1. Cost and Characteristics of Discharge Delays
in Children Admitted for Maltreatment
Angela Bachim, MDb; Michael Lee, MD, JDa; Carolyn Smith, BBAd; Marcella Donaruma-Kwoh, MDb; Binita Patel, MDc
aDepartment of Pediatrics, bSection of Public Health Pediatrics, cSection of Pediatric Emergency Medicine, Baylor College of Medicine, Texas Children’s Hospital; dDecision Support, Texas Children’s Hospital
Abstract
Table 1: Hospital Charges after Medical Clearance
Child abuse and neglect are a tremendous economic burden in the United States. Child maltreatment cases are more costly than medically-similar non-abuse cases. Many of these hospitalizations involve complicated social circumstances resulting in prolonged length of inpatient stays. We conducted a retrospective chart review of Child Protection Team inpatient consults from to assess the cost and characteristics of this population. Date of medical clearance was assessed from the records based on a priori criteria. Clinical characteristics, discharge disposition, and documented reasons for discharge delay were extracted. Comparison of charges and costs was performed on those with no delay and those with a delay greater than one day. Of 375 subjects, 36% had a delayed discharge. Of these, 57.5% were delayed more than 1 day. Total charges for 586 days of hospitalization after medical clearance was $1.83 million. The most significant predictor for having a discharge delay was awaiting a foster home placement. Medically unnecessary hospitalization is neither ideal for the child nor a desirable use of resources. Interventions can be targeted at children with characteristics correlated with prolonged discharge delays.
Total Charges After Medical Clearance
$1.83 million
Total Days After Medical Clearance
586 days
Median per Day of Delay
$3,191
Mean per Day of Delay
$3,121
Median per Delayed Patient
$3,264
Mean per Delayed Patient
$13,648
Table 2: Discharge Delay vs Hospital Charges
Introduction
Hospitalizations for child maltreatment are more costly than medically- similar non-abuse cases.
Maltreated children spend twice as many days in the hospital as children hospitalized for injuries unrelated to maltreatment.
Neither the cost of prolonged hospitalization after medical clearance nor the characteristics of children most likely to have delayed discharge have been studied.
Study Aims
To assess the cost of hospitalization after medical clearance
To characterize the circumstances of hospitalizations with delayed discharges to help plan future interventions
Description of Study
Table 3: Comparison of Median Hospital Costs
Study Design
Retrospective chart review
Study Setting
All Child Protection Team (CPT) consults from from the consult team’s patient database
Financial information from Decision Support Services
Inclusion Criteria
CPT consult with suspected maltreatment and Child Protective Services involvement during hospital admission
Exclusion Criteria
Maltreatment not suspected by CPT, death, maltreatment limited to sexual assault, consults completed in clinic or the Emergency Center, family left AMA, duplicate or test entry
Data Collected
Demographics and clinical characteristics of patients
Date of medical clearance was determined by reviewing the notes in the medical record by the following a priori criteria dependent upon clear documentation in the record, set by authors
Documented reasons for discharge delay
Outcomes Measures
Hospital charges, cost, insurance type and amount collected
Data Analysis
Descriptive data analysis
Regression
Table 4: Predictors of Any Discharge Delay
Predictors OR
95% CI
P-Value
Free water requirement
6.01
1.54 – 23.46
0.01
CPS custody
2.66
1.34 – 5.27
Noted delay from foster care
53.45
6.87 –
<0.001
Discharge dispo: home
0.42
0.22 – 0.81
Christmas holidays after medical clearance
3.86
1.05 – 14.18
0.04
Results
Table 5: Predictors of >1 Day Discharge Delay
Figure 1: Flow diagram of inclusions
Predictors OR
95% CI
P-Value
Free water requirement
30.05
5.09 –
<0.001
CPS custody
4.13
1.70 – 10.03
0.002
Noted delay from foster care
85.01
10.47 –
Discharge dispo: home
0.15
0.04 – 0.59
0.01
New Year’s holiday
11.48
2.09 – 62.97
No significant differences were found between the groups of delay and no delay in the following areas: age, sex, race/ethnicity, type of abuse, trach/vent requirement, days in PICU, number of medications, seizure or injection medications, method or regimen of feeds, other holidays.
Conclusions
Most children hospitalized for maltreatment did not have a discharge delay.
Only a minority of children had lengthy discharge delays.
Even though the frequency of discharge delays was less than expected, in aggregate it is a significant amount in both days and hospital charges.
The outliers had the extremely lengthy discharge delays, but they are the main contributors to the costs of discharge delays.
The main predictor of discharge delay is needing foster care placement.
Only a subset of children with discharge delay require complex medical care.
Continued hospitalization beyond medical clearance is neither ideal for the child nor a wise use of resources.
Figure 2: Number of delayed patients
Total Patients: 375
Delayed Discharge: 134 (36%)
>1 Day Discharge Delay: 77 (20.5%)
>10 Day Discharge Delay: 12 (3%)
References
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Forjuoh, S. Child Abuse & Neglect 2000; 24(8):
Irzuzta JE, McJunkin JE, Danadian K, Arnold F, Zhang J. Child Abuse & Neglect 1997; 21(8):
Rovi S, Chen PH, Johnson MS. American Journal of Public Health 2004; 94(4):
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