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Insurance type impacts bronchoscopy for foreign body aspiration: An analysis of the Kids’ Inpatient Database
International Journal of Pediatric Otorhinolaryngology 134 (2020) 110023
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Insurance type impacts bronchoscopy for foreign body aspiration: An analysis of the Kids’ Inpatient Database
T
Terral Patela, Clarice S. Clemmensa, David R. Whitea, Marvella E. Fordb, Anne L. Andrewsc, Phayvanh P. Pechaa,∗ a
Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA Department of Public Health Sciences, Medical University of South Carolina College of Health Professions, Charleston, SC, USA c Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA b
A R T I C LE I N FO
A B S T R A C T
This manuscript was presented at the American Society of Pediatric Otolaryngology, Spring Meeting. Austin, TX, May 3, 2019.
Objectives: To ascertain whether insurance type is associated with postoperative adverse effects and hospital length of stay for inpatient airway foreign body removal. Methods: Retrospective analysis of children < 18 years of age that underwent inpatient bronchoscopy with removal of airway foreign body in the national Healthcare Cost and Utilization Project Kid's Inpatient Database (KID). Postoperative outcomes and length of stay were analyzed for racial disparities and insurance type using multivariable logistic regression and negative binomial regression. Models adjusted for race, insurance type, sex, age, and presence of pulmonary risk factors. Results: A total of 5,850 children underwent bronchoscopy for foreign body removal. The median age was 2 (IQR: 4–1) years and 61.6% patients were male. Payer status included Medicaid (38.9%), private insurance (51.5%), self-pay (4.3%) and other (9.6%). The Medicaid cohort had a higher proportion of black (19.1%) and Hispanic patients (34.5%) (P < 0.001). Children covered under Medicaid had higher odds of postoperative complications (odds ratio [OR] 1.216; P = 0.031) and a greater length of stay (OR 1.533; P < 0.001) relative to the private insurance group when adjusting for sex, age, race and presence of pulmonary risk factors. The odds of having a greater length of stay was 33% higher for black (P < 0.001) and 37% higher for Hispanic (P < 0.001) children compared to white children. The average adjusted LOS under Medicaid was 8.37 days compared to 5.46 days for privately insured children. Conclusion: This study demonstrated that a difference in postoperative complications and LOS exist between public and privately insured children for foreign body removal via bronchoscopy. Further studies are warranted to investigate factors that drive these disparities.
Keywords: Foreign body aspiration Bronchoscopy Complications Medicaid Payer Insurance Disparities
1. Introduction Bronchoscopy for foreign body aspiration is generally safe and postoperative events remain an important source of adverse morbidity and even mortality in children [1,2]. According to the Center for Disease Control, foreign body aspiration is the fourth leading cause of unintentional death in children between 1 and 5 years of age. The procedure may lead to inpatient hospitalization for a variety of reasons, including persistent hypoxemia, localized edema, bronchospasm, and pneumonia [3]. Less frequently, reintubation, mechanical ventilation, tracheotomy, pneumothorax, cardiac arrest, hypoxic brain injury, and death further complicates airway foreign body extraction [4,5]. The
economic burden of this clinical entity is estimated to be $41 million in annual inpatient costs [6,7]. Foreign body aspiration often occurs in children younger than three years of age with a male predominance. Younger children are at a higher risk of aspiration given immature dentition, underdeveloped swallowing and coughing mechanisms, and a tendency to explore the environment [3]. The diagnosis of foreign body aspiration can be challenging, particularly when the child presents with minimal symptoms, an unclear history, and normal radiography. Rigid bronchoscopy remains the gold standard for diagnosis and treatment of foreign body aspiration. Prompt diagnosis is essential to avoid perioperative adverse events. Prior studies have focused on clinical predictors of
∗ Corresponding author. Medical University of South Carolina, Department of Otolaryngology, Head and Neck Surgery, 135 Rutledge Avenue, MSC 550, Charleston, SC, 29425, USA. E-mail address: [email protected] (P.P. Pecha).
https://doi.org/10.1016/j.ijporl.2020.110023 Received 13 March 2020; Received in revised form 25 March 2020; Accepted 25 March 2020 Available online 27 March 2020 0165-5876/ © 2020 Elsevier B.V. All rights reserved.
International Journal of Pediatric Otorhinolaryngology 134 (2020) 110023
T. Patel, et al.
cystic fibrosis, interstitial lung disease, anomaly of lung, and other diseases of the lung not otherwise specified.
complications from foreign body extraction [8–11]. However, the impact of demographic determinants such as primary insurance type and race on perioperative outcomes from pediatric bronchoscopy for airway foreign body are lacking. The Health Care and Utilization Project - Kids’ Inpatient Database (KID) is the largest all-payer database of pediatric hospital admissions in the United States and contains weighted information on patient demographics, resource use, and outcomes for pediatric patients [12]. This database is able to provide a large sample size and is therefore well suited to study rare events, such as postoperative complications after airway foreign body extraction. The primary goal of the present study is to analyze the KID to determine whether insurance status influences perioperative outcomes and length of stay for children undergoing airway foreign body removal. The secondary objective was to determine whether other individual demographic characteristics influence outcomes and length of hospital stay after the procedure. We hypothesized that children with public insurance have greater complications and length of stay (LOS) after inpatient bronchoscopy for foreign body aspiration.
2.3. Statistical analysis All analyses were performed with SPSS 24.0 (IBM Corporation, Armonk, NY). Categorical variables were summarized by frequency and percentage. All continuous variables were assessed for normality using the Shapiro-Wilk test and summarized by mean ± standard deviation or median and interquartile range (IQR: 75th and 25th) where appropriate. Comparisons of baseline characteristics and outcomes (categorical variables) were performed using a Fisher's exact test or Chi Square test where appropriate. For continuous variables, an independent t-test was used to compare groups. The final analyses were performed with multivariable logistic regression and negative binomial regression to determine differences in complications and LOS according to demographic characteristics. The adjusted odds ratio (OR) or β and its confidence interval (CI) were obtained from the final model as a measure of the association. A p-value of < 0.05 was considered to indicate a significant difference for all statistical tests.
2. Materials and methods 3. Results 2.1. Data source 3.1. Demographics Data for this project was collected from KID which was developed for the Healthcare Cost and Utilization Project (HCUP) and is sponsored by the Agency for Healthcare Research and Quality (AHRQ). KID is the largest all-payer publicly available pediatric inpatient database in the United States. The database samples inpatient admissions for patients under the age of 21 using administrative data for hospital billing. KID includes data from 44 states and contains roughly 3 million discharges each year unweighted and approximately 7 million when weighted. Complications were identified by the International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes that were separate from the principal diagnosis but were related to the patient's admission. Data are released every three years and the present study extracted data from 1997, 2000, 2003, 2006, 2009, and 2012. Demographic data such as age, sex and race/ethnicity were queried. In the regression analysis, age was categorized into intervals of 1–3, 4–8, 9–13, and 14–18 years. The KID records Hispanic ethnicity along with race in a single variable, thus race/ethnicity groups were categorized as non-Hispanic white, non-Hispanic black, Hispanic, and non-Hispanic other for the regression analysis [12]. Payer type included Medicare, Medicaid, private insurance, self-pay, no charge, and other which includes Worker's Compensation, CHAMPUS (Civilian Health and Medical Program of the Uniformed Services), CHAMPVA (Civilian Health and Medical Program of the Department of Veterans Affairs), Title V, and other government programs. This study was exempt from Institutional Review Board approval from the Office of Research Integrity at the Medical University of South Carolina.
A weighted total of 5,850 patients that underwent bronchoscopy for removal of airway foreign body were identified. Demographic information is reported in Table 1. The largest racial/ethnic groups included 2,601 (44.5%) white, 1,006 (17.2%) Hispanic, and 582 (9.9%) black patients in the cohort. The median age was 2 (IQR: 4–1) years and 61.6% patients were male. Approximately half (51.5%) of the children had private insurance and 38.9% were insured by Medicaid. Table 2 outlines the relationship between insurance type and race. A larger proportion of black and Hispanic children were insured by Medicaid (P < 0.001), whereas the majority of white patients had private insurance (P < 0.001). 3.2. Complications and length of stay An unadjusted univariate analysis of insurance type is shown in Table 3. For the purposes of statistical analysis, patients with either private insurance or Medicaid were included in the analysis. Medicaidinsured children had higher rates of overall complications (P = 0.006) and, more specifically, had higher rates of pneumothorax (P = 0.001), sepsis (P = 0.034), and mechanical ventilation > 96 h (P = 0.023). The median LOS for Medicaid-insured children was one day longer than privately-insured children (P < 0.001). The overall complication rate was 15.1% with a mortality rate of 1.5%. The most prevalent postoperative complication was pneumonia (8.1%) and 8.6% of patients had preoperative pulmonary risk factors.
2.2. Measured outcomes
3.3. Multivariate analysis
Six years of data from the KID were weighted for discharges according to the AHRQ protocol and selected for admissions of patients less than 18 years of age containing an ICD-9-CM procedure code for bronchoscopy with removal of airway foreign body (98.15). Patient demographics and payer information, including type of insurance, were collected. Patients with unknown race or payer information were excluded from the final analysis. Outcome measures were LOS, which was recorded in days in KID, and postoperative complications. Postoperative complications related to bronchoscopy included tracheostomy, mechanical ventilation, extracorporeal membrane oxygenation (ECMO), thoracotomy, significant hemorrhage, pneumonia, pneumothorax, sepsis, pneumomediastinum, and in-hospital death. Pulmonary risk factors for patients were collected and included asthma,
Subsequent regression analyses were performed and adjusted for sex, age, race, insurance, and preoperative pulmonary risk factors (Tables 4 and 5). The presence of pulmonary risk factors was predictive of greater LOS (OR: 1.587, P < 0.001), but not complications (P = 0.058). Medicaid-insured children had 22% higher odds of experiencing any postoperative complication compared to privately insured children (OR: 1.216, P = 0.031). Race was not found to be a predictor of postoperative complications in the logistic regression analysis. Black and Hispanic patients were 33% (OR: 1.327, P < 0.001) and 37% (OR: 1.368, P < 0.001) more likely to have greater LOS, respectively. The average adjusted LOS were 5.86, 7.77, and 8.01 days for white, black, and Hispanic children, respectively. Patients insured with Medicaid were 53% more likely to have greater 2
International Journal of Pediatric Otorhinolaryngology 134 (2020) 110023
T. Patel, et al.
Table 1 Characteristics of patients undergoing inpatient bronchoscopy for foreign body aspiration (N = 5,850).
Age (year)
Table 3 Univariate analysis of complications and length of stay according to insurance type.
N/Median
%
Insurance Type
2.0
IQR: 4.0–1.0
Medicaid
Private
N
%
N
%
Complications Death Pneumonia PneumothoraxŦ SepsisŦ Tracheostomy Mechanical Ventilation < 96 h Mechanical Ventilation > 96 hŦ ECMO Pneumomediastinum Overall complicationsŦ
39 185 46 4 2 101 89 12 21 376
1.7 8.1 2.0 0.2 0.1 4.4 3.9 0.5 0.9 16.5
48 241 28 0 3 112 84 14 18 416
1.6 8.0 0.9 0.0 0.1 3.7 2.8 0.5 0.6 13.8
0.734 0.861 0.001 0.034 1.000 0.186 0.023 0.747 0.171 0.006
LOS (days)Ŧ
2
IQR:4-1
1
IQR:2-1
< 0.001
Sex Female
2189
37.4
Race White Black Hispanic Asian or Pacific Islander Native American Other N/A
2601 582 1006 93 54 304 1209
44.5 9.9 17.2 1.6 0.9 5.2 20.7
Payer type Medicare Medicaid Private insurance Self-pay No Charge Other
7 2276 3014 252 29 258
0.1 38.9 51.5 4.3 0.5 4.4
Preoperative Pulmonary Risk Factors
505
8.6
Complications
883
15.1
Death Pneumonia Pneumothorax Sepsis Tracheostomy Mechanical Ventilation < 96 h Mechanical Ventilation > 96 h ECMO Thoracotomy Hemorrhage Pneumomediastinum
87 474 80 4 4 242 183 30 1 0 53
1.5 8.1 1.4 0.1 0.1 4.1 3.1 0.5 0.0 0.0 0.9
LOS, days
2
IQR: 3-1
P-value
Abbreviations: h, hours; ECMO, extracorporeal membrane oxygenation; LOS, length of stay. Ŧ P < 0.05. Table 4 Logistical model of postoperative complications among inpatient pediatric airway foreign body extraction patients stratified by demographics and risk factors.a Race
OR
95% CI
P-value
White Black Hispanic Other
Reference 1.164 0.999 0.872
0.890, 1.524 0.796, 1.254 0.637, 1.193
0.268 0.957 0.385
Reference 1.216
1.010, 1.464
0.031
Reference 0.863
0.721, 1.033
0.108
Reference 0.952 0.924 3.787
0.741, 1.222 0.679, 1.259 2.876, 4.986
0.699 0.618 < 0.001
Reference 1.31
0.991, 1.731
0.058
Payer type Private Medicaid Sex Male Female
Abbreviations: h, hours; ECMO, extracorporeal membrane oxygenation; LOS, length of stay.
Age
Table 2 Frequency of patient race and ethnicity by primary insurance type. Race
White Black Hispanic Other
Medicaid
Private Insurance
N
%
N
%
668 349 630 179
36.6 19.1 34.5 9.8
1705 159 291 227
71.6 6.7 12.2 9.5
< 3 years 4–8 years 9–13 years 14–18 years
P-value
Pulmonary Risk Factor < 0.001 < 0.001 < 0.001 0.65
No risk factors Risk factors present
a Multivariable logistic regression adjusting for race, insurance type, sex, age, and presence of pulmonary risk factors.
LOS compared to privately insured children (OR: 1.533, P < 0.001). The average regression-adjusted LOS for Medicaid children were 8.37 days compared to 5.46 days for privately insured children. Furthermore, older age was a predictor of greater LOS and patients in the 14–18 age groups were significantly more likely to experience any complication (OR: 3.787, P < 0.001).
insured by Medicaid were more likely to have any complication compared to privately insured patients when adjusting for sex, age, race and preoperative pulmonary risk factors. Black and Hispanic patients were covered by Medicaid more frequently than private insurance compared to white children. Patients insured with Medicaid were 53% more likely to have a greater LOS than privately insured children, with an average difference of nearly 3 days. This LOS is longer than might be expected, however the skewed distribution of LOS suggests that higher complexity cases are potentially driving this finding. The likelihood of greater LOS was also higher for black and Hispanic patients compared to white patients. LOS is certainly multifactorial and based upon access
4. Discussion In this large sample of inpatient pediatric airway foreign body extraction patients utilizing the 1997 to 2012 KID, we found that the overall rate of postoperative complications was 15.1%. Children 3
International Journal of Pediatric Otorhinolaryngology 134 (2020) 110023
T. Patel, et al.
et al. analyzed outcomes from one year of data in the KID but the report included procedures for esophageal foreign body and tracheotomy [22]. Another study of the KID assessed anatomic location of foreign body aspiration as a predictor of morbidity in which only half of the cohort underwent bronchoscopy [21]. A recent analysis of the American College of Surgeons National Surgical Quality Improvement Program–Pediatric database (ACS NSQIP-P) identified factors associated with 30-day adverse events, but did not capture information based on insurance status [1]. In the present study, we focus on the impact of payer type on outcomes as a potential barrier to access to care for children that had bronchoscopy for foreign body extraction. Our univariate analysis demonstrated that Medicaid-insured children had a higher frequency of pneumothorax, sepsis, and mechanical ventilation for greater than 96 h compared to patients with private insurance. Compared to other postoperative complications, pneumothorax secondary to foreign body aspiration is rare [24]. Delayed presentation often increases the difficulty of bronchoscopy and extraction of the foreign body when edema and granulation tissue are present. Signs and symptoms typical in delayed presentation include persistent cough, wheezing, pneumonia, and longterm pulmonary complications [4]. Up to 20% of children who had a missed diagnosis of foreign body aspiration are incorrectly treated for more than a month [28]. One study that defined delay in diagnosis as more than a 24 h interval after aspiration found that reasons for delayed diagnosis were due to the physician (17.7%), parents (15.5%), and negative history (12.5%) [2]. Causes for delays in airway foreign body diagnosis are certainly multifactorial and are contingent on interactions at the caregiver, provider, and healthcare systems level. One study reported that preschool children with airway and esophageal foreign bodies were more likely to lack private health insurance and theorized that high risk social situations and caretaker education are risk factors for death given that the children were fed age-inappropriate food [29]. Bittencourt et al. reported an association between the number of health services sought until definitive diagnosis with late removal of the airway foreign body [30], suggesting that providers must also have an appropriate suspicion for foreign body aspiration. The results from the present study suggest that primary insurance status may be an important determinant of access to care for children undergoing bronchoscopy for foreign body aspiration and demonstrated that Medicaid insurance was associated with increased postoperative complications and longer hospitalization. The strengths of the study include the large sample size and professional coding by the AHRQ in the KID following airway foreign body extraction. We analyzed a nationally representative administrative database in a wellpowered study that incorporated diverse geographic regions and practice patterns. We are limited by the construct of the database, which is de-identified and therefore does not contain individual patient-level information such as type of foreign body and time interval from aspiration to bronchoscopy. The quality of the data relies on accurate coding by providers and the use of ICD-9-CM codes, which are limited by missing data. For example, 20% of the cohort lacked racial/ethnic identifiers and so we may not have detected a difference in outcomes between race/ethnicity. The KID includes only inpatient claims, thus children that underwent 23-h observation or were readmitted after discharge were not included in the analysis. The KID is the largest all payer publicly available pediatric inpatient database in the US, and thus does not include non-pediatric and rural hospitals where children with concern for foreign body aspiration can present. Importantly, we could not account for operative time or whether a case was emergent, urgent or elective based on the availability of the dataset, and were not able to study whether underinsured children more commonly underwent nonelective procedures. In addition, within the privately insured group, we could not determine the level of insurance coverage, such as a highdeductible health plans, which may impact parental decision-making
Table 5 Predictors of length of stay among inpatient pediatric airway foreign body extraction patients.a. Race
OR
95% CI
P-value
White Black Hispanic Other
Reference 1.327 1.368 0.978
1.188, 1.484 1.246, 1.503 0.864, 1.109
< 0.001 < 0.001 0.733
Reference 1.533
1.421, 1.655
< 0.001
Reference 1.067
0.992, 1.147
0.083
Reference 1.190 1.247 3.383
1.079, 1.313 1.107, 1.405 2.940, 3.892
0.001 < 0.001 < 0.001
Reference 1.587
1.409, 1.788
< 0.001
Payer type Private Insurance Medicaid Sex Male Female Age < 3 years 4–8 years 9–13 years 14–18 years Pulmonary Risk Factor No risk factors Risk factors present a
Negative binomial regression adjusting for race, payment methods, sex, age, and presence of pulmonary risk factors.
to primary care, quality of the treating physicians, and parental perception of sometimes vague symptoms such as fever, cough or a choking episode. Our findings suggest older age and presence of pulmonary risk factors were also predictive of greater LOS. Prior pulmonary risk factors such as asthma may mask symptoms of an airway foreign body leading to a misdiagnosis and may add to the severity of those cases [1,13]. Altogether, these findings indicate that postoperative adverse events following bronchoscopy for airway foreign body are infrequent but disproportionately affect patients insured with Medicaid. There is a growing body of literature detailing inequities in access to pediatric surgical care based on type of insurance, particularly between the public and private sector [14,15]. Studies have demonstrated differences for Medicaid-insured children compared to commercially insured children in areas such as prenatal care, postpartum care, childhood immunizations, well-child visits, and pediatric surgical services [14,16–19]. When compared to commercially insured children, Medicaid-insured children have been seen to score lower on multiple performance indicators of healthcare quality, including access to physicians [16]. A survey demonstrated that 97% of otolaryngologists in Southern California would provide consultation to a child with commercial insurance but only 27% would provide the same service for children with public coverage [20]. Insurance type has been reported to affect multiple pediatric otolaryngology conditions including hearing health, sleep disordered breathing, and rhinosinusitis. However, insurance type has not been studied in bronchoscopy for foreign body aspiration [15]. The clinical profile of the patients in this analysis are consistent with characteristics of children most at risk for foreign body aspiration, which typically consist of younger males [3]. The overall complication rate in this study revealed a morbidity rate of 15.1% and mortality rate of 1.5%, which reflect previously reported rates of 10–20% and 0.3–0.42%, respectively [1,4,5,21]. The vast majority of reports on foreign body aspiration come from single institutions and focus on clinical predictors of outcomes such as radiographs, type of foreign body, anatomic location, and duration of procedure [1,21–23]. Shah 4
International Journal of Pediatric Otorhinolaryngology 134 (2020) 110023
T. Patel, et al.
and desire to pursue surgical care [31]. [5] [6] [7] [8]
5. Conclusion Significant differences in postoperative complications and LOS exist between public and private insurance for inpatient foreign body removal. Black and Hispanic patients were more frequently insured with Medicaid and significantly more likely to have a prolonged LOS. Primary payer status and patient demographics may be useful in preoperative risk stratification. Further studies are warranted to investigate factors that drive these disparities.
[9] [10] [11] [12] [13]
Financial disclosure
[14] [15]
None.
[16]
Declaration of competing interest [17]
None.
[18] [19]
Acknowledgments
[20]
We would like to acknowledge and thank Dr. Annie Simpson (Medical University of South Carolina) for her contributions to the statistical analyses of the data.
[21] [22] [23]
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Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Insurance type impacts bronchoscopy for foreign body aspiration: An analysis of the Kids’ Inpatient Database
T
Terral Patela, Clarice S. Clemmensa, David R. Whitea, Marvella E. Fordb, Anne L. Andrewsc, Phayvanh P. Pechaa,∗ a
Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA Department of Public Health Sciences, Medical University of South Carolina College of Health Professions, Charleston, SC, USA c Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA b
A R T I C LE I N FO
A B S T R A C T
This manuscript was presented at the American Society of Pediatric Otolaryngology, Spring Meeting. Austin, TX, May 3, 2019.
Objectives: To ascertain whether insurance type is associated with postoperative adverse effects and hospital length of stay for inpatient airway foreign body removal. Methods: Retrospective analysis of children < 18 years of age that underwent inpatient bronchoscopy with removal of airway foreign body in the national Healthcare Cost and Utilization Project Kid's Inpatient Database (KID). Postoperative outcomes and length of stay were analyzed for racial disparities and insurance type using multivariable logistic regression and negative binomial regression. Models adjusted for race, insurance type, sex, age, and presence of pulmonary risk factors. Results: A total of 5,850 children underwent bronchoscopy for foreign body removal. The median age was 2 (IQR: 4–1) years and 61.6% patients were male. Payer status included Medicaid (38.9%), private insurance (51.5%), self-pay (4.3%) and other (9.6%). The Medicaid cohort had a higher proportion of black (19.1%) and Hispanic patients (34.5%) (P < 0.001). Children covered under Medicaid had higher odds of postoperative complications (odds ratio [OR] 1.216; P = 0.031) and a greater length of stay (OR 1.533; P < 0.001) relative to the private insurance group when adjusting for sex, age, race and presence of pulmonary risk factors. The odds of having a greater length of stay was 33% higher for black (P < 0.001) and 37% higher for Hispanic (P < 0.001) children compared to white children. The average adjusted LOS under Medicaid was 8.37 days compared to 5.46 days for privately insured children. Conclusion: This study demonstrated that a difference in postoperative complications and LOS exist between public and privately insured children for foreign body removal via bronchoscopy. Further studies are warranted to investigate factors that drive these disparities.
Keywords: Foreign body aspiration Bronchoscopy Complications Medicaid Payer Insurance Disparities
1. Introduction Bronchoscopy for foreign body aspiration is generally safe and postoperative events remain an important source of adverse morbidity and even mortality in children [1,2]. According to the Center for Disease Control, foreign body aspiration is the fourth leading cause of unintentional death in children between 1 and 5 years of age. The procedure may lead to inpatient hospitalization for a variety of reasons, including persistent hypoxemia, localized edema, bronchospasm, and pneumonia [3]. Less frequently, reintubation, mechanical ventilation, tracheotomy, pneumothorax, cardiac arrest, hypoxic brain injury, and death further complicates airway foreign body extraction [4,5]. The
economic burden of this clinical entity is estimated to be $41 million in annual inpatient costs [6,7]. Foreign body aspiration often occurs in children younger than three years of age with a male predominance. Younger children are at a higher risk of aspiration given immature dentition, underdeveloped swallowing and coughing mechanisms, and a tendency to explore the environment [3]. The diagnosis of foreign body aspiration can be challenging, particularly when the child presents with minimal symptoms, an unclear history, and normal radiography. Rigid bronchoscopy remains the gold standard for diagnosis and treatment of foreign body aspiration. Prompt diagnosis is essential to avoid perioperative adverse events. Prior studies have focused on clinical predictors of
∗ Corresponding author. Medical University of South Carolina, Department of Otolaryngology, Head and Neck Surgery, 135 Rutledge Avenue, MSC 550, Charleston, SC, 29425, USA. E-mail address: [email protected] (P.P. Pecha).
https://doi.org/10.1016/j.ijporl.2020.110023 Received 13 March 2020; Received in revised form 25 March 2020; Accepted 25 March 2020 Available online 27 March 2020 0165-5876/ © 2020 Elsevier B.V. All rights reserved.
International Journal of Pediatric Otorhinolaryngology 134 (2020) 110023
T. Patel, et al.
cystic fibrosis, interstitial lung disease, anomaly of lung, and other diseases of the lung not otherwise specified.
complications from foreign body extraction [8–11]. However, the impact of demographic determinants such as primary insurance type and race on perioperative outcomes from pediatric bronchoscopy for airway foreign body are lacking. The Health Care and Utilization Project - Kids’ Inpatient Database (KID) is the largest all-payer database of pediatric hospital admissions in the United States and contains weighted information on patient demographics, resource use, and outcomes for pediatric patients [12]. This database is able to provide a large sample size and is therefore well suited to study rare events, such as postoperative complications after airway foreign body extraction. The primary goal of the present study is to analyze the KID to determine whether insurance status influences perioperative outcomes and length of stay for children undergoing airway foreign body removal. The secondary objective was to determine whether other individual demographic characteristics influence outcomes and length of hospital stay after the procedure. We hypothesized that children with public insurance have greater complications and length of stay (LOS) after inpatient bronchoscopy for foreign body aspiration.
2.3. Statistical analysis All analyses were performed with SPSS 24.0 (IBM Corporation, Armonk, NY). Categorical variables were summarized by frequency and percentage. All continuous variables were assessed for normality using the Shapiro-Wilk test and summarized by mean ± standard deviation or median and interquartile range (IQR: 75th and 25th) where appropriate. Comparisons of baseline characteristics and outcomes (categorical variables) were performed using a Fisher's exact test or Chi Square test where appropriate. For continuous variables, an independent t-test was used to compare groups. The final analyses were performed with multivariable logistic regression and negative binomial regression to determine differences in complications and LOS according to demographic characteristics. The adjusted odds ratio (OR) or β and its confidence interval (CI) were obtained from the final model as a measure of the association. A p-value of < 0.05 was considered to indicate a significant difference for all statistical tests.
2. Materials and methods 3. Results 2.1. Data source 3.1. Demographics Data for this project was collected from KID which was developed for the Healthcare Cost and Utilization Project (HCUP) and is sponsored by the Agency for Healthcare Research and Quality (AHRQ). KID is the largest all-payer publicly available pediatric inpatient database in the United States. The database samples inpatient admissions for patients under the age of 21 using administrative data for hospital billing. KID includes data from 44 states and contains roughly 3 million discharges each year unweighted and approximately 7 million when weighted. Complications were identified by the International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes that were separate from the principal diagnosis but were related to the patient's admission. Data are released every three years and the present study extracted data from 1997, 2000, 2003, 2006, 2009, and 2012. Demographic data such as age, sex and race/ethnicity were queried. In the regression analysis, age was categorized into intervals of 1–3, 4–8, 9–13, and 14–18 years. The KID records Hispanic ethnicity along with race in a single variable, thus race/ethnicity groups were categorized as non-Hispanic white, non-Hispanic black, Hispanic, and non-Hispanic other for the regression analysis [12]. Payer type included Medicare, Medicaid, private insurance, self-pay, no charge, and other which includes Worker's Compensation, CHAMPUS (Civilian Health and Medical Program of the Uniformed Services), CHAMPVA (Civilian Health and Medical Program of the Department of Veterans Affairs), Title V, and other government programs. This study was exempt from Institutional Review Board approval from the Office of Research Integrity at the Medical University of South Carolina.
A weighted total of 5,850 patients that underwent bronchoscopy for removal of airway foreign body were identified. Demographic information is reported in Table 1. The largest racial/ethnic groups included 2,601 (44.5%) white, 1,006 (17.2%) Hispanic, and 582 (9.9%) black patients in the cohort. The median age was 2 (IQR: 4–1) years and 61.6% patients were male. Approximately half (51.5%) of the children had private insurance and 38.9% were insured by Medicaid. Table 2 outlines the relationship between insurance type and race. A larger proportion of black and Hispanic children were insured by Medicaid (P < 0.001), whereas the majority of white patients had private insurance (P < 0.001). 3.2. Complications and length of stay An unadjusted univariate analysis of insurance type is shown in Table 3. For the purposes of statistical analysis, patients with either private insurance or Medicaid were included in the analysis. Medicaidinsured children had higher rates of overall complications (P = 0.006) and, more specifically, had higher rates of pneumothorax (P = 0.001), sepsis (P = 0.034), and mechanical ventilation > 96 h (P = 0.023). The median LOS for Medicaid-insured children was one day longer than privately-insured children (P < 0.001). The overall complication rate was 15.1% with a mortality rate of 1.5%. The most prevalent postoperative complication was pneumonia (8.1%) and 8.6% of patients had preoperative pulmonary risk factors.
2.2. Measured outcomes
3.3. Multivariate analysis
Six years of data from the KID were weighted for discharges according to the AHRQ protocol and selected for admissions of patients less than 18 years of age containing an ICD-9-CM procedure code for bronchoscopy with removal of airway foreign body (98.15). Patient demographics and payer information, including type of insurance, were collected. Patients with unknown race or payer information were excluded from the final analysis. Outcome measures were LOS, which was recorded in days in KID, and postoperative complications. Postoperative complications related to bronchoscopy included tracheostomy, mechanical ventilation, extracorporeal membrane oxygenation (ECMO), thoracotomy, significant hemorrhage, pneumonia, pneumothorax, sepsis, pneumomediastinum, and in-hospital death. Pulmonary risk factors for patients were collected and included asthma,
Subsequent regression analyses were performed and adjusted for sex, age, race, insurance, and preoperative pulmonary risk factors (Tables 4 and 5). The presence of pulmonary risk factors was predictive of greater LOS (OR: 1.587, P < 0.001), but not complications (P = 0.058). Medicaid-insured children had 22% higher odds of experiencing any postoperative complication compared to privately insured children (OR: 1.216, P = 0.031). Race was not found to be a predictor of postoperative complications in the logistic regression analysis. Black and Hispanic patients were 33% (OR: 1.327, P < 0.001) and 37% (OR: 1.368, P < 0.001) more likely to have greater LOS, respectively. The average adjusted LOS were 5.86, 7.77, and 8.01 days for white, black, and Hispanic children, respectively. Patients insured with Medicaid were 53% more likely to have greater 2
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Table 1 Characteristics of patients undergoing inpatient bronchoscopy for foreign body aspiration (N = 5,850).
Age (year)
Table 3 Univariate analysis of complications and length of stay according to insurance type.
N/Median
%
Insurance Type
2.0
IQR: 4.0–1.0
Medicaid
Private
N
%
N
%
Complications Death Pneumonia PneumothoraxŦ SepsisŦ Tracheostomy Mechanical Ventilation < 96 h Mechanical Ventilation > 96 hŦ ECMO Pneumomediastinum Overall complicationsŦ
39 185 46 4 2 101 89 12 21 376
1.7 8.1 2.0 0.2 0.1 4.4 3.9 0.5 0.9 16.5
48 241 28 0 3 112 84 14 18 416
1.6 8.0 0.9 0.0 0.1 3.7 2.8 0.5 0.6 13.8
0.734 0.861 0.001 0.034 1.000 0.186 0.023 0.747 0.171 0.006
LOS (days)Ŧ
2
IQR:4-1
1
IQR:2-1
< 0.001
Sex Female
2189
37.4
Race White Black Hispanic Asian or Pacific Islander Native American Other N/A
2601 582 1006 93 54 304 1209
44.5 9.9 17.2 1.6 0.9 5.2 20.7
Payer type Medicare Medicaid Private insurance Self-pay No Charge Other
7 2276 3014 252 29 258
0.1 38.9 51.5 4.3 0.5 4.4
Preoperative Pulmonary Risk Factors
505
8.6
Complications
883
15.1
Death Pneumonia Pneumothorax Sepsis Tracheostomy Mechanical Ventilation < 96 h Mechanical Ventilation > 96 h ECMO Thoracotomy Hemorrhage Pneumomediastinum
87 474 80 4 4 242 183 30 1 0 53
1.5 8.1 1.4 0.1 0.1 4.1 3.1 0.5 0.0 0.0 0.9
LOS, days
2
IQR: 3-1
P-value
Abbreviations: h, hours; ECMO, extracorporeal membrane oxygenation; LOS, length of stay. Ŧ P < 0.05. Table 4 Logistical model of postoperative complications among inpatient pediatric airway foreign body extraction patients stratified by demographics and risk factors.a Race
OR
95% CI
P-value
White Black Hispanic Other
Reference 1.164 0.999 0.872
0.890, 1.524 0.796, 1.254 0.637, 1.193
0.268 0.957 0.385
Reference 1.216
1.010, 1.464
0.031
Reference 0.863
0.721, 1.033
0.108
Reference 0.952 0.924 3.787
0.741, 1.222 0.679, 1.259 2.876, 4.986
0.699 0.618 < 0.001
Reference 1.31
0.991, 1.731
0.058
Payer type Private Medicaid Sex Male Female
Abbreviations: h, hours; ECMO, extracorporeal membrane oxygenation; LOS, length of stay.
Age
Table 2 Frequency of patient race and ethnicity by primary insurance type. Race
White Black Hispanic Other
Medicaid
Private Insurance
N
%
N
%
668 349 630 179
36.6 19.1 34.5 9.8
1705 159 291 227
71.6 6.7 12.2 9.5
< 3 years 4–8 years 9–13 years 14–18 years
P-value
Pulmonary Risk Factor < 0.001 < 0.001 < 0.001 0.65
No risk factors Risk factors present
a Multivariable logistic regression adjusting for race, insurance type, sex, age, and presence of pulmonary risk factors.
LOS compared to privately insured children (OR: 1.533, P < 0.001). The average regression-adjusted LOS for Medicaid children were 8.37 days compared to 5.46 days for privately insured children. Furthermore, older age was a predictor of greater LOS and patients in the 14–18 age groups were significantly more likely to experience any complication (OR: 3.787, P < 0.001).
insured by Medicaid were more likely to have any complication compared to privately insured patients when adjusting for sex, age, race and preoperative pulmonary risk factors. Black and Hispanic patients were covered by Medicaid more frequently than private insurance compared to white children. Patients insured with Medicaid were 53% more likely to have a greater LOS than privately insured children, with an average difference of nearly 3 days. This LOS is longer than might be expected, however the skewed distribution of LOS suggests that higher complexity cases are potentially driving this finding. The likelihood of greater LOS was also higher for black and Hispanic patients compared to white patients. LOS is certainly multifactorial and based upon access
4. Discussion In this large sample of inpatient pediatric airway foreign body extraction patients utilizing the 1997 to 2012 KID, we found that the overall rate of postoperative complications was 15.1%. Children 3
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et al. analyzed outcomes from one year of data in the KID but the report included procedures for esophageal foreign body and tracheotomy [22]. Another study of the KID assessed anatomic location of foreign body aspiration as a predictor of morbidity in which only half of the cohort underwent bronchoscopy [21]. A recent analysis of the American College of Surgeons National Surgical Quality Improvement Program–Pediatric database (ACS NSQIP-P) identified factors associated with 30-day adverse events, but did not capture information based on insurance status [1]. In the present study, we focus on the impact of payer type on outcomes as a potential barrier to access to care for children that had bronchoscopy for foreign body extraction. Our univariate analysis demonstrated that Medicaid-insured children had a higher frequency of pneumothorax, sepsis, and mechanical ventilation for greater than 96 h compared to patients with private insurance. Compared to other postoperative complications, pneumothorax secondary to foreign body aspiration is rare [24]. Delayed presentation often increases the difficulty of bronchoscopy and extraction of the foreign body when edema and granulation tissue are present. Signs and symptoms typical in delayed presentation include persistent cough, wheezing, pneumonia, and longterm pulmonary complications [4]. Up to 20% of children who had a missed diagnosis of foreign body aspiration are incorrectly treated for more than a month [28]. One study that defined delay in diagnosis as more than a 24 h interval after aspiration found that reasons for delayed diagnosis were due to the physician (17.7%), parents (15.5%), and negative history (12.5%) [2]. Causes for delays in airway foreign body diagnosis are certainly multifactorial and are contingent on interactions at the caregiver, provider, and healthcare systems level. One study reported that preschool children with airway and esophageal foreign bodies were more likely to lack private health insurance and theorized that high risk social situations and caretaker education are risk factors for death given that the children were fed age-inappropriate food [29]. Bittencourt et al. reported an association between the number of health services sought until definitive diagnosis with late removal of the airway foreign body [30], suggesting that providers must also have an appropriate suspicion for foreign body aspiration. The results from the present study suggest that primary insurance status may be an important determinant of access to care for children undergoing bronchoscopy for foreign body aspiration and demonstrated that Medicaid insurance was associated with increased postoperative complications and longer hospitalization. The strengths of the study include the large sample size and professional coding by the AHRQ in the KID following airway foreign body extraction. We analyzed a nationally representative administrative database in a wellpowered study that incorporated diverse geographic regions and practice patterns. We are limited by the construct of the database, which is de-identified and therefore does not contain individual patient-level information such as type of foreign body and time interval from aspiration to bronchoscopy. The quality of the data relies on accurate coding by providers and the use of ICD-9-CM codes, which are limited by missing data. For example, 20% of the cohort lacked racial/ethnic identifiers and so we may not have detected a difference in outcomes between race/ethnicity. The KID includes only inpatient claims, thus children that underwent 23-h observation or were readmitted after discharge were not included in the analysis. The KID is the largest all payer publicly available pediatric inpatient database in the US, and thus does not include non-pediatric and rural hospitals where children with concern for foreign body aspiration can present. Importantly, we could not account for operative time or whether a case was emergent, urgent or elective based on the availability of the dataset, and were not able to study whether underinsured children more commonly underwent nonelective procedures. In addition, within the privately insured group, we could not determine the level of insurance coverage, such as a highdeductible health plans, which may impact parental decision-making
Table 5 Predictors of length of stay among inpatient pediatric airway foreign body extraction patients.a. Race
OR
95% CI
P-value
White Black Hispanic Other
Reference 1.327 1.368 0.978
1.188, 1.484 1.246, 1.503 0.864, 1.109
< 0.001 < 0.001 0.733
Reference 1.533
1.421, 1.655
< 0.001
Reference 1.067
0.992, 1.147
0.083
Reference 1.190 1.247 3.383
1.079, 1.313 1.107, 1.405 2.940, 3.892
0.001 < 0.001 < 0.001
Reference 1.587
1.409, 1.788
< 0.001
Payer type Private Insurance Medicaid Sex Male Female Age < 3 years 4–8 years 9–13 years 14–18 years Pulmonary Risk Factor No risk factors Risk factors present a
Negative binomial regression adjusting for race, payment methods, sex, age, and presence of pulmonary risk factors.
to primary care, quality of the treating physicians, and parental perception of sometimes vague symptoms such as fever, cough or a choking episode. Our findings suggest older age and presence of pulmonary risk factors were also predictive of greater LOS. Prior pulmonary risk factors such as asthma may mask symptoms of an airway foreign body leading to a misdiagnosis and may add to the severity of those cases [1,13]. Altogether, these findings indicate that postoperative adverse events following bronchoscopy for airway foreign body are infrequent but disproportionately affect patients insured with Medicaid. There is a growing body of literature detailing inequities in access to pediatric surgical care based on type of insurance, particularly between the public and private sector [14,15]. Studies have demonstrated differences for Medicaid-insured children compared to commercially insured children in areas such as prenatal care, postpartum care, childhood immunizations, well-child visits, and pediatric surgical services [14,16–19]. When compared to commercially insured children, Medicaid-insured children have been seen to score lower on multiple performance indicators of healthcare quality, including access to physicians [16]. A survey demonstrated that 97% of otolaryngologists in Southern California would provide consultation to a child with commercial insurance but only 27% would provide the same service for children with public coverage [20]. Insurance type has been reported to affect multiple pediatric otolaryngology conditions including hearing health, sleep disordered breathing, and rhinosinusitis. However, insurance type has not been studied in bronchoscopy for foreign body aspiration [15]. The clinical profile of the patients in this analysis are consistent with characteristics of children most at risk for foreign body aspiration, which typically consist of younger males [3]. The overall complication rate in this study revealed a morbidity rate of 15.1% and mortality rate of 1.5%, which reflect previously reported rates of 10–20% and 0.3–0.42%, respectively [1,4,5,21]. The vast majority of reports on foreign body aspiration come from single institutions and focus on clinical predictors of outcomes such as radiographs, type of foreign body, anatomic location, and duration of procedure [1,21–23]. Shah 4
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and desire to pursue surgical care [31]. [5] [6] [7] [8]
5. Conclusion Significant differences in postoperative complications and LOS exist between public and private insurance for inpatient foreign body removal. Black and Hispanic patients were more frequently insured with Medicaid and significantly more likely to have a prolonged LOS. Primary payer status and patient demographics may be useful in preoperative risk stratification. Further studies are warranted to investigate factors that drive these disparities.
[9] [10] [11] [12] [13]
Financial disclosure
[14] [15]
None.
[16]
Declaration of competing interest [17]
None.
[18] [19]
Acknowledgments
[20]
We would like to acknowledge and thank Dr. Annie Simpson (Medical University of South Carolina) for her contributions to the statistical analyses of the data.
[21] [22] [23]
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