TEN YEAR TRENDS IN CHILDREN ’ S HOSPITAL RESOURCE UTILIZATION by Type of Psychiatric Comorbidity Bonnie T. Zima MD MPH, Jonathan Rodean MPP, Matt Hall PhD, Naomi S. Bardach MD MAS, Tumaini R. Coker MD MBA, Jay G. Berry MD MPH Academy Health June 2016
Significance • 10% of all U.S. pediatric hospitalizations are for a primary psychiatric diagnosis 1 • $1.3 B (2009) • > costs for asthma • 50% rise in U.S. pediatric hospitalizations for mental disorders (2006-2011) 2 • Total expenditures $11.6 B • Co-occurring psychiatric diagnoses are important drivers of pediatric hospitalizations and costs • Common mental disorders (ADHD, ASD) 3-5 • Common chronic medical conditions (asthma, sickle cell, obesity) 6-8
Objectives To describe: 1. Sociodemographic and clinical characteristics of children hospitalized in freestanding children ’ s hospitals By Psychiatric Comorbid 2. Ten year trends in children ’ s hospital Type resource use 3. Most recent % change in hospital resource use
Psychiatric Comorbid Types All Children ’ • s 2005-2014 • Hospitalizations 33 hospitals • With/Without Any Psychiatric Psychiatric Diagnosis Med + Psych • Psychiatric Psych + Med Comorbid Types Psych Only
Study Design & Data Source • Retrospective cohort analysis • Pediatric Health Information System (PHIS) • Hospital discharges from 46 tertiary care children ’ s hospitals • Demographic characteristics • Billing information • 52 procedures • 41 ICD-9 diagnoses • Patient may contribute more than 1 record
Study Population • All inpatient + short term (1-2 days) observation unit stays • 2005-2014 • Ages 3-17 years • 33 hospitals • Discharge and billing data available for entire study time period • Total resource use • 3,114,099 hospitalizations • 12,253,353 hospital days • $45.5 B
Hospital Resource Use • # Hospital discharges • Days spent in hospital • Aggregate hospital costs • Billed hospital charges converted to costs using cost-to-charge ratios specific to year, hospital, and service line • Medicare Cost Report System database (Truven Health Analytics) • Adjusted for regional cost of living • Inflated to 2014 dollars using Consumer Price Index for Medical Care
Psychiatric Diagnostic Groups • Adapted the multi-level groupings from ICD-9 based Clinical Classification Software (CCS) • AHRQ • Adapted multi-level CCS groups using 2 prior approaches for national estimates for pediatric hospitalizations for psychiatric disorders. 1,2 • Created 3 subcategories a priori : • Psychiatric disorders • medical etiology • related to a neurologic disorder • mimic a medical illness
Psychiatric Comorbid Types • With vs. Without Any Psychiatric Diagnoses • Primary or secondary • All “ non-psychiatric ” dx ’ s ≈ “ medical ” • Psychiatric Comorbid Subgroups • Med + Psych • Medical primary dx + any secondary psychiatric dx • Ex: Traumatic injury + Self-injury or suicide • Psych + Med • Psychiatric primary dx + any secondary medical dx • Ex: Depression + Asthma • Psych Only • Primary and (if any) all secondary dx ’ s are psychiatric • Ex: Anorexia Nervosa + Depression
Patient Characteristics • Sociodemographics • Age, sex, race/ethnicity • Insurance type • Public, private, self-pay, other • Medical complexity • Feudtner ’ s Complex Chronic Conditions (CCC) • “ Any medical condition that can be reasonably expected to last at least 12 months (unless death intervenes) and to involve either several different organ systems or 1 organ system severe enough to require specialty pediatric care and probably some period of hospitalization in a tertiary care center ” . 11
Statistical Analysis • Demographic and clinical characteristics by psych comorbid group • Bivariate Rao-Scott chi-square tests • Accounting for hospital clustering • Trends in hospital discharges, days, costs • Generalized estimating equations • Fixed: demographics, clinical • Fixed: US child population: total children, # non-neonatal U.S. pediatric hospitalizations, # U.S. children enrolled in Medicaid, # U.S. children living in poverty • Interaction term: psych comorbid group x year • Mean annual growth: annual % change between consecutive yrs • Cumulative growth: % change between 2005-2014
Total Sample (2005-2014) • n=3,114,099 All Children ’ • s 12,253,353 days • Hospitalizations $45.5 B • 18.3% • n=568,449 Any Psychiatric • 3,534,038 days • $11.2 B Med + Psych • 76.6% $9.8 B • Psych + Med 17.6% $995 M • 5.7% $257 M Psych Only
Hospitalizations: With vs. Without a Psychiatric Diagnosis
Child Demographics by Any Psych Dx (p ≤ .001) 80% 60% 40% 20% 0% Any Psych No Psych
Complex Chronic Conditions by Any Psych Dx (p ≤ .001) 70% 60% 50% 40% 30% 20% 10% 0% Any Psych No Psych
10 Year Trends in Hospitalizations by Any Psychiatric Dx Number of Hospitalizations Any Psych 160 +137.7% 140 Any Psych % Growth in Reference to 2005 No Psych 120 100 80 60 No Psych 40 +26.0% 20 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Year
10 Year Trends in Hospital Days by Any Psychiatric Dx Total Bed Days 160 140 Any Psych % Growth in Reference to 2005 120 No Psych Any Psych 100 +92.9% 80 60 40 No Psych 20 +5.9% 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Year
10 Year Trends in Hospital Costs by Any Psychiatric Dx Total Hospital Cost Any Psych 160 +142.7% 140 $671M → $1.6B Any Psych % Growth in Reference to 2005 120 No Psych 100 80 60 No Psych 40 +18.9% 20 $3.1B → $3.7B 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Year
Hospitalizations: By Psychiatric Comorbid Type
Child Demographics by Psych Comorbid Type (p ≤ .001) 100% 80% 60% 40% 20% 0% Med + Psych Psych + Med Psych Only
Complex Chronic Conditions by Psych Comorbid Type (p ≤ .001) 100% 80% 60% 40% 20% 0% Med + Psych Psych + Med Psych Only
10 Year Trends in Hospitalizations by Psychiatric Comorbid Type Med+Psych Number of Hospitalizations by Psychiatric Comorbid Group +160.5% Med + Psych Psych+Med Psych + Med 130 +143.0% Psych Only % Growth in Reference to 2004 80 30 Psych Only -21.1% -20 -70 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Year
10 Year Trends in Hospital Days by Psychiatric Comorbid Type Total Bed Days by Psychiatric Complexity Med+Psych Med + Psych 130 Psych + Med +120.8% % Growth in Reference to 2004 Psych Only Psych+Med 80 +102.8% 30 No Psych -20 -47.8% -70 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Year
10 Year Trends in Hospital Costs by Psychiatric Comorbid Type Total Hospitalization Cost by Psychiatric Complexity Med+Psych +156.2% $573M → $1.5B Med + Psych 130 Psych + Med Psych+Med Psych Only % Growth in Reference to 2004 +115.5% $66M → $142M 80 30 Psych Only -20 -38.8% $30M → $20M -70 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Year
2014 Hospital Resource Use
2014 Hospital Resource Use • n=373,671 All Children ’ • s 1,372,109 days • Hospitalizations $5.3 B • 23.3% • n=87,002 Any Psychiatric • 480,341 days • $1.63 B Med + Psych • 77.8% $1.5 B • Psych + Med 18.7% $142 M • 3.6% $20 M Psych Only
3 Most Common Comorbid Psych Dx 22% Developmental Disorder Med + 18% ADHD Psych 14% Anxiety Disorders 14% Anxiety Disorders Psych + 14% Suicide/Self-injury Med 13% Depression Depression 18% Psych Anxiety Disorders 16% Only Suicide/Self-injury 14% 0% 10% 20% 30%
Limitations • Administrative data • 33 freestanding children ’ s hospitals • Validity of psychiatric dx not established • Repeat utilizers not excluded • Bias toward children with greater medical complexity • Contextual factors not assessed • ↑ Prevalence of child psychiatric disorders • ↑ Provider recognition • ∆ Coding practices/time • ↑ Coding of psych dx with ↑ LOS • ↑ Mental health services → ↑ billing for psych dx • Child and parent predictors of hospitalizations missing
Main Findings Ten Year Rise in Pediatric Hospitalizations ↑ • Any Psych Diagnosis >5x> No Psych Diagnosis • +137.7% vs +26% • Rise Among Hospitalizations for Any Psych Diagnosis • Driven by Med + Psych (160.5%) • 2014 • 4/5 Hospitalizations • 90% hospital costs • $1.5 B • Developmental disorder, ADHD, anxiety disorders
Implications Strategic planning to meet the rise demand for psychiatric care in freestanding children ’ s hospitals should place high priority on the needs of children with a primary medical condition and comorbid developmental disorders, ADHD, and anxiety disorders.
Future Research Examine the impact of changes in children ’ • s hospital capacity to deliver behavioral health services • Child/youth • Provider • Hospital • Stratify influence by type of psychiatric comorbidity
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