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Utilization and expenditure of hospital admission in patients with autism spectrum disorder: National Health Insurance claims database analysis
Research in Autism Spectrum Disorders 5 (2011) 1138–1142
Contents lists available at ScienceDirect
Research in Autism Spectrum Disorders Journal homepage: http://ees.elsevier.com/RASD/default.asp
Utilization and expenditure of hospital admission in patients with autism spectrum disorder: National Health Insurance claims database analysis Jin-Ding Lin a,*, Wen-Jiu Hung a, Lan-Ping Lin b, Chia-Im Lai c a b c
School of Public Health, National Defense Medical Center, Taipei, Taiwan Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan Office of Medical Service, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
A R T I C L E I N F O
A B S T R A C T
Article history: Received 15 December 2010 Accepted 31 December 2010 Available online 26 January 2011
There were not many studies to provide information on health access and health utilization of people with autism spectrum disorders (ASD). The present study describes a general profile of hospital admission and the medical cost among people with ASD, and to analyze the determinants of medical cost. A retrospective study was employed to analyze medical fee of 397 individuals with ASD based on population-based National Health Insurance (NHI) claims data in Taiwan. The average frequency of hospital admission in the respondents was 3.5 annually, mean of hospital stay was 111.9 days, and the mean medical expenditure was 94,293 NTD in the year of 2005. Those autistic individuals with characteristics of younger age (OR = 31.085, 95% CI = 12.772–75.659), hold a serious illness card (OR = 4.980, 95% CI = 1.690–14.673), more frequent in inpatient care (OR = 7.636, 95% CI = 2.643–22.066), longer days in acute ward (OR = 3.840, 95% CI = 1.989–7.416), and days in acute + chronic wards (OR = 3.804, 95% CI = 1.334–10.846) were more likely to consume more medical expenditure than their counterparts. The present study provides valuable medical care utilization information to health care decision makers to initiate a supportive healing environment for people with ASD. ß 2011 Elsevier Ltd. All rights reserved.
Keywords: Autism spectrum disorder Hospital admission Medical expenditure
1. Introduction In recent years, surveillance results indicate an increased prevalence of identified autism spectrum disorder (ASD) among U.S. children and underscore the need to regard ASD as an urgent public health concern (Centers for Disease Control and Prevention, 2009). Sun and Allison (2010) reviewed recent studies found that the overall reported prevalence of ASD was higher than the previously reported in Asia. In Taiwan, the registered number of people with autism drastically increased from 2062 to 7207 (increase rate = 249.5%), and the reported prevalence of each age group, aged 0–5 years was 2.4–7.8/ 10,000, aged 6–11 was 5.0–17.3/10,000, and aged 12–17 years was 2.1–10.4/10,000 from year 2000 to 2007 (Lin, Lin, & Wu, 2009). However, the trend test revealed that child dependency ratio in autism decrease significantly as the identified younger aged number increase during the past decade (Lin, Lin, Sung, & Wu, 2011). An increase in prevalence would suggest the need for more attention and funding of services for this group of people.
* Corresponding author at: School of Public Health, National Defense Medical Center, No. 161, Min-Chun East Road, Section 6, Nei-Hu, Taipei, Taiwan. Tel.: +886 2 87923100x18447; fax: +886 2 87923147. E-mail address: [email protected] (J.-D. Lin). 1750-9467/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.rasd.2010.12.010
J.-D. Lin et al. / Research in Autism Spectrum Disorders 5 (2011) 1138–1142
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Children with ASD have a social communication disorder with rigid or repetitive behaviors and poor imagination (Brooks, Marshallsay, & Fraser, 2004). Brown, Ouellette-Kuntz, Hunter, and Kelley (2010) found that the autistic child’s adaptive skills and challenging behaviors were important in predicting the extent of the parent’s perceived unmet need. There is a need to tailor care to children with ASD who may find interfaces with healthcare services for any reason extremely stressful, particularly in admission to hospital care (Brooks et al., 2004). Researchers have found that individuals with ASD who use psychiatric hospitals have high clinical needs that are not always well met. Medical staff needs to be trained in the assessment, diagnosis and treatment to provide more appropriate services for them (Lunsky, Gracey, & Bradley, 2009). Studies revealed that many autistic individual often experience a number comorbid medical conditions, but the nature and prevalence of which remain as yet, poorly defined (Bauman, 2010; Lauritsen, Mors, Mortensen, & Ewald, 2002). They also incur elevated medical utilization and costs (Croen, Najjar, Ray, Lotspeich, & Bernal, 2006; Shimabukuro, Grosse, & Rice, 2008), which continually increase the burden in the health care system (Leslie & Martin, 2007). Understanding how to improve the health care access, quality, and outcomes for individual with ASD is extremely complex (Young, Ruble, & McGrew, 2009). For a child with an ASD, hospitalization can be an overwhelming sensory and cognitive experience (Scarpinato et al., 2010). However, little information is known about hospitalization profile and their medical cost in health services of individuals with ASD. Such information is important and provides valuable information in health care decision for this group of people. Therefore, this study aimed to describe the use of hospitalization and medical fee of people with ASD based on population-based National Health Insurance (NHI) claims data in Taiwan. 2. Methods A retrospective analysis was conducted by using an merged database of hospital medical care discharge claims by Taiwan Bureau of National Health Insurances (NHI), and Disability Registration System which administered by Ministry of the Interior in Taiwan. The database was derived from the demographic data of people with ASD and their hospital inpatient care utilization in 2005. The ASD case was ASD entified according to the International Classification of Diseases, 9th revision, Clinical Modified (ICD-9-CM) coding system which has been used in Taiwan NHI diagnosis system. Those ASD cases are ICD code 299, 299.0, 299.00, and 299.01. Data were analyzed by SPSS 18.0 software which the main methods included number, percentage, mean, and Chi-square test to describe research subject admitted to hospital characteristics and inpatient care fee of people with ASD. Logistic regression analyses were used to test the relation of ASD case’s demographic characteristics, inpatient care use and medical fee in people with ASD.
Table 1 Demographic characteristics of people with ASD. Variable Gender (n = 397) Female Male Age (years) (n = 297) 10 11–20 21–30 31–40 41 Severe illness card holder (n = 397) No Yes Low income family (n = 397) No Yes Frequency of inpatient care (n = 397) 2 3–4 5 Days in acute ward (n = 222) 4 5–21 22 Days in chronic ward (n = 223) 82 83–188 189 Days in acute + chronic ward (n = 397) 21 22–128 129
n (%)
Mean SD
70 (17.6) 327 (82.4) 11.3 10.860 253 78 44 12 10
(63.7) (19.6) (11.1) (3.0) (2.5)
102 (25.7) 295 (74.3) 383 (96.5) 14 (3.5) 3.5 2.804 188 (47.4) 90 (22.7) 119 (30.0) 40.4 67.038 76 (34.2) 72 (32.4) 74 (33.3) 159.1 117.4 77 (34.5) 72 (32.3) 74 (33.2) 111.91 117.442 134 (33.8) 131 (33.0) 129 (33.2)
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J.-D. Lin et al. / Research in Autism Spectrum Disorders 5 (2011) 1138–1142
Table 2 Annual inpatient fee among people with ASD. Items
n
Mean (NTD)
Total fee Consultation fee Ward fee Exam/lab test fee Medicine and pharmacy service fee Psychiatric treatment fee
397 207 396 205 259 69
94293.36 8038.43 59965.67 4564.71 9438.44 70591.32
3. Results Table 1 presents the demographic characteristics and hospital admission profile of people with ASD in Taiwan. There were 397 persons with ASD admitted to hospital care within the year of 2005 Taiwan NHI claims. There were 327 (82.4%) male and 70 (17.6%) female patients. The majority of the children were age under 10 years (63.7%) and the mean age of the patients was 11.3 years old. With regard to the household income, 3.5% patients come from low income family in the study respondents. Among those inpatient care users, there were 74.3% cases hold severe illness cards which their medical copayment can partially waive from NHI scheme if medical necessary. Average hospital admission in the respondents was 3.5 annually, there was 47.4% cases used less than twice inpatient cares, 22.7% used 3–4 times, and 30.0% were hospitalized more than five times in the year of 2005. The results also show that the mean of hospital stay was 111.9 days, which staying in acute ward was 40.4 days and in chronic ward was 159.1 days. The annual inpatient fee among people with ASD shown in Table 2, the results revealed that the mean expenditure was 94,293 NTD (1 USD = 30 NTD) in the year of 2005. The medical fee mainly includes ward fee (mean = 59,965 NTD), medicine and pharmacy service fee (mean = 9438 NTD), exam/lab test fee (mean = 4564 NTD) physician consultant fee (mean = 8038 NTD). There were 69 cases used psychiatric service, and the mean of their treatment fee was 70,591 NTD. Table 3 describes the relations of ASD case’s characteristics, inpatient care and medical fees in Chi-square tests. We found that variables of patient’s age, a severe illness card holder, low income family, frequency of inpatient care, hospital stay either in acute ward or chronic ward were significant differences between low (109,900 NTD) and high (>109,900 NTD) groups of inpatient care expenditure. Finally, we use logistic regression model to identify the possible factors which affected the level (low vs. high) of annual inpatient fee in people with ASD. Table 4 shows that factors – age (reference: 12 years; OR = 31.085, 95% CI = 12.772–75.659), hold a serious illness card (reference: no; OR = 4.980, 95% CI = 1.690–14.673), frequency of inpatient care (reference: 3; OR = 7.636, 95% CI = 2.643–22.066), days in acute ward (reference: 9; OR = 3.840, 95%
Table 3 Relation of demographic characteristics, inpatient care and annual inpatient fee in Chi-square tests. Variable
Gender (n = 397) Female Male Age (n = 397) 12 >12 Severe illness care holder (n = 397) No Yes Low income family (n = 397) No Yes Frequency of inpatient care (n = 397) 3 4 Days in acute ward (n = 222) 9 10 Days in chronic ward (n = 223) 126 127 Days in acute + chronic ward (n = 397) 74 75
x2
Annual inpatient fee Low, n (%)
High, n (%)
52 (17.4) 246 (82.6)
18 (18.2) 81 (81.8)
240 (80.5) 58 (19.5)
27 (27.3) 72 (72.7)
95 (31.9) 203 (68.1)
7 (7.1) 92 (92.9)
293 (98.3) 5 (1.7)
90 (90.9) 9 (9.1)
218 (73.2) 80 (26.8)
23 (23.2) 76 (76.8)
108 (66.7) 54 (33.3)
8 (13.3) 52 (86.7)
100 (62.5) 60 (37.5)
12 (19.0) 51 (81.0)
180 (60.4) 118 (39.6)
19 (19.2) 80 (80.8)
p value
0.027
0.868
95.732
<0.001
23.956
<0.001
12.004
0.001
77.640
<0.001
49.918
<0.001
34.139
<0.001
50.483
<0.001
Low and high annual inpatient fee groups were categorized by 75% percentile: low: 109,900 NTD and high: >109,900 NTD.
J.-D. Lin et al. / Research in Autism Spectrum Disorders 5 (2011) 1138–1142
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Table 4 Logistic regression of annual inpatient fee (low vs. high) in people with ASD. Variables (reference) Constant Age (12 years) Severe illness card holder (No) Frequency of inpatient care (3) Days in acute ward (9) Days in chronic ward (126) Days in acute + chronic ward (74)
b 14.680 3.437 1.605 2.033 1.346 0.782 1.336
Wald
O.R. (95% C.I.)
p-value
81.879 57.344 8.479 14.100 16.056 3.559 6.246
<0.001 31.085 4.980 7.636 3.840 2.185 3.804
<0.001 <0.001 0.004 <0.001 <0.001 0.059 0.012
(12.772–75.659) (1.690–14.673) (2.643–22.066) (1.989–7.416) (0.970–4.922) (1.334–10.846)
CI = 1.989–7.416), and days in acute + chronic wards (reference: 74; OR = 3.804, 95% CI = 1.334–10.846) were more likely to consume more medical care fees than their counterparts. 4. Discussions Our previous study revealed that the reported prevalence of autistic cases significantly increased from 0.93 to 3.96 per 10,000 and the group of mild disability grade was the most increased group of four disability levels in the year of 2000 and 2009 in Taiwan (Lin, Sung, et al., 2011). Although the number of studies published on ASD continues to increase and the most frequently studied topics include genetics, perception and cognition, neurobiology, physiology and nosology (Matson & LoVullo, 2009). There have not been many studies providing information on health access and health utilization of this group of people. The present study describes a general profile of medical care use and medical cost among people with ASD. These results will provide valuable information for health care decision makers to initiate appropriate health policy for this group of people. Our results revealed that people with ASD used more hospital admission (mean = 3.5 annually) than the general population. Those cases who were of a younger age, held a serious illness card. More frequent hospital admissions and longer stays in the hospital resulted in the consumption of more medical cost than their counterparts. Comparing to other studies in the US, individuals with an ASD had average medical expenditures that exceeded those without an ASD by $4110–$6200 per year. On average, medical expenditures for individuals with an ASD were 4.1–6.2 times greater than for those without an ASD (Shimabukuro et al., 2008). Wang and Leslie (2010) found that the mean total health care expenditures per child with ASD were $22,079 in 2000 (in 2003 US dollars), and rose by 3.1% to $22,772 in 2003 in Medicaid beneficiaries. Leslie and Martin (2007) analyzed average health care expenditures for individuals with an ASD increased 20.4% from $4965 per patient in 2000 to $5979 per patient in 2004, even after adjustment for inflation. Autistic children are participating in a wide range of therapies with most individuals using multiple treatments simultaneously (Goin-Kochel, Myers, & Mackintosh, 2007). Over 70% had tried at least one complementary and alternative medicine (CAM) treatment with their child, and about half were currently using one or more CAMs (Christon, Mackintosh, & Myers, 2010). The present study also found that psychiatric treatment was the leading medical cost in hospital admission among people with ASD. Matson and Hess (2011) assessed current prescription practices and concluded that the use of psychotropic medication in general and antipsychotic drugs in particular is at an all time high among children and adults diagnosed with autism. Croen et al. (2006) found that children with ASD experienced nearly 9 times more likely to use psychotherapeutic medications as children without ASD. Fujiwara, Okuyama, and Funahashi (2011) suggested that a national health policy to facilitate a referral system that coordinates hospitals that offer psychiatric services with other settings is needed, to promote the timely provision of child psychiatric services. The present paper provides the evidence-based information of medical care utilization data for decision making to initiate quality of care for people with ASD. As researcher Inglese (2009) suggested, knowing the core medical care features of ASD and realizing a particular individual’s sensitivities will allow health providers to create a supportive healing environment. References Bauman, M. L. (2010). Medical comorbidities in autism: Challenges to diagnosis and treatment. Neurotherapeutics, 7, 320–327. Brooks, R., Marshallsay, M., & Fraser, W. I. (2004). Autism spectrum disorder: How to help children and families. Current Paediatrics, 14, 208–213. Brown, H. K., Ouellette-Kuntz, H., Hunter, D., & Kelley, E. (2010). Assessing need in school-aged children with an autism spectrum disorder. Research in Autism Spectrum Disorders, 4, 539–547. Centers for Disease Control and Prevention (CDC). (2009). Prevalence of autism spectrum disorders—Autism and developmental disabilities monitoring network, United States, 2006. MMWR Surveillance Summaries, 58, 1–20. Christon, L. M., Mackintosh, V. H., & Myers, B. J. (2010). Use of complementary and alternative medicine (CAM) treatments by parents of children with autism spectrum disorders. Research in Autism Spectrum Disorders, 4, 249–259. Croen, L. A., Najjar, D. V., Ray, G. T., Lotspeich, L., & Bernal, P. (2006). A comparison of health care utilization and costs of children with and without autism spectrum disorders in a large group-model health plan. Pediatrics, 118, e1203–1211. Fujiwara, T., Okuyama, M., & Funahashi, K. (2011). Factors influencing time lag between first parental concern and first visit to child psychiatric services in children with autism spectrum disorders in Japan. Research in Autism Spectrum Disorders, 5, 584–591. Goin-Kochel, R. P., Myers, B. J., & Mackintosh, V. H. (2007). Parental reports on the use of treatments and therapies for children with autism spectrum disorders. Research in Autism Spectrum Disorders, 1, 195–209.
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Inglese, M. D. (2009). Caring for children with autism spectrum disorder, part II: Screening, diagnosis, and management. Journal of Pediatric Nursing, 24, 49–59. Lauritsen, M. B., Mors, O., Mortensen, P. B., & Ewald, H. (2002). Medical disorders among inpatients with autism in Denmark according to ICD-8: A nationwide register-based study. Journal of Autism and Developmental Disorders, 32, 115–119. Leslie, D. L., & Martin, A. (2007). Health care expenditures associated with autism spectrum disorders. Archives of Pediatrics & Adolescent Medicine, 161, 350–355. Lin, J. D., Lin, L. P., Sung, C. L., & Wu, J. L. (2011). Aged and dependency ratios among autism, intellectual disability and other disabilities: 10-year trend analysis. Research in Autism Spectrum Disorders, 5, 523–528. Lin, J. D., Lin, L. P., & Wu, J. L. (2009). Administrative prevalence of autism spectrum disorders based on national disability registers in Taiwan. Research in Autism Spectrum Disorders, 3, 269–274. Lin, J. D., Sung, C. L., Lin, L. P., Hsu, S. W., Chien, W. C., Su, S. L., et al. (2011). Ten-year trend analysis of autism severity: A nationwide population-based register study. Research in Autism Spectrum Disorders, 5, 570–574. Lunsky, Y., Gracey, C., & Bradley, E. (2009). Adults with autism spectrum disorders using psychiatric hospitals in Ontario: Clinical profile and service needs. Research in Autism Spectrum Disorders, 3, 1006–1013. Matson, J. L., & Hess, J. A. (2011). Psychotropic drug efficacy and side effects for persons with autism spectrum disorders. Research in Autism Spectrum Disorders, 5, 230–236. Matson, J. L., & LoVullo, S. V. (2009). Trends and topics in autism spectrum disorders research. Research in Autism Spectrum Disorders, 3, 252–257. Scarpinato, N., Bradley, J., Kurbjun, K., Bateman, X., Holtzer, B., & Ely, B. (2010). Caring for the child with an autism spectrum disorder in the acute care setting. Journal for Specialists in Pediatric Nursing, 15, 244–254. Shimabukuro, T. T., Grosse, S. D., & Rice, C. (2008). Medical expenditures for children with an autism spectrum disorder in a privately insured population. Journal of Autism and Developmental Disorders, 38, 546–552. Sun, X., & Allison, C. (2010). A review of the prevalence of autism spectrum disorder in Asia. Research in Autism Spectrum Disorders, 4, 156–167. Wang, L., & Leslie, D. L. (2010). Health care expenditures for children with autism spectrum disorders in Medicaid. Journal of American Academy of Child and Adolescent Psychiatry, 49, 1165–1171. Young, A., Ruble, L., & McGrew, J. (2009). Public vs. private insurance: Cost, use, accessibility, and outcomes of services for children with autism spectrum disorders. Research in Autism Spectrum Disorders, 3, 1023–1033.
Contents lists available at ScienceDirect
Research in Autism Spectrum Disorders Journal homepage: http://ees.elsevier.com/RASD/default.asp
Utilization and expenditure of hospital admission in patients with autism spectrum disorder: National Health Insurance claims database analysis Jin-Ding Lin a,*, Wen-Jiu Hung a, Lan-Ping Lin b, Chia-Im Lai c a b c
School of Public Health, National Defense Medical Center, Taipei, Taiwan Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan Office of Medical Service, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
A R T I C L E I N F O
A B S T R A C T
Article history: Received 15 December 2010 Accepted 31 December 2010 Available online 26 January 2011
There were not many studies to provide information on health access and health utilization of people with autism spectrum disorders (ASD). The present study describes a general profile of hospital admission and the medical cost among people with ASD, and to analyze the determinants of medical cost. A retrospective study was employed to analyze medical fee of 397 individuals with ASD based on population-based National Health Insurance (NHI) claims data in Taiwan. The average frequency of hospital admission in the respondents was 3.5 annually, mean of hospital stay was 111.9 days, and the mean medical expenditure was 94,293 NTD in the year of 2005. Those autistic individuals with characteristics of younger age (OR = 31.085, 95% CI = 12.772–75.659), hold a serious illness card (OR = 4.980, 95% CI = 1.690–14.673), more frequent in inpatient care (OR = 7.636, 95% CI = 2.643–22.066), longer days in acute ward (OR = 3.840, 95% CI = 1.989–7.416), and days in acute + chronic wards (OR = 3.804, 95% CI = 1.334–10.846) were more likely to consume more medical expenditure than their counterparts. The present study provides valuable medical care utilization information to health care decision makers to initiate a supportive healing environment for people with ASD. ß 2011 Elsevier Ltd. All rights reserved.
Keywords: Autism spectrum disorder Hospital admission Medical expenditure
1. Introduction In recent years, surveillance results indicate an increased prevalence of identified autism spectrum disorder (ASD) among U.S. children and underscore the need to regard ASD as an urgent public health concern (Centers for Disease Control and Prevention, 2009). Sun and Allison (2010) reviewed recent studies found that the overall reported prevalence of ASD was higher than the previously reported in Asia. In Taiwan, the registered number of people with autism drastically increased from 2062 to 7207 (increase rate = 249.5%), and the reported prevalence of each age group, aged 0–5 years was 2.4–7.8/ 10,000, aged 6–11 was 5.0–17.3/10,000, and aged 12–17 years was 2.1–10.4/10,000 from year 2000 to 2007 (Lin, Lin, & Wu, 2009). However, the trend test revealed that child dependency ratio in autism decrease significantly as the identified younger aged number increase during the past decade (Lin, Lin, Sung, & Wu, 2011). An increase in prevalence would suggest the need for more attention and funding of services for this group of people.
* Corresponding author at: School of Public Health, National Defense Medical Center, No. 161, Min-Chun East Road, Section 6, Nei-Hu, Taipei, Taiwan. Tel.: +886 2 87923100x18447; fax: +886 2 87923147. E-mail address: [email protected] (J.-D. Lin). 1750-9467/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.rasd.2010.12.010
J.-D. Lin et al. / Research in Autism Spectrum Disorders 5 (2011) 1138–1142
1139
Children with ASD have a social communication disorder with rigid or repetitive behaviors and poor imagination (Brooks, Marshallsay, & Fraser, 2004). Brown, Ouellette-Kuntz, Hunter, and Kelley (2010) found that the autistic child’s adaptive skills and challenging behaviors were important in predicting the extent of the parent’s perceived unmet need. There is a need to tailor care to children with ASD who may find interfaces with healthcare services for any reason extremely stressful, particularly in admission to hospital care (Brooks et al., 2004). Researchers have found that individuals with ASD who use psychiatric hospitals have high clinical needs that are not always well met. Medical staff needs to be trained in the assessment, diagnosis and treatment to provide more appropriate services for them (Lunsky, Gracey, & Bradley, 2009). Studies revealed that many autistic individual often experience a number comorbid medical conditions, but the nature and prevalence of which remain as yet, poorly defined (Bauman, 2010; Lauritsen, Mors, Mortensen, & Ewald, 2002). They also incur elevated medical utilization and costs (Croen, Najjar, Ray, Lotspeich, & Bernal, 2006; Shimabukuro, Grosse, & Rice, 2008), which continually increase the burden in the health care system (Leslie & Martin, 2007). Understanding how to improve the health care access, quality, and outcomes for individual with ASD is extremely complex (Young, Ruble, & McGrew, 2009). For a child with an ASD, hospitalization can be an overwhelming sensory and cognitive experience (Scarpinato et al., 2010). However, little information is known about hospitalization profile and their medical cost in health services of individuals with ASD. Such information is important and provides valuable information in health care decision for this group of people. Therefore, this study aimed to describe the use of hospitalization and medical fee of people with ASD based on population-based National Health Insurance (NHI) claims data in Taiwan. 2. Methods A retrospective analysis was conducted by using an merged database of hospital medical care discharge claims by Taiwan Bureau of National Health Insurances (NHI), and Disability Registration System which administered by Ministry of the Interior in Taiwan. The database was derived from the demographic data of people with ASD and their hospital inpatient care utilization in 2005. The ASD case was ASD entified according to the International Classification of Diseases, 9th revision, Clinical Modified (ICD-9-CM) coding system which has been used in Taiwan NHI diagnosis system. Those ASD cases are ICD code 299, 299.0, 299.00, and 299.01. Data were analyzed by SPSS 18.0 software which the main methods included number, percentage, mean, and Chi-square test to describe research subject admitted to hospital characteristics and inpatient care fee of people with ASD. Logistic regression analyses were used to test the relation of ASD case’s demographic characteristics, inpatient care use and medical fee in people with ASD.
Table 1 Demographic characteristics of people with ASD. Variable Gender (n = 397) Female Male Age (years) (n = 297) 10 11–20 21–30 31–40 41 Severe illness card holder (n = 397) No Yes Low income family (n = 397) No Yes Frequency of inpatient care (n = 397) 2 3–4 5 Days in acute ward (n = 222) 4 5–21 22 Days in chronic ward (n = 223) 82 83–188 189 Days in acute + chronic ward (n = 397) 21 22–128 129
n (%)
Mean SD
70 (17.6) 327 (82.4) 11.3 10.860 253 78 44 12 10
(63.7) (19.6) (11.1) (3.0) (2.5)
102 (25.7) 295 (74.3) 383 (96.5) 14 (3.5) 3.5 2.804 188 (47.4) 90 (22.7) 119 (30.0) 40.4 67.038 76 (34.2) 72 (32.4) 74 (33.3) 159.1 117.4 77 (34.5) 72 (32.3) 74 (33.2) 111.91 117.442 134 (33.8) 131 (33.0) 129 (33.2)
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J.-D. Lin et al. / Research in Autism Spectrum Disorders 5 (2011) 1138–1142
Table 2 Annual inpatient fee among people with ASD. Items
n
Mean (NTD)
Total fee Consultation fee Ward fee Exam/lab test fee Medicine and pharmacy service fee Psychiatric treatment fee
397 207 396 205 259 69
94293.36 8038.43 59965.67 4564.71 9438.44 70591.32
3. Results Table 1 presents the demographic characteristics and hospital admission profile of people with ASD in Taiwan. There were 397 persons with ASD admitted to hospital care within the year of 2005 Taiwan NHI claims. There were 327 (82.4%) male and 70 (17.6%) female patients. The majority of the children were age under 10 years (63.7%) and the mean age of the patients was 11.3 years old. With regard to the household income, 3.5% patients come from low income family in the study respondents. Among those inpatient care users, there were 74.3% cases hold severe illness cards which their medical copayment can partially waive from NHI scheme if medical necessary. Average hospital admission in the respondents was 3.5 annually, there was 47.4% cases used less than twice inpatient cares, 22.7% used 3–4 times, and 30.0% were hospitalized more than five times in the year of 2005. The results also show that the mean of hospital stay was 111.9 days, which staying in acute ward was 40.4 days and in chronic ward was 159.1 days. The annual inpatient fee among people with ASD shown in Table 2, the results revealed that the mean expenditure was 94,293 NTD (1 USD = 30 NTD) in the year of 2005. The medical fee mainly includes ward fee (mean = 59,965 NTD), medicine and pharmacy service fee (mean = 9438 NTD), exam/lab test fee (mean = 4564 NTD) physician consultant fee (mean = 8038 NTD). There were 69 cases used psychiatric service, and the mean of their treatment fee was 70,591 NTD. Table 3 describes the relations of ASD case’s characteristics, inpatient care and medical fees in Chi-square tests. We found that variables of patient’s age, a severe illness card holder, low income family, frequency of inpatient care, hospital stay either in acute ward or chronic ward were significant differences between low (109,900 NTD) and high (>109,900 NTD) groups of inpatient care expenditure. Finally, we use logistic regression model to identify the possible factors which affected the level (low vs. high) of annual inpatient fee in people with ASD. Table 4 shows that factors – age (reference: 12 years; OR = 31.085, 95% CI = 12.772–75.659), hold a serious illness card (reference: no; OR = 4.980, 95% CI = 1.690–14.673), frequency of inpatient care (reference: 3; OR = 7.636, 95% CI = 2.643–22.066), days in acute ward (reference: 9; OR = 3.840, 95%
Table 3 Relation of demographic characteristics, inpatient care and annual inpatient fee in Chi-square tests. Variable
Gender (n = 397) Female Male Age (n = 397) 12 >12 Severe illness care holder (n = 397) No Yes Low income family (n = 397) No Yes Frequency of inpatient care (n = 397) 3 4 Days in acute ward (n = 222) 9 10 Days in chronic ward (n = 223) 126 127 Days in acute + chronic ward (n = 397) 74 75
x2
Annual inpatient fee Low, n (%)
High, n (%)
52 (17.4) 246 (82.6)
18 (18.2) 81 (81.8)
240 (80.5) 58 (19.5)
27 (27.3) 72 (72.7)
95 (31.9) 203 (68.1)
7 (7.1) 92 (92.9)
293 (98.3) 5 (1.7)
90 (90.9) 9 (9.1)
218 (73.2) 80 (26.8)
23 (23.2) 76 (76.8)
108 (66.7) 54 (33.3)
8 (13.3) 52 (86.7)
100 (62.5) 60 (37.5)
12 (19.0) 51 (81.0)
180 (60.4) 118 (39.6)
19 (19.2) 80 (80.8)
p value
0.027
0.868
95.732
<0.001
23.956
<0.001
12.004
0.001
77.640
<0.001
49.918
<0.001
34.139
<0.001
50.483
<0.001
Low and high annual inpatient fee groups were categorized by 75% percentile: low: 109,900 NTD and high: >109,900 NTD.
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Table 4 Logistic regression of annual inpatient fee (low vs. high) in people with ASD. Variables (reference) Constant Age (12 years) Severe illness card holder (No) Frequency of inpatient care (3) Days in acute ward (9) Days in chronic ward (126) Days in acute + chronic ward (74)
b 14.680 3.437 1.605 2.033 1.346 0.782 1.336
Wald
O.R. (95% C.I.)
p-value
81.879 57.344 8.479 14.100 16.056 3.559 6.246
<0.001 31.085 4.980 7.636 3.840 2.185 3.804
<0.001 <0.001 0.004 <0.001 <0.001 0.059 0.012
(12.772–75.659) (1.690–14.673) (2.643–22.066) (1.989–7.416) (0.970–4.922) (1.334–10.846)
CI = 1.989–7.416), and days in acute + chronic wards (reference: 74; OR = 3.804, 95% CI = 1.334–10.846) were more likely to consume more medical care fees than their counterparts. 4. Discussions Our previous study revealed that the reported prevalence of autistic cases significantly increased from 0.93 to 3.96 per 10,000 and the group of mild disability grade was the most increased group of four disability levels in the year of 2000 and 2009 in Taiwan (Lin, Sung, et al., 2011). Although the number of studies published on ASD continues to increase and the most frequently studied topics include genetics, perception and cognition, neurobiology, physiology and nosology (Matson & LoVullo, 2009). There have not been many studies providing information on health access and health utilization of this group of people. The present study describes a general profile of medical care use and medical cost among people with ASD. These results will provide valuable information for health care decision makers to initiate appropriate health policy for this group of people. Our results revealed that people with ASD used more hospital admission (mean = 3.5 annually) than the general population. Those cases who were of a younger age, held a serious illness card. More frequent hospital admissions and longer stays in the hospital resulted in the consumption of more medical cost than their counterparts. Comparing to other studies in the US, individuals with an ASD had average medical expenditures that exceeded those without an ASD by $4110–$6200 per year. On average, medical expenditures for individuals with an ASD were 4.1–6.2 times greater than for those without an ASD (Shimabukuro et al., 2008). Wang and Leslie (2010) found that the mean total health care expenditures per child with ASD were $22,079 in 2000 (in 2003 US dollars), and rose by 3.1% to $22,772 in 2003 in Medicaid beneficiaries. Leslie and Martin (2007) analyzed average health care expenditures for individuals with an ASD increased 20.4% from $4965 per patient in 2000 to $5979 per patient in 2004, even after adjustment for inflation. Autistic children are participating in a wide range of therapies with most individuals using multiple treatments simultaneously (Goin-Kochel, Myers, & Mackintosh, 2007). Over 70% had tried at least one complementary and alternative medicine (CAM) treatment with their child, and about half were currently using one or more CAMs (Christon, Mackintosh, & Myers, 2010). The present study also found that psychiatric treatment was the leading medical cost in hospital admission among people with ASD. Matson and Hess (2011) assessed current prescription practices and concluded that the use of psychotropic medication in general and antipsychotic drugs in particular is at an all time high among children and adults diagnosed with autism. Croen et al. (2006) found that children with ASD experienced nearly 9 times more likely to use psychotherapeutic medications as children without ASD. Fujiwara, Okuyama, and Funahashi (2011) suggested that a national health policy to facilitate a referral system that coordinates hospitals that offer psychiatric services with other settings is needed, to promote the timely provision of child psychiatric services. The present paper provides the evidence-based information of medical care utilization data for decision making to initiate quality of care for people with ASD. As researcher Inglese (2009) suggested, knowing the core medical care features of ASD and realizing a particular individual’s sensitivities will allow health providers to create a supportive healing environment. References Bauman, M. L. (2010). Medical comorbidities in autism: Challenges to diagnosis and treatment. Neurotherapeutics, 7, 320–327. Brooks, R., Marshallsay, M., & Fraser, W. I. (2004). 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