Hypothetical Network Adequacy Schemes For Children Fail To Ensure Patients' Access To In-Network Children's Hospital.

2018

873-880

2018 Jun

1544-5208

<p>Insurers are increasingly adopting narrow network strategies. Little is known about how these strategies may affect children's access to needed specialty care. We examined the percentage of pediatric specialty hospitalizations that would be beyond existing Medicare Advantage network adequacy distance requirements for adult hospital care and, as a secondary analysis, a pediatric adaptation of the Medicare Advantage requirements. We examined 748,920 hospitalizations at eighty-one children's hospitals that submitted data for the period October 2014-September 2015. Nearly half of specialty hospitalizations were outside the Medicare Advantage distance requirements. Under the pediatric adaptation, there was great variability among the hospitals, with the percent of hospitalizations beyond the distance requirements ranging from less than 1&nbsp;percent to 35&nbsp;percent. Instead of, or in addition to, time and distance standards, policy makers may need to consider more nuanced network definitions, including functional capabilities of the pediatric care network or clear exception policies for essential specialty care services.</p>

10.1377/hlthaff.2017.1339

Health Aff (Millwood)

29863927

Regional Variation in Standardized Costs of Care at Children's Hospitals.

2017

818-825

2017 Oct

1553-5606

<p><strong>OBJECTIVE: </strong>(1) To evaluate regional variation in costs of care for 3 inpatient pediatric conditions, (2) assess potential drivers of variation, and (3) estimate cost savings from reducing variation.</p>

<p><strong>DESIGN/SETTING: </strong>Retrospective cohort study of hospitalizations for asthma, diabetic ketoacidosis (DKA), and acute gastroenteritis (AGE) at 46 children</p>

<p><strong>MEASUREMENTS:</strong> Variation in trimmed standardized costs were assessed within and across regions. Linear mixed effects models were adjusted for patient- and encounter-level variables to assess drivers of variation.</p>

<p><strong>RESULTS:</strong> After adjusting for patient-level factors, variation remained. Using census division clusters, mean trimmed and adjusted total standardized costs were 120% higher for asthma ($1920 vs $4227), 46% higher for DKA ($7429 vs $10,881), and 150% higher for AGE ($3316 vs $8292) in the highest-cost compared with the lowest-cost region. Comparing hospitals in the same region, standardized costs were significantly different (P &lt; 0.001) for each condition in each region. Drivers of variation were encounter-level variables including length of stay and intensive care unit utilization. For this cohort, annual savings from reducing variation would equal $69.1 million at the interregional level and $25.2 million at the intraregional level.</p>

<p><strong>CONCLUSIONS:</strong> Pediatric hospital costs vary between and within regions. Future studies should examine how much of this variation is avoidable. To the extent that less spending does not compromise outcomes, care models may be adjusted to eliminate unwarranted variation and reduce costs.</p>

10.12788/jhm.2729

J Hosp Med

28991947

Adding Social Determinant Data Changes Children's Hospitals' Readmissions Performance.

2017

2017 May 02

1097-6833

<p><strong>OBJECTIVES: </strong>To determine whether social determinants of health (SDH) risk adjustment changes hospital-level performance on the 30-day Pediatric All-Condition Readmission (PACR) measure and improves fit and accuracy of discharge-level models.</p>

<p><strong>STUDY DESIGN: </strong>We performed a retrospective cohort study of all hospital discharges meeting criteria for the PACR from 47 hospitals in the Pediatric Health Information database from January to December 2014. We built four nested regression models by sequentially adding risk adjustment factors as follows: chronic condition indicators (CCIs); PACR patient factors (age and sex); electronic health record-derived SDH (race, ethnicity, payer), and zip code-linked SDH (families below poverty level, vacant housing units, adults without a high school diploma, single-parent households, median household income, unemployment rate). For each model, we measured the change in hospitals' readmission decile-rank and assessed model fit and accuracy.</p>

<p><strong>RESULTS: </strong>For the 458 686 discharges meeting PACR inclusion criteria, in multivariable models, factors associated with higher discharge-level PACR measure included age &lt;1 year, female sex, 1 of 17 CCIs, higher CCI count, Medicaid insurance, higher median household income, and higher percentage of single-parent households. Adjustment for SDH made small but significant improvements in fit and accuracy of discharge-level PACR models, with larger effect at the hospital level, changing decile-rank for 17 of 47 hospitals.</p>

<p><strong>CONCLUSIONS: </strong>We found that risk adjustment for SDH changed hospitals' readmissions rate rank order. Hospital-level changes in relative readmissions performance can have considerable financial implications; thus, for pay for performance measures calculated at the hospital level, and for research associated therewith, our findings support the inclusion of SDH variables in risk adjustment.</p>

10.1016/j.jpeds.2017.03.056

J. Pediatr.

28476461

Intravenous Versus Oral Antibiotics for Postdischarge Treatment of Complicated Pneumonia.

2016

2016 Dec

1098-4275

<p><strong>BACKGROUND AND OBJECTIVES: </strong>Postdischarge treatment of complicated pneumonia includes antibiotics administered intravenously via a peripherally inserted central venous catheter (PICC) or orally. Antibiotics administered via PICC, although effective, may result in serious complications. We compared the effectiveness and treatment-related complications of postdischarge antibiotics delivered by these 2 routes.</p>

<p><strong>METHODS: </strong>This multicenter retrospective cohort study included children ≥2 months and &lt;18 years discharged with complicated pneumonia between 2009 and 2012. The main exposure was the route of postdischarge antibiotic administration, classified as PICC or oral. The primary outcome was treatment failure. Secondary outcomes included PICC complications, adverse drug reactions, other related revisits, and a composite of all 4 outcomes, termed "all related revisits."</p>

<p><strong>RESULTS: </strong>Among 2123 children, 281 (13.2%) received antibiotics via PICC. Treatment failure rates were 3.2% among PICC and 2.6% among oral antibiotic recipients and were not significantly different between the groups in across-hospital-matched analysis (matched odds ratio [OR], 1.26; 95% confidence interval [CI], 0.54 to 2.94). PICC complications occurred in 7.1%. Adverse drug reactions occurred in 0.6% of children; PICC antibiotic recipients had greater odds of adverse drug reaction in across hospital matched analysis (matched OR, 19.1; 95% CI, 4.2 to 87.3). The high rate of PICC complications and differences in adverse drug reactions contributed to higher odds of the composite outcome of all related revisits among PICC antibiotic recipients (matched OR, 4.71; 95% CI, 2.97 to 7.46).</p>

<p><strong>CONCLUSIONS: </strong>Treatment failure rates between PICC and oral antibiotics did not differ. Children with complicated pneumonia should preferentially receive oral antibiotics at discharge when effective oral options are available.</p>

10.1542/peds.2016-1692

Pediatrics

27940695

Financial Loss for Inpatient Care of Medicaid-Insured Children.

2016

2016 Sep 12

2168-6211

<p><strong>Importance: </strong>Medicaid payments tend to be less than the cost of care. Federal Disproportionate Share Hospital (DSH) payments help hospitals recover such uncompensated costs of Medicaid-insured and uninsured patients. The Patient Protection and Affordable Care Act reduces DSH payments in anticipation of fewer uninsured patients and therefore decreased uncompensated care. However, unlike adults, few hospitalized children are uninsured, while many have Medicaid coverage. Therefore, DSH payment reductions may expose extensive Medicaid financial losses for hospitals serving large absolute numbers of children.</p>

<p><strong>Objectives: </strong>To identify types of hospitals with the highest Medicaid losses from pediatric inpatient care and to estimate the proportion of losses recovered through DSH payments.</p>

<p><strong>Design, Setting, and Participants: </strong>This retrospective cross-sectional analysis evaluated Medicaid-insured hospital discharges of patients 20 years and younger from 23 states in the 2009 Kids' Inpatient Database. The dates of the analysis were March to September 2015. Hospitals were categorized as freestanding children's hospitals (FSCHs), children's hospitals within general hospitals, non-children's hospital teaching hospitals, and non-children's hospital nonteaching hospitals. Financial records of FSCHs in the data set were used to estimate the proportion of Medicaid losses recovered through DSH payments.</p>

<p><strong>Main Outcomes and Measures: </strong>Hospital financial losses from inpatient care of Medicaid-insured children (defined as the reimbursement minus the cost of care) were compared across hospital types. For our subsample of FSCHs, Medicaid-insured inpatient financial losses were calculated with and without each hospital's DSH payment.</p>

<p><strong>Results: </strong>The 2009 Kids' Inpatient Database study population included 1485 hospitals and 843 725 Medicaid-insured discharges. Freestanding children's hospitals had a higher median number of Medicaid-insured discharges (4082; interquartile range [IQR], 3524-5213) vs non-children's hospital teaching hospitals (674; IQR, 258-1414) and non-children's hospital nonteaching hospitals (161; IQR, 41-420). Freestanding children's hospitals had the largest median Medicaid losses from pediatric inpatient care (-$9 722 367; IQR, -$16 248 369 to -$2 137 902). Smaller losses were experienced by non-children's hospital teaching hospitals (-$204 100; IQR, -$1 014 100 to $14 700]) and non-children's hospital nonteaching hospitals (-$28 310; IQR, -$152 370 to $9040]). Disproportionate Share Hospital payments to FSCHs reduced their Medicaid losses by almost half.</p>

<p><strong>Conclusions and Relevance: </strong>Estimated financial losses from pediatric inpatients covered by Medicaid were much larger for FSCHs than for other hospital types. For children's hospitals, small anticipated increases in insured children are unlikely to offset the reductions in DSH payments.</p>

10.1001/jamapediatrics.2016.1639

JAMA Pediatr

27618284

Association of Social Determinants With Children's Hospitals' Preventable Readmissions Performance.

2016

350-8

2016 Apr 1

2168-6211

<p><strong>IMPORTANCE: </strong>Performance-measure risk adjustment is of great interest to hospital stakeholders who face substantial financial penalties from readmissions pay-for-performance (P4P) measures. Despite evidence of the association between social determinants of health (SDH) and individual patient readmission risk, the effect of risk adjusting for SDH on readmissions P4P penalties to hospitals is not well understood.</p>

<p><strong>OBJECTIVE: </strong>To determine whether risk adjustment for commonly available SDH measures affects the readmissions-based P4P penalty status of a national cohort of children's hospitals.</p>

<p><strong>DESIGN, SETTING, AND PARTICIPANTS: </strong>Retrospective cohort study of 43 free-standing children's hospitals within the Pediatric Health Information System database in the calendar year 2013. We evaluated hospital discharges from 2013 that met criteria for 3M Health Information Systems' potentially preventable readmissions measure for calendar year 2013. The analysis was conducted from July 2015 to August 2015.</p>

<p><strong>EXPOSURES: </strong>Two risk-adjustment models: a baseline model adjusted for severity of illness and an SDH-enhanced model that adjusted for severity of illness and the following 4 SDH variables: race, ethnicity, payer, and median household income for the patient's home zip code.</p>

<p><strong>MAIN OUTCOMES AND MEASURES: </strong>Change in a hospital's potentially preventable readmissions penalty status (ie, change in whether a hospital exceeded the penalty threshold) using an observed-to-expected potentially preventable readmissions ratio of 1.0 as a penalty threshold.</p>

<p><strong>RESULTS: </strong>For the 179 400 hospital discharges from the 43 hospitals meeting inclusion criteria, median (interquartile range [IQR]) hospital-level percentages for the SDH variables were 39.2% nonwhite (n = 71 300; IQR, 28.6%-54.6%), 17.9% Hispanic (n = 32 060; IQR, 6.7%-37.0%), and 58.7% publicly insured (n = 106 116; IQR, 50.4%-67.8%). The hospital median household income for the patient's home zip code was $40 674 (IQR, $35 912-$46 190). When compared with the baseline model, adjustment for SDH resulted in a change in penalty status for 3 hospitals within the 15-day window (2 were no longer above the penalty threshold and 1 was newly penalized) and 5 hospitals within the 30-day window (3 were no longer above the penalty threshold and 2 were newly penalized).</p>

<p><strong>CONCLUSIONS AND RELEVANCE: </strong>Risk adjustment for SDH changed hospitals' penalty status on a readmissions-based P4P measure. Without adjusting P4P measures for SDH, hospitals may receive penalties partially related to patient SDH factors beyond the quality of hospital care.</p>

10.1001/jamapediatrics.2015.4440

JAMA Pediatr

26881387

Socioeconomic Status and Hospitalization Costs for Children with Brain and Spinal Cord Injury.

2016

250-5

2016 Feb

1097-6833

<p><strong>OBJECTIVE: </strong>To determine if household income is associated with hospitalization costs for severe traumatic brain injury (TBI) and spinal cord injury (SCI).</p>

<p><strong>STUDY DESIGN: </strong>Retrospective cohort study of inpatient, nonrehabilitation hospitalizations at 43 freestanding children's hospitals for patients &lt;19&nbsp;years old with unintentional severe TBI and SCI from 2009-2012. Standardized cost of care for hospitalizations was modeled using mixed-effects methods, adjusting for age, sex, race/ethnicity, primary payer, presence of chronic medical condition, mechanism of injury, injury severity, distance from residence to hospital, and trauma center level. Main exposure was zip code level median annual household income.</p>

<p><strong>RESULTS: </strong>There were 1061 patients that met inclusion criteria, 833 with TBI only, 227 with SCI only, and 1 with TBI and SCI. Compared with those with the lowest-income zip codes, patients from the highest-income zip codes were more likely to be older, white (76.7% vs 50.4%), have private insurance (68.9% vs 27.9%), and live closer to the hospital (median distance 26.7 miles vs 81.2 miles). In adjusted models, there was no significant association between zip code level household income and hospitalization costs.</p>

<p><strong>CONCLUSIONS: </strong>Children hospitalized with unintentional, severe TBI and SCI showed no difference in standardized hospital costs relative to a patient's home zip code level median annual household income. The association between household income and hospitalization costs may vary by primary diagnosis.</p>

10.1016/j.jpeds.2015.10.043

J. Pediatr.

26563534

Socioeconomic status and in-hospital pediatric mortality.

2013

e182-90

2013 Jan

1098-4275

<p><strong>OBJECTIVE: </strong>Socioeconomic status (SES) is inversely related to pediatric mortality in the community. However, it is unknown if this association exists for in-hospital pediatric mortality. Our objective was to determine the association of SES with in-hospital pediatric mortality among children's hospitals and to compare observed mortality with expected mortality generated from national all-hospital inpatient data.</p>

<p><strong>METHODS: </strong>This is a retrospective cohort study from 2009 to 2010 of all 1,053,101 hospitalizations at 42 tertiary care, freestanding children's hospitals. The main exposure was SES, determined by the median annual household income for the patient's ZIP code. The main outcome measure was death during the admission. Primary outcomes of interest were stratified by income and diagnosis-based service lines. Observed-to-expected mortality ratios were created, and trends across quartiles of SES were examined.</p>

<p><strong>RESULTS: </strong>Death occurred in 8950 (0.84%) of the hospitalizations. Overall, mortality rates were associated with SES (P &lt; .0001) and followed an inverse linear association (P &lt; .0001). Similarly, observed-to-expected mortality was associated with SES in an inverse association (P = .014). However, mortality overall was less than expected for all income quartiles (P &lt; .05). The association of SES and mortality varied by service line; only 3 service lines (cardiac, gastrointestinal, and neonatal) demonstrated an inverse association between SES and observed-to-expected mortality.</p>

<p><strong>CONCLUSIONS: </strong>Within children's hospitals, SES is inversely associated with in-hospital mortality, but is lower than expected for even the lowest SES quartile. The association between SES and mortality varies by service line. Multifaceted interventions initiated in the inpatient setting could potentially ameliorate SES disparities in in-hospital pediatric mortality.</p>

10.1542/peds.2012-1215

Pediatrics

23248226