Classification System and the Pareto Principle to Study Children - - PowerPoint PPT Presentation

Integration of the AHRQ Clinical Classification System and the Pareto Principle to Study Children with Multiple Chronic Conditions

Jay G. Berry, MD MPH

Division of General Pediatrics I Complex Care Service Boston Children’s Hospital I Harvard Medical School

• Funding Source: Agency for Healthcare

Research and Quality (R21 HS023092-01)

• No conflicts of interest
• My wife says that I ramble

Disclosures

• Definition

– 2 or more co-occurring chronic conditions

• Prevalence and impact

– 1% of all children – 30% of healthcare spending on children

• Quality of care

– Fragmented, uncoordinated, crisis-driven

Background

Children with Multiple Chronic Conditions

Asthma, Respiratory Insufficiency Apnea, Dysphagia, Chronic Aspiration Epilepsy Urinary retention, recurrent infection Gastroesophageal reflux, constipation Malnutrition, Skin breakdown Cardiac autonomic instability Hip dysplasia, Osteopenia, Fractures, Spasticity Kyphoscoliosis

Multiple Chronic Conditions

Example: Children with Cerebral Palsy

Blindness Deafness

Cerebral Palsy: movement disorder caused by brain dysregulation

• Assess which conditions affect the health
• utcomes and resource use the most
• Target conditions for clinical interventions

– Prevent occurrence – Control severity – Optimize care management – Contain cost

Population Health Initiatives

Children with Multiple Chronic Conditions

• Assess which conditions affect the health
• utcomes and resource use the most

– Vilfredo Pareto’s “80-20” Rule (ca. 1896)

80% of land in Italy owned by 20% of the population

– Perhaps Pareto’s rule might apply to healthcare spending in co-occurring conditions

Most of the spending is driven by a few conditions

Population Health Initiatives

Children with Multiple Chronic Conditions

• Administrative healthcare claims are often

the most forthcoming source of data

– State Medicaid program claims – Billing codes recorded for each encounter

• Diagnosis classification systems are often

applied to the claims data

– Use ICD9 diagnosis codes – Identify and count an individual’s conditions

Population Health Methods

Children with Multiple Chronic Conditions

• AHRQ Clinical Classification System

– Transparent, open source diagnosis system developed for adult patients – Classifies ~14,000 ICD9 codes as chronic or not chronic – Maps each code to a mutually-exclusive diagnosis category

Population Health Methods

Children with Multiple Chronic Conditions

• Epidemiology of chronic conditions in

children

– Heterogeneous array of conditions – Low prevalence of many conditions

• Existing diagnosis classification schemes

for use with administrative data

– Incomplete listing of childhood conditions – Non-specific categorization of the conditions

Population Health Methods Challenges

Children with Multiple Chronic Conditions

• 1. To adapt for children the adult-based

AHRQ Clinical Classification System to identify and count multiple chronic conditions in children

• 2. To test the adapted system on children

with cerebral palsy, identifying which co-

• ccurring conditions influence healthcare

spending the most using the Pareto Principle

Objectives

• Retrospective cohort analysis
• Truven Medicaid Marketscan Database

– 10 state Medicaid programs in 2013 – Health administrative claims and spending

• Across the care continuum
• ICD9 diagnosis codes
• Children with cerebral palsy

– ICD9 codes 343.XX

Study Design, Setting, and Population

• Total healthcare spending for health

services across the care continuum

– Payment made by Medicaid – Health services: inpatient, outpatient, community, home, pharmacy, durable medical equipment, etc. – Out-of-pocket spending not included

Main Outcome Measure

• Comorbid Health Conditions in Children

with Cerebral Palsy (CP)

–AHRQ Clinical Classification System –Chronic condition definition

“Lasts 12 months or longer and (a) places limitations

• n self-care, independent living, and social

interactions; or (b) results in the need for ongoing intervention with medical products, services, and special equipment”

–Identified with ICD9 codes across all healthcare encounters

Main Independent Variable

• Two complex care pediatricians reviewed

CCS for adaptation

– Diagnosis categories – Individual diagnoses within each category

• Findings presented to a larger study team

– Revision and affirmation of adaptations – Adjudication of few instances of differences in judgment

Pediatric Adaptation

AHRQ Clinical Classification System (CCS)

Three staged approach to assess the impact

• f comorbid conditions on healthcare

spending for children with cerebral palsy

• 1. Pareto principle ranking
• 2. Multivariable linear regression
• 3. Classification and regression tree analysis

Statistical Analysis

• Goal

– To create a ranked list of the comorbid conditions in the population of children with cerebral palsy that account for the most healthcare spending

• Procedure

– Distinguish the top-ranked comorbidity – Remove all children with it from the cohort – Repeat with the 2nd-ranked comorbidity

Pareto Principle Ranking

Impact of Comorbidities on Healthcare Spending

• Goal

– To quantify the contribution of each comorbid condition on healthcare spending for individuals with cerebral palsy

• Model derivation

– Outcome = total healthcare spending – Primary cofactors = comorbid conditions – Confounders = demographic characteristics – Backward elimination approach

Multivariable Linear Regression

Impact of Comorbidities on Healthcare Spending

• Goal

– To distinguish which combinations of comorbid conditions account for the greatest amount of healthcare spending for children with cerebral palsy

• Model derivation

– Assesses every possible combination of conditions – Creates a tree with a branch for the presence

• f each condition string with the greatest

spending increase

Classification & Regression Tree

Impact of Comorbidities on Healthcare Spending

159 new chronic condition categories

• Identified from non-specific categories in

the original system

– Dysphagia, gastroesophageal reflux, scoliosis

• Created de novo

– Enterostomy, tracheostomy

Results

Pediatric Adaptation of AHRQ CCS

Attribute Finding

Number of individuals 16,695 Median (IQR) No. of Chronic Conditions 6 (4-10) Total Annual Healthcare Spending $610 million Median (IQR) Annual Spending Per Individual $10,700 ($4,070-35,570)

Results

Children with Cerebral Palsy (CP) in Medicaid

Population Spending for CP

Comorbid Conditions with Greatest Impact

20 40 60

Neurogenic bladder Asthma Enterostomy Intellectual disability Epilepsy

Prevalence Spending

Percent of Total

Population Spending for CP

Comorbid Conditions with Greatest Impact

20 40 60

Neurogenic bladder Asthma Enterostomy Intellectual disability Epilepsy

Prevalence Spending

Percent of Total

78% of Total Spending

Population Spending for CP

Comorbid Conditions with Greatest Impact

20 40 60

Neurogenic bladder Asthma Enterostomy Intellectual disability Epilepsy

Prevalence Spending

Percent of Total

38% Prevalence 60% of Total Spending

Epilepsy Healthcare Setting Present Absent

Specialty Care $101 $70 Inpatient Care $92 $46 Pharmacy $33 $13

Population Annual Spending for CP

With vs. Without Epilepsy

U.S. $ millions

Individual Annual Spending for CP

Comorbid Conditions with Greatest Impact

20,000 40,000 60,000 Asthma Dysphagia Scoliosis Epilepsy Esophageal reflux Neurogenic bladder Intellectual disability Enterostomy Tracheostomy

Mean (SE) Additional Spending

Individual Annual Spending for CP

Comorbid Conditions with Greatest Impact

20,000 40,000 60,000 Asthma Dysphagia Scoliosis Epilepsy Esophageal reflux Neurogenic bladder Intellectual disability Enterostomy Tracheostomy

Mean (SE) Additional Spending

Base Spending = $1950

Individual Annual Spending for CP

Comorbid Conditions with Greatest Impact

20,000 40,000 60,000 Asthma Dysphagia Scoliosis Epilepsy Esophageal reflux Neurogenic bladder Intellectual disability Enterostomy Tracheostomy

Mean (SE) Additional Spending

Base Spending = $1950 + $56,670 + $25,710

Tracheostomy Enterostomy

Combination Spending

Enterostomy, Tracheostomy, & Chronic respiratory failure $225,590*

Individual Annual Spending for CP

Comorbidity Combination with Greatest Impact

*Derived from Classification and Regression Tree Model

• Integration of the adapted AHRQ CCS and

the Pareto Principle

– Distinguished with clinical fidelity the co-occurring conditions responsible for the most healthcare spending in children with cerebral palsy – Performed well on the population and individual patient levels

Main Findings

• Variation in coding practices may affect

identification of chronic conditions

• Restrictiveness of study setting to

children in Medicaid from 10 states may limit generalizability

• Subjectivity of the AHRQ CCS adaptions

cannot be understated

Limitations

• Opportunity to improve care delivery for the

highlighted co-occurring conditions with the most spending in children with CP

– Epilepsy: limited evidence on how to best achieve seizure control – Tracheostomy and enterostomy: rising use in children with severe CP without clear understanding of which patients receive the greatest quality of life benefit

Discussion

• Apply the methods from the present work

– To additional childhood chronic conditions – To entire populations of children

• Take action on the findings

– Assess how to minimize the health effects and cost of care for the highlighted co-occurring conditions in children with cerebral palsy

Next Steps

• Eyal Cohen, MD
• Arlene Ash, PhD
• Matthew Hall, PhD
• Fareesa Hasan, BS
• Rishi Agrawal, MD
• Dennis Kuo, MD
• Denise Goodman, MD
• Laurie Glader, MD

Acknowledgments

jay.berry@childrens.harvard.edu

Thank you!