The effect of hospital characteristics on pediatric neuromuscular scoliosis fusion cost

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OBJECTIVE

Spinal fusion is used in the treatment of pediatric neuromuscular scoliosis (NMS) to improve spine alignment and delay disease progression. However, patients with NMS are often medically complex and require a higher level of care than those with other types of scoliosis, leading to higher treatment costs. The purpose of this study was to 1) characterize the cost of pediatric NMS fusion in the US and 2) determine hospital characteristics associated with changes in overall cost.

METHODS

Patients were identified from the National Inpatient Sample (2012 to the first 3 quarters of 2015). Inclusion criteria selected for patients with NMS, spinal fusion of at least 4 vertebral levels, and elective hospitalization. Patients with no cost information were excluded. Sociodemographics, treating hospital characteristics, disease etiology/severity, comorbidities, length of stay, and hospital costs were collected. Univariable analysis and multivariable gamma log-link regression were used to determine hospital characteristics associated with changes in cost.

RESULTS

A total of 1780 weighted patients met inclusion criteria. The median cost was $68,815. Following multivariable regression, both small (+$11,580, p < 0.001) and medium (+$6329, p < 0.001) hospitals had higher costs than large hospitals. Rural hospitals had higher costs than urban teaching hospitals (+$32,438, p < 0.001). Nonprofit hospitals were more expensive than both government (–$4518, p = 0.030) and investor-owned (–$10,240, p = 0.001) hospitals. There was significant variability by US census division; compared with the South Atlantic, all other divisions except for the Middle Atlantic had significantly higher costs, most notably the West North Central (+$15,203, p < 0.001) and the Pacific (+$22,235, p < 0.001). Hospital fusion volume was not associated with total cost.

CONCLUSIONS

A number of hospital factors were associated with changes in fusion cost. Larger hospitals may be able to achieve decreased costs due to economies of scale. Regional differences could reflect uncontrolled-for variability in underlying patient populations or systems-level and policy differences. Overall, this analysis identified multiple systemic patterns that could be targets of further cost-related interventions.

ABBREVIATIONS AHRQ = Agency for Healthcare Research and Quality; AIS = adolescent idiopathic scoliosis; APR-DRG = All Patient Refined Diagnosis Related Group; CCR = charge-to-cost ratio; HCUP = Healthcare Cost and Utilization Project; LOS = length of hospital stay; NCHS = National Center for Health Statistics; NIS = National Inpatient Sample; NMS = neuromuscular scoliosis; RPP = regional price parity.
Article Information

Contributor Notes

Correspondence Jonathan Dallas: Vanderbilt University School of Medicine, Nashville, TN. jonathan.c.dallas@vanderbilt.edu.INCLUDE WHEN CITING Published online September 27, 2019; DOI: 10.3171/2019.7.PEDS19194.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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