Resource Utilization of Pediatric Patients Exposed to Venom 9_20_11Presentation Transcript
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
Pediatric exposure to venom is relatively uncommon, and often not treated with anti-venom. However, when used, anti-venom treatment is costly.
Observation status is a billing designation that can be applied to patients treated in observation units or inpatient units based on predefined criteria.
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.
Observation status is often reimbursed at a lower rate than inpatient care.
To characterize resource utilization among patients exposed to venom who received anti-venom therapy compared with those who did not receive anti-venom.
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).
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.
Patients were included if they entered the hospital via the emergency department (ED) in calendar year 2009.
Patient's age, length of stay (LOS), charges (adjusted for geographic region), ICU flags, and anti-venom utilization were included.
2,755 patients had primary diagnosis of toxic effect of venom and 2,420 (88%) were treated and released from EDs.
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%)
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 ).
Charges were substantially higher for patients who received anti-venom, regardless of status, with the preponderance for pharmacy (Fig 1, bars).
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 )
64 patients spent time in an ICU (2 observation-status and 62 inpatient-status); 43 received anti-venom (all from the inpatient-status group).
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.
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.
Care for envenomation represents a high-charge outlier within short-stay hospitalizations, particularly when anti-venom is given to observation-status patients
Whether observation-status or inpatient-status, these patients appear to have received high-cost therapy, albeit for a brief time.
Toxicologists providing observation care for envenomation injury may benefit from investigating their local reimbursement patterns.
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.
Per diem reimbursement : Payer reimburses the hospital a fixed amount for each day a member patient is hospitalized.
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.
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.
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.
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.
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.
Observation status : a billing designation applied prospectively or retrospectively to patients who do not meet predetermined criteria for inpatient status reimbursement