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 
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 
View Large

Table B.
AML
Overall<60 miles≥60 milesp-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 
AML
Overall<60 miles≥60 milesp-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 
View Large

Disclosures

No relevant conflicts of interest to declare.

Topics:
chemotherapy regimen, child, childhood cancer, geographic area, health care use, hospital admission, length of stay, leukemia, leukemia, lymphocytic, acute, childhood, ventilators, mechanical

Author notes

*

Asterisk with author names denotes non-ASH members.

© 2015 by The American Society of Hematology
2015
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