4 medications with the highest spending were all psychotropic medications. Polypharmacy was common across all high-expenditure classes.

CONCLUSIONS

Medicaid expenditure on pediatric medicines is concentrated among a relatively small number of medication classes most commonly used in children with chronic conditions. Interventions to improve medication safety and effectiveness and contain costs may benefit from better delineation of the appropriate prescription of these medications.

The Medical Home at 50: Are Children With Medical Complexity the Key to Proving Its Value?

The medical home has been widely promoted as a model of primary care with the potential to transform the health care delivery system. Although this model was initially focused on children with chronic conditions, the American Academy of Pediatrics has endorsed a generalization of the model, promoting the statement, "Every child deserves a medical home." Recently, other major professional and governmental organizations have embraced this more inclusive vision, and the medical home concept has been promoted in provisions of the Affordable Care Act. Yet, rigorous evaluations of the value of the medical home, within pediatrics and beyond, have been limited, and the results have been mixed. Early results from large demonstration projects in adults have generally noted modest improvements in quality without accompanying reductions in cost. At this critical period in health care, with widespread interest in health care delivery and payment reform, these results present a potential threat to the medical home. Understanding possible reasons for these early findings is crucial to sustaining the spread of the medical home beyond its first 50 years. With this aim, we review the history of the medical home and trends in child health, and we explore the concepts of value and complexity as they pertain to pediatric health care delivery. We propose that, because of the demographic characteristics and economics of child health and current policy imperatives with regard to health care, a strong value proposition for the medical home in pediatrics involves children with medical complexity.

Trends in Hospital Utilization and Costs among Pediatric Palliative Care Recipients

OBJECTIVE AND BACKGROUND

Few previous studies have explored how pediatric palliative care (PPC) influences hospital utilization. We evaluated this among PPC recipients in a single center.

METHODS

This is a retrospective cohort study of 109 patients ≥2 years of age who received PPC consultation at a large quaternary children's hospital from April 2009 to September 2010. We assessed frequencies of hospital admissions and emergency department (ED) visits, use of intensive interventions, and hospital costs. Generalized estimating equations were used to compare outcomes in the two years before and after PPC consultation, stratifying by whether a patient survived two or more years following PPC enrollment.

RESULTS

Median age at PPC consultation was 13 years (interquartile range 6-18); 56.0% were male (n = 61), 69.7% white non-Hispanic (n = 76). Fifty-nine percent (n = 64) of patients died during the study period. Overall, annual hospital admission rates decreased from 4.6 (95% confidence interval [CI] 4.0-5.4) before PPC consultation to 3.7 (95% CI 3.4-4.4) after (p = 0.025). Annual ED visits decreased from 0.9 (95% CI 0.7-1.2) to 0.6 (95% CI 0.4-0.8) (p = 0.030). Survivors had significantly decreased hospital admissions [rate ratio (RR) 0.57 (95% CI 0.45-0.73), p < 0.001] and ED visits [RR 0.33 (95% CI 0.20-0.54), p < 0.001]. Decedents had increased intensive care unit use (p = 0.029) but decreased operations (p = 0.002); survivors experienced no change in these outcomes after PPC consultation. Hospital costs remained stable for all (p = 0.929).

DISCUSSION

PPC involvement may contribute to decreased hospital and ED use, without escalating costs. These outcomes are most evident in survivors. Hence, PPC may have a measurable long-term impact on hospital use in seriously ill children.

Impact of Chronic Conditions on Emergency Department Visits of Children Using Medicaid

OBJECTIVE

To assess the impact of chronic conditions on children's emergency department (ED) use.

STUDY DESIGN

Retrospective analysis of 1 850 027 ED visits in 2010 by 3 250 383 children ages 1-21 years continuously enrolled in Medicaid from 10 states included in the Truven Marketscan Medicaid Database. The main outcome was the annual ED visit rate not resulting in hospitalization per 1000 enrollees. We compared rates by enrollees' characteristics, including type and number of chronic conditions, and medical technology (eg, gastrostomy, tracheostomy), using Poisson regression. To assess chronic conditions, we used the Agency for Healthcare Research and Quality's Chronic Condition Indicator system, assigning chronic conditions with ED visit rates ≥75th percentile as having the "highest" visit rates.

RESULTS

The overall annual ED visit rate was 569 per 1000 enrollees. As the number of the children's chronic conditions increased from 0 to ≥3, visit rates increased by 180% (from 376 to 1053 per 1000 enrollees, P < .001). Rates were 174% higher in children assisted with vs without medical technology (1546 vs 565, P < .001). Sickle cell anemia, epilepsy, and asthma were among the chronic conditions associated with the highest ED visit rates (all ≥1003 per 1000 enrollees).

CONCLUSIONS

The highest ED visit rates resulting in discharge to home occurred in children with multiple chronic conditions, technology assistance, and specific conditions such as sickle cell anemia. Future studies should assess the preventability of ED visits in these populations and identify opportunities for reducing their ED use.

Spending on Children's Personal Health Care in the United States, 1996-2013

IMPORTANCE

Health care spending on children in the United States continues to rise, yet little is known about how this spending varies by condition, age and sex group, and type of care, nor how these patterns have changed over time.

OBJECTIVE

To provide health care spending estimates for children and adolescents 19 years and younger in the United States from 1996 through 2013, disaggregated by condition, age and sex group, and type of care.

EVIDENCE REVIEW

Health care spending estimates were extracted from the Institute for Health Metrics and Evaluation Disease Expenditure 2013 project database. This project, based on 183 sources of data and 2.9 billion patient records, disaggregated health care spending in the United States by condition, age and sex group, and type of care. Annual estimates were produced for each year from 1996 through 2013. Estimates were adjusted for the presence of comorbidities and are reported using inflation-adjusted 2015 US dollars.

FINDINGS

From 1996 to 2013, health care spending on children increased from $149.6 (uncertainty interval [UI], 144.1-155.5) billion to $233.5 (UI, 226.9-239.8) billion. In 2013, the largest health condition leading to health care spending for children was well-newborn care in the inpatient setting. Attention-deficit/hyperactivity disorder and well-dental care (including dental check-ups and orthodontia) were the second and third largest conditions, respectively. Spending per child was greatest for infants younger than 1 year, at $11 741 (UI, 10 799-12 765) in 2013. Across time, health care spending per child increased from $1915 (UI, 1845-1991) in 1996 to $2777 (UI, 2698-2851) in 2013. The greatest areas of growth in spending in absolute terms were ambulatory care among all types of care and inpatient well-newborn care, attention-deficit/hyperactivity disorder, and asthma among all conditions.

CONCLUSIONS AND RELEVANCE

These findings provide health policy makers and health care professionals with evidence to help guide future spending. Some conditions, such as attention-deficit/hyperactivity disorder and inpatient well-newborn care, had larger health care spending growth rates than other conditions.

Trends in Health Care Spending for Children in Medicaid With High Resource Use

OBJECTIVES

To assess characteristics associated with health care spending trends among child high resource users in Medicaid.

METHODS

This retrospective analysis included 48 743 children ages 1 to 18 years continuously enrolled from 2009-2013 in 10 state Medicaid programs (Truven MarketScan Medicaid Database) also in the top 5% of all health care spending in 2010. Using multivariable regression, associations were assessed between baseline demographic, clinical, and health services characteristics (using 2009-2010 data) with subsequent health care spending (ie, transiently, intermittently, persistently high) from 2011-2013.

RESULTS

High spending from 2011-2013 was transient for 54.2%, persistent for 32.9%, and intermittent for 12.9%. Regarding demographic characteristics, the highest likelihood of persistent versus transient spending occurred in children aged 13 to 18 years versus 1 to 2 years in 2010 (odds ratio [OR], 3.0 [95% confidence interval (CI), 2.7-3.4]). Regarding clinical characteristics, the highest likelihoods were in children with ≥6 chronic conditions (OR, 4.8 [95% CI, 3.5-6.6]), a respiratory complex chronic condition (OR, 2.5 [95% CI, 2.2-2.8]), or a neuromuscular complex chronic condition (OR, 2.3 [95% CI, 2.2-2.5]). Hospitalization and emergency department (ED) use in 2010 were associated with a decreased likelihood of persistent spending in 2011-2013 (hospitalization OR, 0.7 [95% CI, 0.7-0.7]); ED OR, 0.8 [95% CI, 0.8-0.8]).

CONCLUSIONS

Most children with high spending in Medicaid are without persistently high spending in subsequent years. Adolescent age, multiple chronic conditions, and certain complex chronic conditions increased the likelihood of persistently high spending; hospital and ED use decreased it. These data may help inform the development of new models of care and financing to optimize health and save resources in children with high resource use.