Comparing the Utilization of Health Care Resources in Children with ALL and AML Based on Geographic Location: A Retrospective Analysis Utilizing the PHIS Database
Authors: Hall Nathan Scott , Gamis Alan S. , Hall Matt 
Published: October 2019

Abstract
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

Disclosures
No relevant conflicts of interest to declare.