- Email: [email protected]
Hospital cost of pediatric patients with complicated acute sinusitis
International Journal of Pediatric Otorhinolaryngology 80 (2016) 17–20
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Hospital cost of pediatric patients with complicated acute sinusitis§ Reema Padia a, Andrew Thomas a, Jeremiah Alt a, Craig Gale b, Jeremy D. Meier a,* a b
Division of Otolaryngology—Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States Intermountain Healthcare, Surgical Services Clinical Program, Murray, UT, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Received 23 September 2015 Received in revised form 15 November 2015 Accepted 18 November 2015 Available online 24 November 2015
Objective: Review costs for pediatric patients with complicated acute sinusitis. Methods: A retrospective case series of patients in a pediatric hospital was created to determine hospital costs using a standardized activity-based accounting system for inpatient treatment between November 2010 and December 2014. Children less than 18 years of age who were admitted for complicated acute sinusitis were included in the study. Demographics, length of stay, type of complication and cost of care were determined for these patients. Results: The study included 64 patients with a mean age of 10 years. Orbital cellulitis (orbital/preseptal/ postseptal cellulitis) accounted for 32.8% of patients, intracranial complications (epidural/subdural abscess, cavernous sinus thrombosis) for 29.7%, orbital abscesses (subperiosteal/intraorbital abscesses) for 25.0%, potts puffy tumor for 7.8%, and other (including facial abscess and dacryocystitis) for 4.7%. The average length of stay was 5.7 days. The mean cost per patient was $20,748. Inpatient floor costs (31%) and operating room costs (18%) were the two greatest expenditures. The major drivers in variation of cost between types of complications included pediatric intensive care unit stays and pharmacy costs. Conclusion: Although complicated acute sinusitis in the pediatric population is rare, this study demonstrates a significant financial impact on the health care system. Identifying ways to reduce unnecessary costs for these visits would improve the value of care for these patients. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Acute sinusitis Complication Cost Pediatric
1. Background Rhinosinusitis is one of the most common disease processes in the pediatric population and affects an estimated 5–7% of patients who present with upper respiratory infection symptoms [1,2]. An acute episode of sinusitis can cause orbital and/or intracranial complications in 5–10% of these patients by either direct extension or hematogenous spread [3]. Orbital complications are more common and present from an extension of ethmoid sinus disease [4]. Five classes of orbital complications have been described by Chandler: Preseptal cellulitis, orbital cellulitis, subperiosteal abscess, orbital abscess and cavernous sinus thrombosis [5]. Intracranial complications include meningitis and epidural or subdural abscesses. Currently, healthcare costs associated with these extra sinus complications are unknown.
§ This paper was presented at the American Rhinologic Society Meeting; Dallas, Texas, Sept. 26–Sept. 30, 2015. * Corresponding author. Tel.: +1 801 585 7143; fax: +1 801 585 5744. E-mail address: [email protected] (J.D. Meier).
http://dx.doi.org/10.1016/j.ijporl.2015.11.021 0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
With the widespread prevalence of acute sinusitis in the pediatric population, orbital and intracranial complications can create a burden on healthcare costs. Inpatient stays, imaging, other diagnostic tests, and medical and surgical intervention all contribute to the total costs. Total resource utilization for these complex conditions is unknown. However, the changing landscape of healthcare delivery is transitioning to a value-based system and bundled payments are becoming more common. Understanding how and where resources are used for specific disease processes is imperative. There have not been any studies to date that have focused on pediatric patients with complicated acute sinusitis and the total hospital cost broken down in categories to determine where most of the expense lies. The purpose of this study is to identify the major hospital expenses at a tertiary children’s hospital for complicated acute pediatric sinusitis. Determining the major sources of resource utilization for these encounters could identify strategies to reduce unnecessary costs and improve care delivery in the future. 2. Methods This study was approved by the Institutional Review Boards at the University of Utah and Intermountain Healthcare. Intermountain
18
R. Padia et al. / International Journal of Pediatric Otorhinolaryngology 80 (2016) 17–20
Healthcare (Intermountain) is a not-for-profit, integrated health care system that includes 22 hospitals ranging from tertiary care referral centers to community and rural hospitals in the Intermountain West. Primary Children’s Hospital is the tertiary children’s hospital within Intermountain. Intermountain houses the Enterprise Data Warehouse (EDW), a comprehensive database that contains administrative, financial and clinical information. The financial data in the EDW are beneficial in that hospital costs, and not simply charges, are recorded. Charge data depend on payment agreements between hospitals and third-party payers without correlation to the actual cost of the operation. Alternatively, cost data represent a more accurate assessment of resources actually utilized. We have previously used this database to evaluate variation in adenotonsillectomy costs and complications among hospitals and surgeons within a tertiary children’s hospital [6] and across the Intermountain system [7]. A retrospective chart review was performed on 724 patients between the ages 1–18 years between November 2010 and December 2014 with one of the following ICD-9 codes: 473.0– 473.9 (chronic rhinosinusitis), 461.0 (maxillary acute sinusitis), 461.1 (frontal), 461.2 (ethmoidal), 461.3 (sphenoidal) or 461.9 (acute sinusitis NOS) and had an otolaryngology consultation. The chart review yielded 64 patients who had a complication secondary to their sinus disease that required an inpatient admission. The standardized activity-based accounting system within Intermountain was used to determine the hospital costs (not charges) related to each hospital encounter. Costs were broken down into categories including: (1) Pediatric Intensive Care Unit (PICU), (2) Inpatient floor, (3) Operating Room (OR), (4) Imaging, (5), Laboratory, (6) Pharmacy, and (7) Other. Professional fees for any inpatient medical consultations and follow-up, surgical intervention, and anesthesia care were not included. In addition, the length of hospital stay was measured. Patients were divided by type of complication into those who had an (1) orbital related cellulitis (preseptal, postseptal, orbital cellulitis), (2) orbital abscess (subperiosteal, orbital), (3) intracranial complication (epidural abscess, subdural abscess, cavernous sinus thrombosis), (4) potts puffy tumor, or (5) other (facial abscess, dacryocysitis). Hospital costs and length of stay were compared between the 5 groups of patients. Statistical analysis was completed using the Fisher’s exact test or chi-square test with a statistical significant set at p < 0.05. 3. Results A total of 64 patients with a complication associated with acute sinusitis were included in the cohort from the reviewed 724 patients who had a diagnosis of acute sinusitis (8.8%). None of the 64 patients had any immunological disease, cystic fibrosis, Kartagener disease or primary ciliary dyskinesia that could have predisposed them to a higher risk of complication from an episode of acute sinusitis or created a higher cost burden from their hospital stay. The mean age was 10 5 years. Orbital cellulitis (orbital/ preseptal/postseptal cellulitis) accounted for 21 (32.8%) patients, orbital abscesses (subperiosteal, intraorbital abscesses) accounted for 16 (25%), potts puffy for 5 (7.8%), intracranial complications (epidural/subdural abscess, cavernous sinus thrombosis) for 19 (29.7%) and other (including
facial abscess and dacryocystitis) for 3 (4.7%). The average length of stay was 5.7 5.1 days (range 1–28 days). The mean length of stay for the orbital cellulitis group was 2.6 1.2 days while the stay for the intracranial complication group was 10.1 6.9 days (Table 1). The mean cost per patient was $20,748 $23,549 (range $2181–$116,925). Across the entire cohort, the inpatient floor accounted for the highest percentage of total costs, followed by the OR (Fig. 1). Within each complication group, the greatest expenditure varied (Fig. 2). The inpatient floor costs were not included in each individual group analysis as the length of stay directly influenced the cost accounted by the inpatient floor category. Separating that from the other categories of expenditure aided in identifying the other contributors that played a role in the management of these patients. Also, within each group, the calculations disregarded the 12.9% of ‘‘other’’ expenditures that included phlebotomy costs, anesthesia medications, post-anesthesia care, etc. from which the emergency department had the greatest percentage at 2.2% of the total cost for all of the patients. 4. Discussion The unique cost-accounting database at Intermountain healthcare enables analysis of hospital costs for children admitted to a tertiary pediatric hospital for complicated acute sinusitis. We demonstrate that each clinical encounter has a substantial expense with an average cost of just over $20,000 per hospital admission. This is most likely an underrepresentation, as the data only reflects the costs to the hospital, not the charges, which are usually several magnitudes greater. Including the physician professional fees and potential lost family income during these illnesses would substantially increase this number. Our goal was to better understand what contributes to these costs, so that targets to reduce unnecessary expenses could be identified. The largest expenditure category was the inpatient floor costs and these costs directly correlate with the length of stay. Dugar et al. found that the average length of stay for all patients with acute sinusitis admitted to the hospital was 4.2 days [8]. Other studies have suggested that the average length of stay increases to an average of 5.8 days in patients with severe orbital complications and 10–21 days in patients with Potts puffy tumor [2,9]. Despite our study showing shorter length of stays, there still was a large burden of cost from these inpatient stays. Admittedly, the severity of each patient’s illness varies significantly. Intracranial complications can be more critical and require more intensive care which likely reflects the increased length of stay and expenditure found in these patients. Across the cohort, decreasing the length of stay by one day could reduce costs per encounter by $4453 (p-value <0.0001) (Fig. 3). Currently, quality measures for health systems and providers include 30-day readmission rates. Whether concerns over increased readmissions lead to unnecessary length of stays is unknown. Developing care process models or standardized discharge criteria for children with complicated acute sinusitis could lead to shorter admissions without sacrificing care quality. Operating room costs were the second most expensive cost overall and was either first or second highest within each complication group. Given its high burden of cost, further scrutiny
Table 1 Average length of stay for each complication group.
Orbital cellulitis Orbital abscess Intracranial complication Potts puffy tumor Other
Number of patients, N (% of total)
Mean total cost ($)
Average length of stay (days)
21 16 19 5 3
5954 13,380 46,167 22,135 7694
2.6 4.6 10.1 6.8 3.3
(32.8%) (25.0%) (29.7%) (7.8%) (4.7%)
R. Padia et al. / International Journal of Pediatric Otorhinolaryngology 80 (2016) 17–20
Breakdown of Percentage of Average Cost For
All Paents
Imaging 4% $809
Laboratory 5% $1037
Pharmacy 12% $2575
Inpaent Floor 32% $6535
Imaging Laboratory Pharmacy
Other 13% $2676
Other PICU Operang Room Inpaent Floor
Operang Room 18% $3734
PICU 16% $3381
Fig. 1. Breakdown of percentage of average cost for all patients.
120
Breakdown of Percentage of Cost by Complicaon
Percentage (%)
100 80
Imaging
60
Laboratory Pharmacy
40
Operang Room
20
PICU
0 Intracranial
Orbital Abscess
Orbital Cellulis
Pos Puffy
Other
Type of Complicaon
Fig. 2. Comparison of contributing variables in cost divided by complication.
Total Cost Based on Length of Stay
140000
y = 4453x - 4496.9 R² = 0.9329
120000
Cost ($)
100000 80000 60000 40000 20000 0 -20000
0
5
10 15 20 Length of Stay (Days)
25
30
Fig. 3. Linear regression model comparing total cost based on length of stay.
into the exact costs within the operating room group, such as equipment, time, anesthesia, etc. would help to identify areas where more efficient use of these resources can be analyzed and implemented. A study comparing the healthcare burden of orbital complications from acute sinusitis in 2000 and 2009 with the institution of the heptavalent pneumococcal vaccine showed that
19
the rate of surgical treatment for these patients has increased. This further highlights the importance of attempting to reduce costs in the operating room as this is a large part of the treatment for these patients [10]. Laboratory costs played a large role in these patients, accounting for 5% of the overall cost and 7.9–15.3% within each group. Many times, labs are ordered to monitor trends and to supplement clinical and physical exam to determine if a patient is improving. However, in many cases daily labs may not be necessary and clinical suspicion should be the impetus for ordering them rather than habit. Implementing clinical guidelines for appropriate indications for laboratory tests, educating ordering physicians, and improving communication between different teams caring for the patient would be helpful to prevent unnecessary laboratory orders [11]. Pharmacy costs accounted for 12.4% of the total costs for all of these patients. This is likely secondary to the intravenous antibiotics and pain medications that are administered to these admitted patients. Efforts to reduce cost could include involving the infectious disease team in the care for the patient if one is available. One study indicated an 18% decrease in the total antimicrobial cost and 40% decrease in the ICU length of stay in non-cardiac ICU patients who had an infectious disease team consulting versus not. The role of home intravenous antibiotics could also reduce not only the hospital length of stay but also pharmacy cost. Decreased costs and equivalent outcomes were achieved when home instead of hospital intravenous antibiotics were used in a select adult population [12]. Imaging played an important role in the inpatient costs for these patients and this consisted of CT and MRI scans. These studies accounted for 4% of the total cost. Although the utility of CT and MRI is critical for both diagnosis and management, it is unknown if imaging is over-utilized in these cases. The highest use of imaging was found with intracranial complications both before and after surgical intervention, and many of these complications were only identified with imaging. A review of intracranial and orbital complications from acute sinusitis showed that in children older than 7 years of age presenting with orbital complications from acute sinusitis, MRI in addition to CT scan can be helpful in identifying concurrent intracranial complications in patients at risk [13]. Current clinical guidelines advocate for imaging when complications from acute sinusitis are suspected, although utility of repeat imaging is unclear [1]. Lastly, socioeconomic status may have impacted the presentation of the patients in this cohort. Our children’s hospital is a tertiary care facility that treats patients from a large geographical catchment area spanning various socioeconomic classes and areas with limited immediate healthcare access. As noted in a crosssectional study in 2008, patients with intracranial complications were associated with a lower socioeconomic status [14]. Though our study did not stratify patients by socioeconomic class, a potential target to reduce the healthcare burden of complicated acute sinusitis would be improving healthcare accessibility to disadvantaged patients, thereby potentially preventing advanced disease with intracranial complications. This study is the first to systematically evaluate the breakdown of costs for hospital admissions for complications of acute sinusitis in the pediatric population. Understanding what contributes to these costs and increased length of hospital stay will help improve efficiency of care for these patients and inform providers and families regarding the length of stay expected for each complication. A limitation to this study is its retrospective nature which relied on adequate coding from providers. Some patients may have been missed in this study, reducing the potential power of the analysis. Additionally, we did not have access to physician professional fees or outpatient follow-up so the entire cost of
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R. Padia et al. / International Journal of Pediatric Otorhinolaryngology 80 (2016) 17–20
care was not measured. Pediatric acute sinusitis is a disease process that requires prompt attention from the provider as the complications that can arise from it are severe and require inpatient admission in most cases, and at times, surgical intervention. Further prospective studies would be beneficial in identifying strategies to more efficiently care for these patients while either maintaining or improving the quality of care. 5. Conclusions Hospital admissions for complicated acute pediatric sinusitis have a high cost per encounter. As expected, more severe conditions such as intracranial complications appear to have the highest burden of healthcare costs as compared to orbital complications. The inpatient floor, operating room, and PICU account for the majority of costs for these encounters. Strategies to address these costs should be explored to more efficiently treat these patients and improve the value of care. Financial support None.
References [1] E.R. Wald, K.E. Applegate, C. Bordley, D.H. Darrow, M.P. Glode, S.M. Marcy, et al. American Academy of P, Pediatrics 132 (2013) e262–e280 (2013). [2] L.E. Oxford, J. McClay, Int. J. Pediatr. Otorhinolaryngol. 70 (2006) 1853–1861 (2006). [3] I. Brook, Int. J. Pediatr. Otorhinolaryngol. 73 (2009) 1183–1186 (2009). [4] M. Caversaccio, S. Heimgartner, C. Aebi, Laryngorhinootologie 84 (2005) 817–821 (2005). [5] J. Bedwell, N.M. Bauman, Curr. Opin. Otolaryngol. Head Neck Surg. 19 (2011) 467–473 (2011). [6] J.D. Meier, M. Duval, J. Wilkes, S. Andrews, E.K. Korgenski, A.H. Park, et al. Otolaryngology—Head Neck Surg. 150 (2014) 887–892 (official journal of American Academy of Otolaryngology-Head and Neck Surgery). [7] J.D. Meier, Y. Zhang, T.H. Greene, J.L. Curtis, R. Srivastava, Laryngoscope 125 (2014) 1215–1220 (2014). [8] D.R. Dugar, L. Lander, A. Mahalingam-Dhingra, R.K. Shah, Laryngoscope 120 (2010) 2313–2321 (2010). [9] L. Mekhitarian Neto, S. Pignatari, S. Mitsuda, A.S. Fava, A. Stamm, Braz. J. Otorhinolaryngol. 73 (2007) 75–79 (2007). [10] G. Capra, B. Liming, M.E. Boseley, M.T. Brigger, JAMA Otolaryngol. Head Neck Surg. 141 (2015) 12–17 (2015). [11] T.J. Iwashyna, A. Fuld, D.A. Asch, L.M. Bellini, Acad. Med. 86 (2011) 139–145 (2011). [12] J.M. Wolter, R.A. Cagney, J.G. McCormack, J. Infect. 48 (2004) 263–268 (2004). [13] B.W. Herrmann, J.W. Forsen Jr., Int. J. Pediatr. Otorhinolaryngol 68 (2004) 619– 625 (2004). [14] A.R. Sedaghat, C.O. Wilke, M.J. Cunningham, S.L. Ishman, Laryngoscope 124 (2014) 1700–1706 (2014).
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Hospital cost of pediatric patients with complicated acute sinusitis§ Reema Padia a, Andrew Thomas a, Jeremiah Alt a, Craig Gale b, Jeremy D. Meier a,* a b
Division of Otolaryngology—Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States Intermountain Healthcare, Surgical Services Clinical Program, Murray, UT, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Received 23 September 2015 Received in revised form 15 November 2015 Accepted 18 November 2015 Available online 24 November 2015
Objective: Review costs for pediatric patients with complicated acute sinusitis. Methods: A retrospective case series of patients in a pediatric hospital was created to determine hospital costs using a standardized activity-based accounting system for inpatient treatment between November 2010 and December 2014. Children less than 18 years of age who were admitted for complicated acute sinusitis were included in the study. Demographics, length of stay, type of complication and cost of care were determined for these patients. Results: The study included 64 patients with a mean age of 10 years. Orbital cellulitis (orbital/preseptal/ postseptal cellulitis) accounted for 32.8% of patients, intracranial complications (epidural/subdural abscess, cavernous sinus thrombosis) for 29.7%, orbital abscesses (subperiosteal/intraorbital abscesses) for 25.0%, potts puffy tumor for 7.8%, and other (including facial abscess and dacryocystitis) for 4.7%. The average length of stay was 5.7 days. The mean cost per patient was $20,748. Inpatient floor costs (31%) and operating room costs (18%) were the two greatest expenditures. The major drivers in variation of cost between types of complications included pediatric intensive care unit stays and pharmacy costs. Conclusion: Although complicated acute sinusitis in the pediatric population is rare, this study demonstrates a significant financial impact on the health care system. Identifying ways to reduce unnecessary costs for these visits would improve the value of care for these patients. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Acute sinusitis Complication Cost Pediatric
1. Background Rhinosinusitis is one of the most common disease processes in the pediatric population and affects an estimated 5–7% of patients who present with upper respiratory infection symptoms [1,2]. An acute episode of sinusitis can cause orbital and/or intracranial complications in 5–10% of these patients by either direct extension or hematogenous spread [3]. Orbital complications are more common and present from an extension of ethmoid sinus disease [4]. Five classes of orbital complications have been described by Chandler: Preseptal cellulitis, orbital cellulitis, subperiosteal abscess, orbital abscess and cavernous sinus thrombosis [5]. Intracranial complications include meningitis and epidural or subdural abscesses. Currently, healthcare costs associated with these extra sinus complications are unknown.
§ This paper was presented at the American Rhinologic Society Meeting; Dallas, Texas, Sept. 26–Sept. 30, 2015. * Corresponding author. Tel.: +1 801 585 7143; fax: +1 801 585 5744. E-mail address: [email protected] (J.D. Meier).
http://dx.doi.org/10.1016/j.ijporl.2015.11.021 0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
With the widespread prevalence of acute sinusitis in the pediatric population, orbital and intracranial complications can create a burden on healthcare costs. Inpatient stays, imaging, other diagnostic tests, and medical and surgical intervention all contribute to the total costs. Total resource utilization for these complex conditions is unknown. However, the changing landscape of healthcare delivery is transitioning to a value-based system and bundled payments are becoming more common. Understanding how and where resources are used for specific disease processes is imperative. There have not been any studies to date that have focused on pediatric patients with complicated acute sinusitis and the total hospital cost broken down in categories to determine where most of the expense lies. The purpose of this study is to identify the major hospital expenses at a tertiary children’s hospital for complicated acute pediatric sinusitis. Determining the major sources of resource utilization for these encounters could identify strategies to reduce unnecessary costs and improve care delivery in the future. 2. Methods This study was approved by the Institutional Review Boards at the University of Utah and Intermountain Healthcare. Intermountain
18
R. Padia et al. / International Journal of Pediatric Otorhinolaryngology 80 (2016) 17–20
Healthcare (Intermountain) is a not-for-profit, integrated health care system that includes 22 hospitals ranging from tertiary care referral centers to community and rural hospitals in the Intermountain West. Primary Children’s Hospital is the tertiary children’s hospital within Intermountain. Intermountain houses the Enterprise Data Warehouse (EDW), a comprehensive database that contains administrative, financial and clinical information. The financial data in the EDW are beneficial in that hospital costs, and not simply charges, are recorded. Charge data depend on payment agreements between hospitals and third-party payers without correlation to the actual cost of the operation. Alternatively, cost data represent a more accurate assessment of resources actually utilized. We have previously used this database to evaluate variation in adenotonsillectomy costs and complications among hospitals and surgeons within a tertiary children’s hospital [6] and across the Intermountain system [7]. A retrospective chart review was performed on 724 patients between the ages 1–18 years between November 2010 and December 2014 with one of the following ICD-9 codes: 473.0– 473.9 (chronic rhinosinusitis), 461.0 (maxillary acute sinusitis), 461.1 (frontal), 461.2 (ethmoidal), 461.3 (sphenoidal) or 461.9 (acute sinusitis NOS) and had an otolaryngology consultation. The chart review yielded 64 patients who had a complication secondary to their sinus disease that required an inpatient admission. The standardized activity-based accounting system within Intermountain was used to determine the hospital costs (not charges) related to each hospital encounter. Costs were broken down into categories including: (1) Pediatric Intensive Care Unit (PICU), (2) Inpatient floor, (3) Operating Room (OR), (4) Imaging, (5), Laboratory, (6) Pharmacy, and (7) Other. Professional fees for any inpatient medical consultations and follow-up, surgical intervention, and anesthesia care were not included. In addition, the length of hospital stay was measured. Patients were divided by type of complication into those who had an (1) orbital related cellulitis (preseptal, postseptal, orbital cellulitis), (2) orbital abscess (subperiosteal, orbital), (3) intracranial complication (epidural abscess, subdural abscess, cavernous sinus thrombosis), (4) potts puffy tumor, or (5) other (facial abscess, dacryocysitis). Hospital costs and length of stay were compared between the 5 groups of patients. Statistical analysis was completed using the Fisher’s exact test or chi-square test with a statistical significant set at p < 0.05. 3. Results A total of 64 patients with a complication associated with acute sinusitis were included in the cohort from the reviewed 724 patients who had a diagnosis of acute sinusitis (8.8%). None of the 64 patients had any immunological disease, cystic fibrosis, Kartagener disease or primary ciliary dyskinesia that could have predisposed them to a higher risk of complication from an episode of acute sinusitis or created a higher cost burden from their hospital stay. The mean age was 10 5 years. Orbital cellulitis (orbital/ preseptal/postseptal cellulitis) accounted for 21 (32.8%) patients, orbital abscesses (subperiosteal, intraorbital abscesses) accounted for 16 (25%), potts puffy for 5 (7.8%), intracranial complications (epidural/subdural abscess, cavernous sinus thrombosis) for 19 (29.7%) and other (including
facial abscess and dacryocystitis) for 3 (4.7%). The average length of stay was 5.7 5.1 days (range 1–28 days). The mean length of stay for the orbital cellulitis group was 2.6 1.2 days while the stay for the intracranial complication group was 10.1 6.9 days (Table 1). The mean cost per patient was $20,748 $23,549 (range $2181–$116,925). Across the entire cohort, the inpatient floor accounted for the highest percentage of total costs, followed by the OR (Fig. 1). Within each complication group, the greatest expenditure varied (Fig. 2). The inpatient floor costs were not included in each individual group analysis as the length of stay directly influenced the cost accounted by the inpatient floor category. Separating that from the other categories of expenditure aided in identifying the other contributors that played a role in the management of these patients. Also, within each group, the calculations disregarded the 12.9% of ‘‘other’’ expenditures that included phlebotomy costs, anesthesia medications, post-anesthesia care, etc. from which the emergency department had the greatest percentage at 2.2% of the total cost for all of the patients. 4. Discussion The unique cost-accounting database at Intermountain healthcare enables analysis of hospital costs for children admitted to a tertiary pediatric hospital for complicated acute sinusitis. We demonstrate that each clinical encounter has a substantial expense with an average cost of just over $20,000 per hospital admission. This is most likely an underrepresentation, as the data only reflects the costs to the hospital, not the charges, which are usually several magnitudes greater. Including the physician professional fees and potential lost family income during these illnesses would substantially increase this number. Our goal was to better understand what contributes to these costs, so that targets to reduce unnecessary expenses could be identified. The largest expenditure category was the inpatient floor costs and these costs directly correlate with the length of stay. Dugar et al. found that the average length of stay for all patients with acute sinusitis admitted to the hospital was 4.2 days [8]. Other studies have suggested that the average length of stay increases to an average of 5.8 days in patients with severe orbital complications and 10–21 days in patients with Potts puffy tumor [2,9]. Despite our study showing shorter length of stays, there still was a large burden of cost from these inpatient stays. Admittedly, the severity of each patient’s illness varies significantly. Intracranial complications can be more critical and require more intensive care which likely reflects the increased length of stay and expenditure found in these patients. Across the cohort, decreasing the length of stay by one day could reduce costs per encounter by $4453 (p-value <0.0001) (Fig. 3). Currently, quality measures for health systems and providers include 30-day readmission rates. Whether concerns over increased readmissions lead to unnecessary length of stays is unknown. Developing care process models or standardized discharge criteria for children with complicated acute sinusitis could lead to shorter admissions without sacrificing care quality. Operating room costs were the second most expensive cost overall and was either first or second highest within each complication group. Given its high burden of cost, further scrutiny
Table 1 Average length of stay for each complication group.
Orbital cellulitis Orbital abscess Intracranial complication Potts puffy tumor Other
Number of patients, N (% of total)
Mean total cost ($)
Average length of stay (days)
21 16 19 5 3
5954 13,380 46,167 22,135 7694
2.6 4.6 10.1 6.8 3.3
(32.8%) (25.0%) (29.7%) (7.8%) (4.7%)
R. Padia et al. / International Journal of Pediatric Otorhinolaryngology 80 (2016) 17–20
Breakdown of Percentage of Average Cost For
All Paents
Imaging 4% $809
Laboratory 5% $1037
Pharmacy 12% $2575
Inpaent Floor 32% $6535
Imaging Laboratory Pharmacy
Other 13% $2676
Other PICU Operang Room Inpaent Floor
Operang Room 18% $3734
PICU 16% $3381
Fig. 1. Breakdown of percentage of average cost for all patients.
120
Breakdown of Percentage of Cost by Complicaon
Percentage (%)
100 80
Imaging
60
Laboratory Pharmacy
40
Operang Room
20
PICU
0 Intracranial
Orbital Abscess
Orbital Cellulis
Pos Puffy
Other
Type of Complicaon
Fig. 2. Comparison of contributing variables in cost divided by complication.
Total Cost Based on Length of Stay
140000
y = 4453x - 4496.9 R² = 0.9329
120000
Cost ($)
100000 80000 60000 40000 20000 0 -20000
0
5
10 15 20 Length of Stay (Days)
25
30
Fig. 3. Linear regression model comparing total cost based on length of stay.
into the exact costs within the operating room group, such as equipment, time, anesthesia, etc. would help to identify areas where more efficient use of these resources can be analyzed and implemented. A study comparing the healthcare burden of orbital complications from acute sinusitis in 2000 and 2009 with the institution of the heptavalent pneumococcal vaccine showed that
19
the rate of surgical treatment for these patients has increased. This further highlights the importance of attempting to reduce costs in the operating room as this is a large part of the treatment for these patients [10]. Laboratory costs played a large role in these patients, accounting for 5% of the overall cost and 7.9–15.3% within each group. Many times, labs are ordered to monitor trends and to supplement clinical and physical exam to determine if a patient is improving. However, in many cases daily labs may not be necessary and clinical suspicion should be the impetus for ordering them rather than habit. Implementing clinical guidelines for appropriate indications for laboratory tests, educating ordering physicians, and improving communication between different teams caring for the patient would be helpful to prevent unnecessary laboratory orders [11]. Pharmacy costs accounted for 12.4% of the total costs for all of these patients. This is likely secondary to the intravenous antibiotics and pain medications that are administered to these admitted patients. Efforts to reduce cost could include involving the infectious disease team in the care for the patient if one is available. One study indicated an 18% decrease in the total antimicrobial cost and 40% decrease in the ICU length of stay in non-cardiac ICU patients who had an infectious disease team consulting versus not. The role of home intravenous antibiotics could also reduce not only the hospital length of stay but also pharmacy cost. Decreased costs and equivalent outcomes were achieved when home instead of hospital intravenous antibiotics were used in a select adult population [12]. Imaging played an important role in the inpatient costs for these patients and this consisted of CT and MRI scans. These studies accounted for 4% of the total cost. Although the utility of CT and MRI is critical for both diagnosis and management, it is unknown if imaging is over-utilized in these cases. The highest use of imaging was found with intracranial complications both before and after surgical intervention, and many of these complications were only identified with imaging. A review of intracranial and orbital complications from acute sinusitis showed that in children older than 7 years of age presenting with orbital complications from acute sinusitis, MRI in addition to CT scan can be helpful in identifying concurrent intracranial complications in patients at risk [13]. Current clinical guidelines advocate for imaging when complications from acute sinusitis are suspected, although utility of repeat imaging is unclear [1]. Lastly, socioeconomic status may have impacted the presentation of the patients in this cohort. Our children’s hospital is a tertiary care facility that treats patients from a large geographical catchment area spanning various socioeconomic classes and areas with limited immediate healthcare access. As noted in a crosssectional study in 2008, patients with intracranial complications were associated with a lower socioeconomic status [14]. Though our study did not stratify patients by socioeconomic class, a potential target to reduce the healthcare burden of complicated acute sinusitis would be improving healthcare accessibility to disadvantaged patients, thereby potentially preventing advanced disease with intracranial complications. This study is the first to systematically evaluate the breakdown of costs for hospital admissions for complications of acute sinusitis in the pediatric population. Understanding what contributes to these costs and increased length of hospital stay will help improve efficiency of care for these patients and inform providers and families regarding the length of stay expected for each complication. A limitation to this study is its retrospective nature which relied on adequate coding from providers. Some patients may have been missed in this study, reducing the potential power of the analysis. Additionally, we did not have access to physician professional fees or outpatient follow-up so the entire cost of
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care was not measured. Pediatric acute sinusitis is a disease process that requires prompt attention from the provider as the complications that can arise from it are severe and require inpatient admission in most cases, and at times, surgical intervention. Further prospective studies would be beneficial in identifying strategies to more efficiently care for these patients while either maintaining or improving the quality of care. 5. Conclusions Hospital admissions for complicated acute pediatric sinusitis have a high cost per encounter. As expected, more severe conditions such as intracranial complications appear to have the highest burden of healthcare costs as compared to orbital complications. The inpatient floor, operating room, and PICU account for the majority of costs for these encounters. Strategies to address these costs should be explored to more efficiently treat these patients and improve the value of care. Financial support None.
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