Background Data Pediatric Obesity PHIS (Pediatric Health - - PDF document

12/11/2012 1

Procedure Utilization in Obese American Children

Nicole Steber, MD, PGY2 Indiana University School of Medicine Riley Children’s Hospital

Nicole Steber, MD, PGY2

Nathan Fleming, MD, Kristin Hendrix, PH.D., Jean Molleston, MD, Stephen Downs, MD, William Bennett Jr., MD

I have nothing to disclose I have nothing to disclose

Background

• Pediatric Obesity

– Recent rapid increase – 17% of all children

• Higher rates in some groups

– Obesity affects every organ system

• Increased healthcare cost

– Question – Does obesity affect procedural utilization in children in the US?

• Au, N., The health care cost implications of overweight and obesity during childhood. Health Serv Res, 2012.
• 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.

Data

• PHIS (Pediatric Health Information System)

– Administrative database

• 43 tertiary care pediatric hospitals

– 42 included - with resource utilization data

• Inpatient and ambulatory surgery data
• Discharge/encounter data – demographics,

diagnoses, procedures

• Data de-identified
• Procedures with ICD9 codes included

Obesity ICD9 Codes

• Obesity related ICD9 codes have high specificity

– Study of 17,380 individuals

98 98% ifi it – 98.98% specificity of Obesity Related ICD9 codes in obese

adults – 7.75% sensitive

Martin, B.-J. The Accuracy of Coded Obesity in an Administrative Database. 2011.

Methods

• Children 2-21yrs from PHIS database (2004-

2004-20 2011)

– Inpatient procedures – Ambulatory procedures

• Rate of procedures in children with obesity
• Rate of procedures in children with obesity

related ICD9 codes (ORICs) vs no codes

– 278.00 (Overweight & obesity), 278.01 (Morbid obesity), 278.02 (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

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Methods

• Odds ratio of procedure in obesity coded vs not obesity code
• Two sample Z-test for statistical significance (α = 0.05)
• Bonferroni Correction
• = α/n (number of comparisons)
• Corrects for multiple corrections
• Stringent statistical significance

Demographics

Ambul Ambulatory no not coded

• ded
• b
• bese

ese Ambul Ambulatory code coded obese se In Inpat patient Not c Not coded d

• b
• bese

ese In Inpat patient t code coded obese se Number of cases 2,112,004 26,313 1,418,319 31,651 Mean Age 10 5 10 7 10 5 10 9 Mean Age (yrs) 10.5 10.7 10.5 10.9 Median Age (yrs) 8.9 11 11.7 10.2 13 13.6 Number of males 1,197,844 57% 13,805 52% 770,953 54% 15,755 50%

Demographics - Race

Ambul Ambulatory no ob no obese codes ese codes Ambul Ambulatory code coded ob d obese ese In Inpat patient t no ob no obese code ese code In Inpat patient code coded ob d obese ese Number of cases 2,112,004 26,313 1,418,319 31,651 White 1,450,833 69% 16,069 61% 926,512 65% 16,999 54% Black 297,681 14% 5,192 20% 20% 250,753 18% 8,474 27 27% Asian 42606 2% 313 1% 32058 2% 359 1% Other race 320,884 15% 4,739 18% 208,996 15% 5,819 18%

Demographics - Insurance

Ambul Ambulatory no ob no obesity esity codes codes Ambul Ambulatory code coded ob d obese ese In Inpat patient no ob no obesity esity codes codes In Inpat patient t code coded obese se Number of cases 2,112,004 26,313 1,418,319 31,651 Insurance Type Private 602,403 29% 7,467 28% 279,212 20% 5,431 17% Medicaid 491,888 23% 23% 9,508 36% 36% 325,653 23% 23% 10,714 34% 34% Other Insurance 153,165 7% 1,620 6% 83,681 6% 2,153 7% Unknown Insurance 826,251 39% 7,647 29% 701,338 49% 12,838 41%

Results

• 3,588,287 total procedures included

– 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.

Ambulatory Procedures

Lower rate in ORICs Lower rate in ORICs Higher rate in ORICs Higher rate in ORICs

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Inpatient Procedures

Lower rate in ORICs Lower rate in ORICs Higher rate in ORICs Higher rate in ORICs

Inpatient Cost

Procedu

• cedure

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) T&A 6.66 $2,765.33 CPAP 3.49 $182.24 Lap cholecystectomy 3.89 $1,919.69 p y y 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

Pr Proced

• cedure

Odds Ra Ratio tio Dif iffere renc nce in in ORIC ORIC vs vs non-O non-ORIC IC ($/patient/e atient/encount ncounter er ) T & A 1.73 $125.39 EGD w/ biopsy 1.37 $333.69 Cl d li bi 10 4 $113 04 Closed liver biopsy 10.4

• $113.04

Colonoscopy 1.37 $251.71 Sigmoidoscopy 1.55 $478.91 Rmvl impl dev tib/fib 2.67 $19.51 Myringotomy 0.04

• $176.42

Int fix w/o red femur 5.18

• $181.63

Crown application 0.54 $959.67 Pilonidal cyst exc. 3.86

• $13.98

ORIC = Obesity Related ICD9 Code

Summary

• Increased rate of some procedures in children

with obesity related ICD9 codes

– 6 inpatient procedures

• T&A
• CPAP
• laparoscopic cholecystectomy
• Internal fixation without reduction of femur
• spinal tap
• physical therapy

Summary

• 8 ambulatory procedures increased in children with
• besity related ICD9 codes

– T&A – EGD – liver biopsy – 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?

Summary

• Children with obesity related ICD9 codes are

undergoing certain procedures at a higher rate with increased cost.

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Summary

• Increased rates of some non-obesity related

procedures in children with obesity related ICD9 codes including:

– EGD – Sigmoidoscopy – Colonoscopy

Further Research Needed

• Need to look at rates of procedures in obese

using BMI

• How to improve obesity diagnosis
• Research why there is a cost difference

Questions ?

References

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Demographics with p values