TEN YEAR TRENDS IN CHILDREN S HOSPITAL RESOURCE UTILIZATION by - - PowerPoint PPT Presentation

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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

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SLIDE 1

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

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SLIDE 2

Significance

  • 10% of all U.S. pediatric hospitalizations are for a primary

psychiatric diagnosis1

  • $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
  • f pediatric hospitalizations and costs
  • Common mental disorders (ADHD, ASD)3-5
  • Common chronic medical conditions (asthma, sickle cell, obesity)6-8
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SLIDE 3

Objectives

To describe:

  • 1. Sociodemographic and clinical

characteristics of children hospitalized in freestanding children’ s hospitals

  • 2. Ten year trends in children’

s hospital resource use

  • 3. Most recent % change in hospital resource

use

By Psychiatric Comorbid Type

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SLIDE 4

Psychiatric Comorbid Types

All Children’ s Hospitalizations

  • 2005-2014
  • 33 hospitals

Any Psychiatric

  • With/Without

Psychiatric Diagnosis

Med + Psych Psych + Med Psych Only

  • Psychiatric

Comorbid Types

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SLIDE 5

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
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SLIDE 6

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
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SLIDE 7

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
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SLIDE 8

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
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SLIDE 9

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
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SLIDE 10

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

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SLIDE 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
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SLIDE 12

Total Sample (2005-2014)

All Children’ s Hospitalizations

  • n=3,114,099
  • 12,253,353 days
  • $45.5 B

Any Psychiatric

  • 18.3%
  • n=568,449
  • 3,534,038 days
  • $11.2 B

Med + Psych Psych + Med Psych Only

  • 76.6%

$9.8 B

  • 17.6% $995 M
  • 5.7% $257 M
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SLIDE 13

Hospitalizations: With vs. Without a Psychiatric Diagnosis

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SLIDE 14

0% 20% 40% 60% 80%

Child Demographics by Any Psych Dx (p≤ .001)

Any Psych No Psych

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SLIDE 15

0% 10% 20% 30% 40% 50% 60% 70%

Complex Chronic Conditions by Any Psych Dx (p≤ .001)

Any Psych No Psych

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SLIDE 16

10 Year Trends in Hospitalizations by Any Psychiatric Dx

20 40 60 80 100 120 140 160 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 % Growth in Reference to 2005 Year

Number of Hospitalizations

Any Psych No Psych

+137.7% +26.0%

Any Psych No Psych

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SLIDE 17

10 Year Trends in Hospital Days by Any Psychiatric Dx

20 40 60 80 100 120 140 160 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 % Growth in Reference to 2005 Year

Total Bed Days

Any Psych No Psych

+92.9% +5.9%

Any Psych

No Psych

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SLIDE 18

10 Year Trends in Hospital Costs by Any Psychiatric Dx

20 40 60 80 100 120 140 160 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 % Growth in Reference to 2005 Year

Total Hospital Cost

Any Psych No Psych

+142.7% +18.9% $671M→$1.6B $3.1B→$3.7B

Any Psych No Psych

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SLIDE 19

Hospitalizations: By Psychiatric Comorbid Type

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SLIDE 20

0% 20% 40% 60% 80% 100%

Child Demographics by Psych Comorbid Type (p≤ .001)

Med + Psych Psych + Med Psych Only

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SLIDE 21

0% 20% 40% 60% 80% 100% Complex Chronic Conditions by Psych Comorbid Type (p≤ .001) Med + Psych Psych + Med Psych Only

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SLIDE 22

10 Year Trends in Hospitalizations by Psychiatric Comorbid Type

  • 70
  • 20

30 80 130 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 % Growth in Reference to 2004 Year

Number of Hospitalizations by Psychiatric Comorbid Group

Med + Psych Psych + Med Psych Only

+160.5%

Psych+Med

  • 21.1%

Med+Psych

+143.0%

Psych Only

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SLIDE 23

10 Year Trends in Hospital Days by Psychiatric Comorbid Type

  • 70
  • 20

30 80 130 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 % Growth in Reference to 2004 Year

Total Bed Days by Psychiatric Complexity

Med + Psych Psych + Med Psych Only

+120.8% Psych+Med

  • 47.8%

Med+Psych +102.8% No Psych

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SLIDE 24

10 Year Trends in Hospital Costs by Psychiatric Comorbid Type

  • 70
  • 20

30 80 130 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 % Growth in Reference to 2004 Year

Total Hospitalization Cost by Psychiatric Complexity

Med + Psych Psych + Med Psych Only

+156.2% Psych+Med

  • 38.8%

$30M→$20M $573M→$1.5B $66M→$142M

+115.5% Med+Psych Psych Only

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SLIDE 25

2014 Hospital Resource Use

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SLIDE 26

2014 Hospital Resource Use

All Children’ s Hospitalizations

  • n=373,671
  • 1,372,109 days
  • $5.3 B

Any Psychiatric

  • 23.3%
  • n=87,002
  • 480,341 days
  • $1.63 B

Med + Psych Psych + Med Psych Only

  • 77.8% $1.5 B
  • 18.7% $142 M
  • 3.6% $20 M
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SLIDE 27

3 Most Common Comorbid Psych Dx

0% 10% 20% 30% Suicide/Self-injury Anxiety Disorders Depression Depression Suicide/Self-injury Anxiety Disorders Anxiety Disorders ADHD Developmental Disorder 14% 16% 18% 13% 14% 14% 14% 18% 22% Med + Psych Psych + Med Psych Only

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SLIDE 28

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
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SLIDE 29

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
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SLIDE 30

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.

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SLIDE 31

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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SLIDE 32

References

  • 1. Bardach NS, Coker TR, Zima BT, et al. Common and costly hospitalizations for pediatric mental health disorders.

Pediatrics.133(4):602-609

  • 2. Torio CM, Encinosa W, Berdahl T, McCormick MC, Simpson LA. Annual report on health care for children and youth in the

United States: national estimates of cost, utilization and expenditures for children with mental health conditions. Academic

  • pediatrics. 2015;15(1):19-35.
  • 3. Chan E, Zhan C, Homer CJ. Health care use and costs for children with attention-deficit/hyperactivity disorder: national

estimates form the medical expenditure panel survey. Archives of Pediatrics & Adolescent Medicine. 2002;156(5):504-511.

  • 4. Croen LA, Najjar DV, Ray GT, Lotspeich L, Bernal P. A comparison of health care utilization and costs of children with and

without autism spectrum disorders in a large group-model health plan. Pediatrics. 2006;118(4):e1203-e1211.

  • 5. Guevara J, Lozano P, Wickizer T, Mell L, Gephart H. Utilization and cost of health care services for children with attention-

deficit/hyperactivity disorder. Pediatrics. 2001;108:71-78.

  • 6. Janicke DM, Harman JS, Kelleher KJ, Zhang J. The association of psychiatric diagnoses, health service use, and expenditures

in children with obesity-related health conditions. Journal of pediatric psychology. 2009;34(1):79-88.

  • 7. Myrvik MP, Burks LM, Hoffman RG, Dasgupta M, Panepinto JA. Mental health disorders influence admission rates for pain in

children with sickle cell disease. Pediatric blood & cancer. 2013;60(7):1211-1214.

  • 8. Richardson LP, Russo JE, Lozano P, McCauley E, Katon W. The effect of comorbid anxiety and depressive disorders on health

care utilization and costs among adolescents with asthma. General hospital psychiatry. 2008;30(5):398-406.

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SLIDE 33

Contact

Bonnie T. Zima, MD, MPH

bzima@mednet.ucla.edu http://hss.semel.ucla.edu/