An analysis of data from 38 children's hospitals reveals conditions in pediatric hospital care that are prevalent and costly. Here's a closer look at four of those conditions.
By Jacqueline Kueser
All hospitals want to achieve the best outcomes for their patients while minimizing unnecessary expenses and use of resources. While clinicians strive to implement national, research-based care guidelines, many common and costly pediatric conditions are still being managed differently across organizations. And this must change to improve outcomes and costs in children’s health care.
An initiative funded by children’s hospitals is the first of its kind to prioritize pediatric conditions for developing guidelines for care. A large number of pediatric admissions were needed to conduct the analysis—3 million admissions from 38 children’s hospitals over six years. The large data set is necessary as the number of children affected by any single condition is far less than in the adult population. And it’s difficult to come by since most pediatric data are collected by individual states or payers.
The results of this work now serve as a road map for pediatric comparative effectiveness research, which will allow clinicians to continue investigating the pediatric care standards that result in the best outcomes and lowest costs. This initiative also provides hospitals with an unprecedented understanding of the most costly, prevalent pediatric conditions, making it possible for them to identify and more appropriately manage factors that drive unnecessary variation in care. From here, learning collaboratives will enable others to learn from high performing children’s hospitals.
This three-year work effort combined data and analytic resources from the Children’s Hospital Association with clinical and research expertise from the Pediatric Research in the Inpatient Setting (PRIS) Network, a national group of hospitalist researchers from pediatric providers. The CEOs from the largest academic children’s hospitals invested in this initiative with three goals in mind:
- Develop a cost standardization process for using the hospitalization data.
- Identify the pediatric conditions with the highest prevalence, cost and variation in practice from one hospital to another.
- Analyze individual conditions to understand the existing evidence base, variation in cost and resources.
Researchers have evaluated the first four conditions meeting high-priority criteria: appendicitis, tonsillectomy and adenoidectomy, pneumonia and asthma, and diabetes ketoacidosis (DKA). Here’s a closer look at what they found.
Tonsillectomy and adenoidectomy
Tonsillectomy and adenoidectomy (T&A) ranked number two in prevalence among all pediatric hospital conditions and ranked ninth in total costs. The key finding of this analysis showed variation in cost is driven by perioperative length of stay. The data showed that giving dexamethasone perioperatively—an intravenous steroid that prevents nausea and vomiting postoperatively—was not consistent, nor was the use of antibiotics. From 2004 to 2010, approximately 30 percent of children’s hospital patients for T&A did not receive dexamethasone.
Furthermore, the data showed there was substantial variability in revisit rates after surgery for complications. Research recommendations for this condition include improving perioperative processes for better outcomes at a lower cost through learning collaboratives with high-performing hospitals.
Literature indicates diabetic ketoacidosis (DKA), a serious complication of diabetes, has a relatively high readmission rate and is potentially preventable. The data represents 24,890 DKA episodes across children’s hospitals. The researchers examined children’s hospital data to understand the variability and the potential processes to improve outcomes and lower costs. They found greater expenditures during hospitalization, such as longer, non-ICU stays, were associated with lower rates of readmission. Researchers concluded that successful processes from hospitals with both low cost and readmission rates should be explored and shared.
Representing nearly $150 million in standardized costs for 42 of the largest children’s hospitals, appendectomies rank as the second most costly surgical procedure. Using comparative reporting to focus on the use of diagnostic imaging, peripherally inserted central catheter (PICC) lines, readmissions and emergency department revisit rates, hospitals have shown an ability dramatically improve care for these patients. Researchers incorporated value based care by weighing the cost and potential negative consequences of imaging with the positive consequences of reduced morbidity and re-admissions.
Pneumonia and asthma
Researchers studied 33,000 patients and found that higher variation exists among children’s hospitals for a diagnosis of pneumonia and asthma than for the single diagnoses of pneumonia. This is important because of the longer lengths of stay and high costs for this combination of conditions along with poorer adherence to pneumonia guidelines. The additional treatment uncertainty and higher resource utilization may be due to the multiplicity of conditions. From this analysis, researchers suggest additional guidelines are necessary for this combination of conditions. Further comparisons of the individual resources driving cost and quality may illuminate options for creating value.
The next steps
To get a handle on high variation conditions, senior executives can organize initiatives in their hospitals to:
- Analyze their organization’s specific care patterns against the available evidence base and available measures.
- Compare hospital specific patient cohorts and specific service utilization against other children’s hospitals in the Pediatric Health Information Systems (PHIS) database.
- Further evaluate development of standardized care pathways if variation from the evidence base and other hospitals exist.
Additional comparative effectiveness research is warranted if excessive variation exists in the absence of evidence. When variation exists under a strong evidence base, standardization of care is needed. The next steps on a national level include developing appropriate measures and collaboratively learning across children’s hospitals. A significant commitment to comparative effectiveness research continues within the individual hospitals and at the Association. Health care reform will continue to demand evidence based and cost effective care that the nation’s children’s hospitals can deliver.