Resource Utilization of Pediatric Patients Exposed to Venom 9_20_11


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Resource Utilization of Pediatric Patients Exposed to Venom 9_20_11

  1. 1. Resource Utilization of Pediatric Patients Exposed to Venom Evan Fieldston, MD, MBA, MSHP 1 , Matthew Hall, PhD 2 , Michelle Macy, MD, MS 3 , Elizabeth Alpern, MD, MSCE 1 , Kevin Osterhoudt, MD, MSCE 1 1 The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA; 2 Child Health Corporation of America, Shawnee Mission KS; 3 University of Michigan School of Medicine, Ann Arbor MI The authors have no conflicts of interest to disclose Inpatient-status Observation-status ED only Figure 1: Average Costs and LOS for Non-ICU patients N=2755 N=149 N=42 N=24 N=4 Only N=122 <ul><li>Pediatric exposure to venom is relatively uncommon, and often not treated with anti-venom. However, when used, anti-venom treatment is costly. </li></ul><ul><li>Observation status is a billing designation that can be applied to patients treated in observation units or inpatient units based on predefined criteria. </li></ul><ul><li>Observation status is intended for patients who are expected to respond to <24 hours of care and is commonly considered lower in intensity and cost when compared with traditional inpatient care. </li></ul><ul><li>Observation status is often reimbursed at a lower rate than inpatient care. </li></ul>Background <ul><li>To characterize resource utilization among patients exposed to venom who received anti-venom therapy compared with those who did not receive anti-venom. </li></ul>Objectives <ul><li>Retrospective cohort study of pediatric patients with primary diagnosis of toxic effect of venom (ICD-9 989.5) seen in 33 free-standing children’s hospitals that are members of the Pediatric Health Information System (PHIS). </li></ul><ul><li>Comparisons were conducted in two ways: subgroup by patient admission status (ED-only, observation-status, or inpatient-status) and comparison of recipients of anti-venom in observation status to all other observation-status patients. </li></ul><ul><li>Patients were included if they entered the hospital via the emergency department (ED) in calendar year 2009. </li></ul><ul><li>Patient's age, length of stay (LOS), charges (adjusted for geographic region), ICU flags, and anti-venom utilization were included. </li></ul>Methods <ul><li>2,755 patients had primary diagnosis of toxic effect of venom and 2,420 (88%) were treated and released from EDs. </li></ul><ul><li>Observation-status or inpatient-status patients were >100 times more likely to receive anti-venom (20% and 28% respectively) than ED-only patients (0.2%) </li></ul><ul><li>Average LOS (ALOS) for observation-status and inpatient-status patients differed (approximately 1 day vs. 2 days), but not within groups by anti-venom status ( Fig 1, light blue squares ). </li></ul><ul><li>Charges were substantially higher for patients who received anti-venom, regardless of status, with the preponderance for pharmacy (Fig 1, bars). </li></ul><ul><li>Mean pharmacy charges for inpatient-status patients who received anti-venom were $50,729 (95% CI: $40,234, $61,223) while observation-status were $41,312 (95% CI:$ 27,558, $55,068) ( Fig 1, dark blue bars ) </li></ul><ul><li>64 patients spent time in an ICU (2 observation-status and 62 inpatient-status); 43 received anti-venom (all from the inpatient-status group). </li></ul><ul><li>Across patients who received anti-venom, a mean of 7.2 vials were used (range 1-42). ED patients received an average of 2.8 vials (N=4; range 1-2), while inpatient-status without ICU flags received average 6.3 (N=42; range 1-22) and inpatient-status with ICU flag received average 8.4 (N=43; range 1-28). Observation-status patients received an average of 5.6 (N=24; range 1-28) after removal of one outlier who had received 42 vials. </li></ul><ul><li>Compared against all other observation-status patients with diagnoses other than toxic exposure to venom (N=47,162), observation-status patients who received anti-venom had substantially higher charges. Among all observation-status patients, 99% had LOS<=2 days and median total charges were $5,640; the 99%ile for charges were $25,208. </li></ul>Results <ul><li>Care for envenomation represents a high-charge outlier within short-stay hospitalizations, particularly when anti-venom is given to observation-status patients </li></ul><ul><li>Whether observation-status or inpatient-status, these patients appear to have received high-cost therapy, albeit for a brief time. </li></ul>Conclusions <ul><li>Toxicologists providing observation care for envenomation injury may benefit from investigating their local reimbursement patterns. </li></ul><ul><li>Without percent-of-charge reimbursement or negotiated high-cost pharmaceutical carve-out, hospitals may not be adequately reimbursed for the care of these patients, particularly if paid at a reduced rate under observation-status billing. </li></ul>Implications <ul><li>Per diem reimbursement : Payer reimburses the hospital a fixed amount for each day a member patient is hospitalized. </li></ul><ul><li>Case-based reimbursement : Payer reimburses the hospital for each discharged inpatient at rates prospectively established for groups of cases with similar clinical profile and resource requirements. </li></ul><ul><li>Diagnosis Related Groups (DRGs): Classification scheme which provides a means of relating the type of patients a hospital treats; while all patients are unique, groups of patients have common clinical characteristics that determine their resource needs. DRG-based payments use DRGs as the basis for case-based reimbursement. </li></ul><ul><li>Percent of charges (or discount off charges) : Payer reimburses the hospital a negotiated percent of the total charges incurred in caring for the member patient. </li></ul><ul><li>Carve-out: Specific services (such as high-cost drugs) that may be separated from per diem or case-based reimbursements due to the special circumstances of these services. </li></ul><ul><li>Observation Unit: An area designated for patients expected to require <24 hours to determine their need to be admitted as inpatients or their readiness for discharge home. </li></ul><ul><li>Observation status : a billing designation applied prospectively or retrospectively to patients who do not meet predetermined criteria for inpatient status reimbursement </li></ul>Definitions