Hospital and ED charges for spina bifida care in the United States between 2006 and 2014: Over $2 billion annually.

BACKGROUND: More children with spina bifida (SB) are surviving into adulthood. Unfortunately, little data exist regarding the economic implications of modern SB care. OBJECTIVE: We examined economic data from two national databases to estimate the annual nationwide hospital and emergency charges of SB from 2006-14. METHODS: We analyzed the 2006-2014 Nationwide Inpatient Sample (NIS) and Nationwide Emergency Department Sample (NEDS). SB patients were defined using ICD-9-CM codes. Demographic and charge data were obtained from each database. Multiple imputation was used to estimate missing data (1.6% for NIS and 22% in NEDS). The principal outcomes were mean, median, and total charges for encounters each year. RESULTS: There were 725,646 encounters for individuals with SB between 2006 and 2014. The average age of captured SB patients who were admitted to a hospital or seen in an ER was 29 years. In 2014, the median charge for inpatient encounters was $31,071 (IQR: $15,947, $63,063) and for ER encounters was $2407.02 (IQR: $1321.91, $4211.35). In total, the sum of charges from all SB-related admissions in 2014 was $1,862,016,217 (95% CI: $1.69 billion, $2.03 billion), while the sum of charges of all SB-related ER encounters in 2014 was $176,843,522 (95% CI: $158 million, $196 million). There was a steady increase in charges over the study period. CONCLUSION: Charges for SB-related inpatient and emergency care in the US in 2014 was in excess of $2 billion in contrast to $1.2 billion in 2006, after adjusting for inflation; this is an impressively high figure for a relatively small number of patients.

Crowdsourcing utility estimation for spina bifida in the general population.

INTRODUCTION: Cost-utility analyses (CUA) are useful when the treatment conditions depend on patient preferences that are in turn dependent on health state utility value. Spina bifida (SB) is an example of such a preference-sensitive condition. Historically, the SB utility value for CUA has been gathered via a traditional face-to-face interview. However, due to funding and time constrains, utility estimation via online crowdsourcing has recently gained popularity. Our aim was to estimate the utility value for a generic SB health state using a validated online tool. METHODS: A cross-sectional survey of American adults was conducted using the time-trade-off (TTO) method. Participants were recruited from an online crowdsourcing interface, Amazon's Mechanical Turk (mTurk). Demographic information and prior knowledge of SB were assessed. Respondents were provided a written passage and an online video explaining SB and its potential associated comorbidities. Participants were queried on hypothetical ascending time-trades from a child-parent dyad perspective to determine the utility of a SB health state in an affected 6-year-old child. Respondents were also asked to indicate the percentage of time traded from their life in relation to their child's. Utility estimates were then calculated and compared using bivariate and multivariate analyses. RESULTS: We obtained 503 responses (85% response rate). Mean respondent age was 34 (± 11); 247 (49%) were female; 386 (77%) were white; 189 (38%) were married, and 234 (46%) had children. Mean proportion of longevity traded by participants in the dyadic interaction was 66% (± 27) from the parent's life. Only 51 respondents (9%) reported having "ample" prior knowledge of SB; 8 respondents (0.02%) had SB themselves. Few others had previous experience with SB or myelomeningocele either in a child (4, 1%), or friend/relative (28, 5%). Compared with a perfect health state of 1.0, we found mean utilities of 0.85 (± 0.20) for SB. CONCLUSIONS: Utility estimation for SB is feasible through crowdsourcing, and the resultant values are similar to previous estimates using traditional techniques. Subjects view the SB health state to be inferior to perfect health.

A Nationwide Assessment of the Emergency Department Management of Acute Urinary Retention Due to Urethral Stricture.

OBJECTIVE: To evaluate the nationwide practice patterns of the management of acute urinary retention (AUR) secondary to urethral stricture (US) in an emergency department (ED) setting. MATERIALS AND METHODS: We used the 2006-2010 Nationwide Emergency Department Sample to identify men with US who received treatment for AUR. We excluded patients with benign prostatic hyperplasia, vesicourethral anastomotic stenosis, neurogenic bladder, and bladder cancer. Primary outcome was urethral dilation or suprapubic tube (SPT) placement as initial AUR management. Patient demographics and hospital factors were also examined. Multivariate logistic regression was performed to examine factors associated with initial AUR management. RESULTS: We identified 4794 weighted ED encounters of men with US who underwent urethral dilation or SPT placement for AUR. Mean age was 58.6 ± 0.8 years. A total of 4084 (85%) men received urethral dilation, whereas 710 had SPT (15%) placement. In bivariate analysis, patients who received SPT were likely to be younger (P <.001), treated in recent years (P = .002), and in hospitals in the West region (P = .003). In multivariate analysis, SPT placement was significantly associated with younger age (P = .004), public insurance (P = .03), recent treatment years (P = .02), and hospitals in the West region (P = .02). Income and hospital teaching status did not have significant association with initial treatment choice. CONCLUSION: Urethral dilation remains the most common urologic intervention in the ED for AUR due to US; however, there is an increasing trend toward SPT placement. Patients who are younger, publicly insured, or who receive care in the West region are more likely to receive a SPT for initial treatment of AUR due to US.

Utility Estimation for Pediatric Vesicoureteral Reflux: Methodological Considerations Using an Online Survey Platform.

PURPOSE: The advent of online task distribution has opened a new avenue for efficiently gathering community perspectives needed for utility estimation. Methodological consensus for estimating pediatric utilities is lacking, with disagreement over whom to sample, what perspective to use (patient vs parent) and whether instrument induced anchoring bias is significant. We evaluated what methodological factors potentially impact utility estimates for vesicoureteral reflux. MATERIALS AND METHODS: Cross-sectional surveys using a time trade-off instrument were conducted via the Amazon Mechanical Turk® (https://www.mturk.com) online interface. Respondents were randomized to answer questions from child, parent or dyad perspectives on the utility of a vesicoureteral reflux health state and 1 of 3 "warm-up" scenarios (paralysis, common cold, none) before a vesicoureteral reflux scenario. Utility estimates and potential predictors were fitted to a generalized linear model to determine what factors most impacted utilities. RESULTS: A total of 1,627 responses were obtained. Mean respondent age was 34.9 years. Of the respondents 48% were female, 38% were married and 44% had children. Utility values were uninfluenced by child/personal vesicoureteral reflux/urinary tract infection history, income or race. Utilities were affected by perspective and were higher in the child group (34% lower in parent vs child, p <0.001, and 13% lower in dyad vs child, p <0.001). Vesicoureteral reflux utility was not significantly affected by the presence or type of time trade-off warm-up scenario (p = 0.17). CONCLUSIONS: Time trade-off perspective affects utilities when estimated via an online interface. However, utilities are unaffected by the presence, type or absence of warm-up scenarios. These findings could have significant methodological implications for future utility elicitations regarding other pediatric conditions.

Is the Economic Impact and Utilization of Imaging Studies for Pediatric Urolithiasis Across the United States Increasing?

OBJECTIVE: To identify longitudinal trends of economic impact and resource utilization for management of pediatric urolithiasis using national databases. METHODS: We analyzed the 2006-2012 Nationwide Emergency Department Sample and Nationwide Inpatient Sample. We used ICD-9 (International Classification of Diseases) codes to identify patients (≤18 years) diagnosed with urolithiasis. Diagnostic imaging and surgeries were identified using ICD-9 and Current Procedural Technology codes. We abstracted demographic, imaging, procedure, and charge data. Weighted descriptive statistics were calculated to describe the population's demographics and economic expenditures by clinical setting and year. RESULTS: In total, 45,333 inpatient admissions (68% females) and 234,559 emergency department encounters (63% females) were identified. Most patients (84%) were teenagers and the southern region of the United States was the most common geographic region for all encounters (44%). There was no significant trend in number of urolithiasis encounters over the period studied. Utilization of all imaging techniques increased; in particular, computed tomography was used in 23% of encounters in 2006 and 40% in 2012 (P < .0001). The mean charge per emergency department visit increased by 60% from $3645 in 2006 to $5827 in 2012 (P < .0001). The mean charge increased for inpatient admissions by 102%, from $16,399 in 2006 to $33,205 in 2012 (P < .0001). Total charges increased 72% over the study period from $230 million in 2006 to $395 million in 2012 (P < .0001), outpacing medical inflation over the same period. CONCLUSION: Charges for pediatric urolithiasis management increased by 65% from 2006 to 2012 despite stable frequency of patient encounters. The utilization of computerized tomography in pediatric urolithiasis increased as well.

Estimating the nationwide, hospital based economic impact of pediatric urolithiasis.

PURPOSE: The incidence of urolithiasis is increasing in children and adolescents but the economic impact of this problem is unclear. We examined 2 large databases to estimate the nationwide economic impact of pediatric urolithiasis. MATERIALS AND METHODS: We analyzed the 2009 NEDS and KID, used ICD-9-CM codes to identify children 18 years or younger diagnosed with urolithiasis and abstracted demographic and charge data from each database. RESULTS: We identified 7,348 weighted inpatient discharges in KID and 33,038 emergency department weighted encounters in NEDS. Of the patients 32% and 36% were male, respectively. Inpatients were younger than those who presented to the ED (mean age 13.9 vs 15.7 years). Most patients had private insurance (52.9% to 57.2%) and the South was the most common geographic region (39.5% to 44.4%). The most common procedures were ureteral stent placement in 20.4% to 24.1% of cases, followed by ureteroscopy in 3.8% to 4.4%. Median charges per admission were $13,922 for a weighted total of $229 million per year. Median emergency department charges were $3,991 per encounter for a weighted total of $146 million per year. CONCLUSIONS: Each day in 2009 in the United States an estimated 20 children were hospitalized and 91 were treated in the emergency department for upper tract stones. A conservative estimate of 2009 annual charges related to pediatric urolithiasis in the United States is at least $375 million. This is likely a significant underestimate of the true economic burden of pediatric urolithiasis because it accounts for neither outpatient management nor indirect costs such as caregiver time away from work.