Children with neurological impairment – especially epilepsy – accounted for more than 21% of all hospital charges in 2006, and their impact on children’s hospitals is growing as utilization shifts to those facilities, according to a retrospective, cross-sectional analysis of multiple years of the Kids’ Inpatient Database.
As more resources are used by children with neurological impairment, particularly at children’s hospitals, the institutions will need to make sure that they provide adequate staffing and education to treat these vulnerable children, Dr. Jay G. Berry of Children Hospital Boston and his coauthors recommended in the study, published online Jan. 17 in PLoS Medicine.
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Dr. Jeffrey R. Buchhalter
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"Children’s hospitals, in particular, will need to ensure that (1) adequate clinical and coordinated expertise is focused on the needs of these children, (2) neurological impairment clinical assessment and care management training is developed for trainees and junior graduates in pediatric postgraduate educational programs, (3) partnerships between families of children with [neurological impairment] and hospitals are developed and implemented, and (4) care treatment strategies of both nervous and non-nervous-system problems are rigorously evaluated for these children," the authors wrote.
Dr. Jeffrey Buchhalter, pediatric neurologist at Phoenix Children’s Hospital, said in an interview that the study provides real data on trends that he’s seen in his own institution.
"It’s confirmed for me my clinical suspicions that these are very frequent admissions and very expensive admissions. The bulk of the admissions relate to epilepsy," he said. There are several reasons this could be happening, including increased incidence of neurological impairment, increased severity of the conditions, and an increased desire to deliver medical care, he said.
The investigators analyzed data from more than 25.7 million hospitalizations in the years 1997, 2000, 2003, and 2006 in the Kids’ Inpatient Database. They found that the proportion of hospitalizations attributable to children with neurological impairment – 5.3% in 2006 – did not change significantly over time (PLoS Med. 2012 Jan. 17 [doi:10.1371/journal.pmed.1001158]).
But even though children with neurological impairment represented less than 6% of admissions during that period, they accounted for a significant rise in the proportion of hospital bed days from 12.9% in 1997 to 13.9% in 2006. There was a statistically insignificant rise in hospital charges for children with neurological impairment across all hospitals during this period from 20.8% to 21.6%, the investigators found.
Between 1997 and 2006, the proportion of hospitalizations attributable to children with neurological impairment decreased within non-children’s hospitals, from 3% in 1997 to 2.5% in 2006, but increased within children’s hospitals from 11.7% in 1997 to 13.5% in 2006.
The proportion of bed days at children’s hospitals for children with neurological impairment also grew from 21.8% in 1997 to 25.0% in 2006. Their proportion of hospital charges rose in parallel from 27.1% to 29.0%.
More than 52% of admissions involved a diagnosis of epilepsy. Almost 16% involved a diagnosis of cerebral palsy.
The study’s authors speculated that patients may be gravitating toward children’s hospitals because most U.S. child neurologists work within those hospitals, and multi-disciplinary care coordination clinics have emerged to provide comprehensive care to children with neurological impairment.
Plenty of Doctors, Not Enough Bridge Building
“I think we are definitely
seeing this trend,” said Dr. Michelle M. Marks, director of pediatric
hospitalist medicine at the Cleveland Clinic’s Children’s Hospital. “As
hospital admissions overall go down, the proportion of children with medically
complex illness [including neurologic illness] increases, and we are definitely
seeing that. It’s a function of more of these kids living longer.”
However, she doesn't
believe physician staffing – particularly the number of pediatric neurologists –
needs to increase in most hospitals. “It’s very hospital-specific, but I don’t
think we need more physicians to see” children with neurologic impairment, she
said. However, she said she does see a potential need for more allied health
professionals – nurses, physical therapists and nutritionists, for example – to
assist in caring for neurologically impaired children in the hospital. “Those
resources have become much more difficult to staff,” she said.
In addition, it’s
important to stress the bridge between the home and the hospital, both to
prevent readmissions and to keep vulnerable children out of the hospital in the
first place, Dr. Marks said, adding that it’s possible that additional home
nursing or closer follow-up is needed.
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| Dr. Michelle Marks |
“If we could improve that
bridge, we’d probably be able to make an impact on the readmission rate and the
overall quality of life of these kids and their families.
“I think that one of the
things that people are talking about is, how do we better serve these kids in
their home environment? How do we prevent them from coming to the hospital in
the first place? What services can we provide in their home environment?” Dr.
Marks asked. “It’s an evolving discussion. Clearly, if we can provide more
nursing care at home and more support services, we might prevent some
admissions. But that means coming up with the funding and resources to do that.”
Dr. Marks is a staff
physician in the department of general pediatrics at the Cleveland Clinic’s main campus. She is also the
associate program director of the pediatric residency and director of medical
operations at the Cleveland
Clinic’s Children’s Hospital. She reports having no conflicts of interest.
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