Background Data Pediatric Obesity PHIS (Pediatric Health - PDF document

12/11/2012 Procedure Utilization in Obese American Children I have nothing to disclose I have nothing to disclose Nicole Steber, MD, PGY2 Nathan Fleming, MD, Kristin Hendrix, PH.D., Jean Molleston, MD, Stephen Downs, MD, William Bennett Jr., MD Nicole Steber, MD, PGY2 Indiana University School of Medicine Riley Children’s Hospital Background Data • Pediatric Obesity • PHIS (Pediatric Health Information System) – Recent rapid increase – Administrative database – 17% of all children •43 tertiary care pediatric hospitals •Higher rates in some groups – 42 included - with resource utilization data – Obesity affects every organ system •Inpatient and ambulatory surgery data •Increased healthcare cost •Discharge/encounter data – demographics, – Question – Does obesity affect procedural diagnoses, procedures utilization in children in the US? •Data de-identified • Au, N., The health care cost implications of overweight and obesity during childhood. Health Serv Res, 2012. •Procedures with ICD9 codes included • Woolford, S.J., et al., Persistent gap of incremental charges for obesity as a secondary diagnosis in common pediatric hospitalizations. J Hosp Med, 2009. • Vellinga, A., D. O'Donovan, and D. De La Harpe, Length of stay and associated costs of obesity related hospital admissions in Ireland. BMC Health Serv Res, 2008. • Woolford, S.J., et al., Incremental hospital charges associated with obesity as a secondary diagnosis in children. Obesity (Silver Spring), 2007. • Trasande, L. and S. Chatterjee, The impact of obesity on health service utilization and costs in childhood. Obesity (Silver Spring), 2009. Obesity ICD9 Codes Methods • Children 2-21yrs from PHIS database (2004- 2004-20 2011) • Obesity related ICD9 codes have high specificity – Inpatient procedures – Ambulatory procedures – Study of 17,380 individuals • Rate of procedures in children with obesity • Rate of procedures in children with obesity – 98.98% specificity of Obesity Related ICD9 codes in obese 98 98% ifi it adults related ICD9 codes (ORICs) vs no codes – 278.00 (Overweight & obesity), 278.01 (Morbid obesity), 278.02 – 7.75% sensitive (Overweight), 277.2 (Dysmetabolic syndrome), and 783.1 (Abnormal weight gain) – Procedure = any surgical procedure or intensive intervention with an ICD9 code • Excluded rare procedures with less than 10 cases Martin, B.-J. The Accuracy of Coded Obesity in an Administrative Database . 2011. 1

12/11/2012 Demographics Methods Ambulatory Ambul Ambulatory Ambul In Inpat patient In Inpat patient t • Odds ratio of procedure in obesity coded vs not obesity code no not coded oded code coded obese se Not coded Not c d code coded obese se obese ob ese ob obese ese Number of 2,112,004 26,313 1,418,319 31,651 • Two sample Z-test for statistical significance ( α = 0.05) cases Mean Age Mean Age 10.5 10 5 10.7 10 7 10.5 10 5 10 9 10.9 (yrs) • Bonferroni Correction • = α /n (number of comparisons) Median Age 8.9 11.7 11 10.2 13 13.6 (yrs) • Corrects for multiple corrections • Stringent statistical significance Number of 1,197,844 13,805 770,953 15,755 males 57% 52% 54% 50% Demographics - Race Demographics - Insurance Ambul Ambulatory Ambul Ambulatory Inpat In patient In Inpat patient t Ambulatory Ambul Ambulatory Ambul Inpat In patient t Inpat In patient no obesity no ob esity codes codes code coded ob d obese ese no ob no obesity esity codes codes code coded obese se no ob no obese codes ese codes coded ob code d obese ese no ob no obese code ese code coded ob code d obese ese Number of 2,112,004 26,313 1,418,319 31,651 Number of 2,112,004 26,313 1,418,319 31,651 cases cases Insurance Type White 1,450,833 16,069 926,512 16,999 69% 61% 65% 54% Private 602,403 7,467 279,212 5,431 29% 28% 20% 17% Black 297,681 5,192 250,753 8,474 14% 20% 20% 18% 27% 27 Medicaid 491,888 9,508 325,653 10,714 23% 23% 36% 36% 23% 23% 34% 34% Asian 42606 313 32058 359 Other 153,165 1,620 83,681 2,153 2% 1% 2% 1% Insurance 7% 6% 6% 7% Other race 320,884 4,739 208,996 5,819 Unknown 826,251 7,647 701,338 12,838 15% 18% 15% 18% Insurance 39% 29% 49% 41% Results Ambulatory Procedures • 3,588,287 total procedures included Lower rate Lower rate Higher rate Higher rate in ORICs in ORICs in ORICs in ORICs – 1,449,970 inpatient procedures •31,651 with obesity related ICD9 codes (2.2%) – 2,138,317 ambulatory procedures •26,313 with obesity related ICD9 codes (1.2%) – 17% of all children in US obese (2010) Ogden, C.L., et al., Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. JAMA, 2012. 307 307(5): p. 483-90. 2

12/11/2012 Inpatient Cost Inpatient Procedures Procedu ocedure Odds R dds Ratio tio Dif iffere renc nce in in OR ORIC IC vs non-O non-ORIC ($/patient/e atient/encount ncounter er) Lower rate Lower rate Higher rate Higher rate in ORICs in ORICs in ORICs in ORICs T&A 6.66 $2,765.33 CPAP 3.49 $182.24 Lap cholecystectomy p y y 3.89 $1,919.69 Physical Therapy 1.73 $1,541.21 Spinal tap 1.4 $1,447.22 Lapscp appendectomy 0.55 $1,813.02 Int fix w/o red femur 2.75 -$1,457.36 ORIC = Obesity Related ICD9 Code Ambulatory Cost Summary Pr Proced ocedure Odds Ra Ratio tio Dif iffere renc nce in in ORIC ORIC vs vs • Increased rate of some procedures in children non-ORIC non-O IC ($/patient/e atient/encount ncounter er with obesity related ICD9 codes ) T & A 1.73 $125.39 – 6 inpatient procedures EGD w/ biopsy 1.37 $333.69 •T&A Cl Closed liver biopsy d li bi 10 4 10.4 -$113.04 $113 04 •CPAP Colonoscopy 1.37 $251.71 • laparoscopic cholecystectomy Sigmoidoscopy 1.55 $478.91 Rmvl impl dev tib/fib 2.67 $19.51 • Internal fixation without reduction of femur Myringotomy 0.04 -$176.42 • spinal tap Int fix w/o red femur 5.18 -$181.63 •physical therapy Crown application 0.54 $959.67 Pilonidal cyst exc. 3.86 -$13.98 ORIC = Obesity Related ICD9 Code Summary Summary • 8 ambulatory procedures increased in children with obesity related ICD9 codes – T&A • Children with obesity related ICD9 codes are – EGD undergoing certain procedures at a higher rate – liver biopsy with increased cost. – colonoscopy – sigmoidoscopy – tib/fib device removal – internal fixation without reduction of femur – pilonidal cyst excision • Why are children with obesity related ICD9 codes undergoing more scopes? 3