Comparing the Utilization of Health Care Resources in Children with ALL and AML Based on Geographic Location: A Retrospective Analysis Utilizing the PHIS Database

Introduction: Geographic barriers play a major role in access to health care and can increase health care utilization, especially in the Pediatric cancer patients where leukemia and treatment related complications are life threatening if not promptly managed.   

Objective: To assess health care utilization and costs in the pediatric ALL and AML population based on geographic distance from their primary cancer center based on the hypothesis that those living further away would incur greater cost due to delays in seeking and/or receiving care. 

Methods: To study this, we analyzed data from the Pediatric Health Information System (PHIS) database, which collects information for inpatient resource utilization at 45 children’s hospitals in the USA.  Data from patient’s ≤ 21 years of age with the diagnosis of ALL or AML by ICD-9 code between the first quarter 2010 and the third quarter 2013 were used.  The total number of hospitalizations and resources utilized and billed were measured 1 year following the index visit for ALL and 6 months for AML.  Data collected were total cost / day, length of stay (LOS), and prevalence of ICU, TPN, and ventilator use.  Stratified data depending on chemotherapy vs. non-chemotherapy stays were compared between children living <60 vs. >60 miles from the PHIS hospital using chi-square and Wilcoxon rank-sum statistics (Tables A & B).

Results:  Hospital admissions for chemotherapy (12,884) and non-chemotherapy (13,842) were recorded in the ALL group.  Among chemotherapy admissions, no statistical significance in ICU, TPN or ventilator days in those <60 or ≥60 miles from a PHIS hospital was seen.  There was significantly greater ICU (4.5% vs. 6.1%, p=0.001) and TPN (5.1% vs. 6.6%, p=0.004) use in children living >60 miles from the hospital admitted for non-chemo purposes.   

In children with AML, 2,855 chemo- and 1,414 non-chemo-related admissions were recorded.  Those admitted for chemo living >60 miles away, had longer LOS, and more ICU use (4.1% vs. 6.7%, p=0.09), yet had lower cost per day.  Those admitted for non-chemo purposes living ≥60 miles away had more prevalent ICU (8.3% vs. 14.5%, p= 0.03) and TPN use (9.7% vs. 15.7%, p=0.06), and greater hospitalization cost and cost per day.   

Conclusion: Geographic distance from cancer centers increases health care resource consumption and cost especially in the unplanned admissions for complications in children with ALL and AML.  Prospective studies are needed to confirm the resource utilization and costs associated with geographic distance from cancer center resources and should be considered in pediatric cancer center outreach planning. 

Table A

ALL
	Overall %	<60 miles %	≥60 miles %	p-value
Chemo Admit
Total Admits – N	12884	10663 (82.8%)	2221 (17.2%)
ICU Use	0.4%	0.4%	0.4%	0.969
TPN Use	4.9%	5%	4.9%	0.860
Ventilator	.004%	.0038%	.0045%	0.870
LOS (d): Median [IQR]	3 [2, 4]	3 [2, 4]	3 [2, 4]	0.367
Cost (US$): Median [IQR]	7820.5 [4850.4, 12251.3]	7861.9 [4862.6, 12395]	7666.9 [4825.2, 11647.3]	0.059
Cost/Day: Median [IQR]	2478.9 [1729.6, 3525.3]	2532.3 [1753.9, 3564.7]	2276.3 [1677, 3347]	<.001
Non-Chemo Admit
Total Admits - N	13842	11542 (83.4%)	2300 (16.6%)
ICU Use	4.8%	4.5%	6.1%	0.001
TPN Use	5.4%	5.1%	6.6%	0.004
Ventilator	1.4%	1.4%	1.4%	0.938
LOS (d): Median [IQR]	3 [2, 7]	3 [2, 7]	3 [2, 7]	0.408
Cost (US$): Median [IQR]	8448.4 [4515.3, 18007.6]	8439.7 [4535.4, 18001.3]	8469.2 [4433, 18021.8]	0.706
Cost/Day: Median [IQR]	2559.1 [1866.4, 3580]	2578.8 [1888.1, 3595.5]	2438.6 [1786.2, 3476.8]	<.001

Table B

AML
	Overall	<60 miles	≥60 miles	p-value
Chemo Admit
Total Admits - N	2855	2306 (80.8%)	549 (19.2%)
ICU Use	4.60%	4.10%	6.70%	0.009
TPN Use	8.70%	8.70%	8.70%	0.958
Ventilator	0.90%	0.80%	1.30%	0.264
LOS (d): Median [IQR]	22 [5, 28]	22 [4, 28]	23 [6, 27]	0.010
Cost (US$): Median [IQR]	35483.6 [11914.3, 63738.3]	34782.5 [11339.9, 64075.8]	38384.5 [12817.1, 62315.9]	0.329
Cost/Day: Median [IQR]	2284.5 [1686.8, 3129.8]	2318 [1726.2, 3175.4]	2166.6 [1548.7, 2925.8]	0.002
Non-Chemo Admit
Total Admits - N	1414	1165 (82.4%)	249 (17.6%)
ICU Use	9.40%	8.30%	14.50%	0.003
TPN Use	10.70%	9.70%	15.70%	0.006
Ventilator	3.10%	2.80%	4.40%	0.191
LOS (d): Median [IQR]	7 [3, 17]	7 [3, 17]	8 [2, 17]	0.294
Cost (US$): Median [IQR]	17518.8 [7172.6, 46880.9]	16018.1 [7031.4, 42745.5]	23406.8 [7959.3, 58444.2]	0.014
Cost/Day: Median [IQR]	2967.8 [2085.7, 4053.9]	2907.4 [2086.1, 3914.9]	3317.8 [2063, 4590.2]	0.022