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. 2022 Feb 9;5(2):e2147447. doi: 10.1001/jamanetworkopen.2021.47447

Prevalence, Cost, and Variation in Cost of Pediatric Hospitalizations in Ontario, Canada

Peter J Gill 1,2,3,4,✉, Thaksha Thavam 3, Mohammed Rashidul Anwar 3, Jingqin Zhu 3, Patricia C Parkin 1,2,3,4, Eyal Cohen 1,2,3,4, Teresa To 3,4, Sanjay Mahant 1,2,3,4, Francine Buchanan 2, Wenjia Chen 5, Ronald Cohn 1,2, Mairead Green 6, Matt Hall 7, Kate Langrish 2, Colin Macarthur 1,3,4, Myla Moretti 3,4, Michelle Quinlan 6, Ann Bayliss 8, Ronik Kanani 1,9, Sean Murray 10, Catherine Pound 6,11, Mahmoud Sakran 12,13, Anupam Sehgal 12, Sepi Taheri 14, Gita Wahi 15, for the Ontario Pediatric Hospital Care Study Group (OPHCSG) and the Canadian Paediatric Inpatient Research Network (PIRN)
PMCID: PMC8829658  PMID: 35138399

Key Points

Question

What conditions should be prioritized for research involving hospitalized children?

Findings

In this cross-sectional study of 627 314 inpatient encounters among children at 165 hospitals in Ontario, Canada, 65.0% of encounters and 43.8% of costs occurred at general hospitals. Several newborn and mental health conditions were identified as most prevalent, costly, and with high variation in cost across hospitals.

Meaning

The results of this study can be used to design a research agenda for the care of hospitalized children that includes general hospitals and may inform researchers, health care system leaders, and funders about research areas and quality improvement efforts that could be prioritized.

Abstract

Importance

Identifying conditions that could be prioritized for research based on health care system burden is important for developing a research agenda for the care of hospitalized children. However, existing prioritization studies are decades old or do not include data from both pediatric and general hospitals.

Objective

To assess the prevalence, cost, and variation in cost of pediatric hospitalizations at all general and pediatric hospitals in Ontario, Canada, with the aim of identifying conditions that could be prioritized for future research.

Design, Setting, and Participants

This population-based cross-sectional study used health administrative data from 165 general and pediatric hospitals in Ontario, Canada. Children younger than 18 years with an inpatient hospital encounter between April 1, 2014, and March 31, 2019, were included.

Main Outcomes and Measures

Condition-specific prevalence, cost of pediatric hospitalizations, and condition-specific variation in cost per inpatient encounter across hospitals. Variation in cost was evaluated using (1) intraclass correlation coefficient (ICC) and (2) number of outlier hospitals. Costs were adjusted for inflation to 2018 US dollars.

Results

Overall, 627 314 inpatient hospital encounters (44.8% among children younger than 30 days and 53.0% among boys) at 165 hospitals (157 general and 8 pediatric) costing $3.3 billion were identified. A total of 408 003 hospitalizations (65.0%) and $1.4 billion (43.8%) in total costs occurred at general hospitals. Among the 50 most prevalent and 50 most costly conditions (of 68 total conditions), the top 10 highest-cost conditions accounted for 55.5% of all costs and 48.6% of all encounters. The conditions with highest prevalence and cost included low birth weight (86.2 per 1000 encounters; $676.3 million), preterm newborn (38.0 per 1000 encounters; $137.4 million), major depressive disorder (20.7 per 1000 encounters; $78.3 million), pneumonia (27.3 per 1000 encounters; $71.6 million), other perinatal conditions (68.0 per 1000 encounters; $65.8 million), bronchiolitis (25.4 per 1000 encounters; $54.6 million), and neonatal hyperbilirubinemia (47.9 per 1000 encounters; $46.7 million). The highest variation in cost per encounter among the most costly medical conditions was observed for 2 mental health conditions (other mental health disorders [ICC, 0.28] and anxiety disorders [ICC, 0.19]) and 3 newborn conditions (intrauterine hypoxia and birth asphyxia [ICC, 0.27], other perinatal conditions [ICC, 0.17], and surfactant deficiency disorder [ICC, 0.17]).

Conclusions and Relevance

This population-based cross-sectional study of hospitalized children identified several newborn and mental health conditions as having the highest prevalence, cost, and variation in cost across hospitals. Findings of this study can be used to develop a research agenda for the care of hospitalized children that includes general hospitals and to ultimately build a more substantial evidence base and improve patient outcomes.

This cross-sectional study assesses the prevalence, cost, and variation in cost of pediatric hospitalizations at all general and pediatric hospitals in Ontario, Canada, and identifies conditions that may be prioritized for future research.

Introduction

Hospital care costs account for the largest component of all health care costs.1,2 Among children, hospital expenditures are high, with costs increasing over time.3,4 Despite the large volume and high cost of admissions, hospitalized children may not receive optimal care owing to a lack of high-quality evidence.5,6,7 For example, few randomized clinical trials have been conducted in pediatric hospitals compared with specialty units, such as oncology8 and critical care.9,10 The lack of high-quality research can produce unnecessary variation in clinical practice and outcomes.11,12,13,14

Identifying topics to prioritize for future research is necessary to build a meaningful research agenda for the care of hospitalized children. One factor identified in research prioritization frameworks is the condition-related criterion, which includes assessing the prevalence, cost, and variation in cost of the illness.15,16 Conditions that are common, require costly care, and have high cost variation increase in rank to become high-priority conditions for research.15,16 Existing studies have examined the burden of pediatric hospitalizations in North America,16,17,18,19,20 but study limitations have made it difficult to use their findings for future research. In the US, 3 studies16,17,18 have identified common and costly conditions among hospitalized children. The most recent study18 excluded general hospitals, in which most pediatric hospitalizations occur.17 In Canada, 2 studies19,20 identified the most common reasons for pediatric hospitalization; however, those studies used data that are now more than 2 decades old and did not explore the cost of conditions.

Therefore, the aim of this study was to describe the epidemiologic characteristics of pediatric hospitalizations and identify conditions that could be prioritized for research using population-based data across all general and pediatric hospitals in Ontario, Canada. The specific objectives were to (1) assess the condition-specific prevalence, cumulative cost, and variation in cost of pediatric hospitalizations and (2) rank order the pediatric hospital conditions to identify those with high prevalence, cost, and/or variation in cost as priorities for future research involving hospitalized children.

Methods

Study Design

This population-based cross-sectional study focused on children with hospital encounters in Ontario, the most populous province in Canada with a population of 14.8 million.21 Data were obtained from linked Ontario health administrative databases housed at ICES (formerly known as the Institute for Clinical Evaluative Sciences). The data included all children eligible for provincial health care coverage and all general and pediatric hospitals in Ontario. The study was approved by the Hospital for Sick Children Research Ethics Board with a waiver of informed consent because deidentified data were used. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies.22

Data Sources

Clinical information and intensity of resources consumed for hospital encounters (inpatient discharges or same-day surgery) were obtained from the Canadian Institute for Health Information Discharge Abstract Database and the Same Day Surgery Database. Demographic information was extracted from the Registered Persons Database,23 and annual population estimates for Ontario were obtained from intercensal population estimates and projections for local health integrated networks.24

Study Population

Children younger than 18 years with an inpatient hospital encounter between April 1, 2014, and March 31, 2019, were included. We excluded encounters among children with missing or invalid birth dates, death dates, or discharge dates; encounters among non-Ontario residents; encounters indicating normal newborn birth based on a most responsible diagnostic code (defined as the condition that contributes the greatest extent to the patient's hospital stay) from the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Canada (ICD-10-CA); and same-day surgery encounters (all exclusions are shown in the eFigure in the Supplement).

Pediatric Clinical Classification System

For each hospital encounter, the most responsible diagnosis was determined using the ICD-10-CA discharge diagnostic code and classified into discrete clinical condition categories using codes from the Pediatric Clinical Classification System. This system classifies 16 992 ICD-10-CA codes into 781 clinically meaningful categories to identify specific pediatric conditions, including treatments (eg, chemotherapy). The Pediatric Clinical Classification System was first developed for the US International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding system and evaluated using US administrative pediatric hospitalization data.25 This grouping system categorized conditions into medical, surgical, and medical/surgical based on the percentage of encounters for the condition that had a surgical procedure code. If fewer than 30% of encounters for the condition had a surgical procedure code, the condition was classified as medical; if more than 70% of encounters for the condition had a surgical procedure code, the condition was classified as surgical; and if between 30% and 70% of encounters for the condition had a surgical procedure code, the condition was classified as medical/surgical.18

Outcome Measures

We estimated the condition-specific prevalence of hospitalization for each condition, with condition-specific prevalence defined as the proportion of hospital encounters owing to the specific condition over the study period. We also calculated the condition-specific cost of hospitalization for each condition as a proxy for the volume of resources used to manage the condition.16 Costs were estimated using an ICES costing algorithm, which multiplied the resource intensity weight assigned to each inpatient case recorded in the Canadian Institute for Health Information Discharge Abstract Database with the provincial mean unit cost of acute hospitalization (ie, cost per weighted case) for the corresponding fiscal year.26 The resource intensity weight represents the amount of resources used by the inpatient case relative to an average inpatient case.26 Costs were adjusted for inflation to 2018 US dollars (mean exchange rate: $0.77 US dollars = $1.00 Canadian dollar). Details on the case-costing methods are available online.26 We also estimated the condition-specific variation in cost per encounter across hospitals to measure the variation in resources used to manage each condition across hospitals.16

Patient, Encounter, and Hospital Characteristics

Patient characteristics included age at the time of the hospital encounter (<30 days, ≥30 days to <1 year, 1-4 years, 5-12 years, and 13 to <18 years),16 sex, and rural vs urban residence (measured using the Rurality Index for Ontario, with urban defined as a score <40 and rural defined as a score ≥40).27,28 The components used to calculate the Rurality Index for Ontario included community population size and density as well as travel time to the nearest basic and advanced referral centers.27 The number of complex chronic conditions (CCCs) present (0, 1, 2, or ≥3)29,30 for each patient was estimated using the diagnostic and procedural codes adopted by the Canadian Institute for Health Information.31 To identify whether CCCs were present, for each encounter, the patient’s hospital data were examined for the previous 2 years or until birth if the patient was younger than 2 years. To measure the socioeconomic status of the cohort, the Ontario Marginalization Index was used to identify material deprivation32 by quintile (with quintile 1 indicating least deprived and quintile 5 indicating most deprived). The factors used to measure material deprivation were income, quality of housing, educational level, and family structure characteristics.32,33 For hospital encounter characteristics, we identified the condition type (medical, surgical, or medical/surgical) and length of stay in days.

For hospital characteristics, we identified hospital type, which was categorized as general or pediatric (defined as a tertiary care children’s hospital or a hospital with a level 3 neonatal intensive care unit). The hospital region (central east, central south, central west, east, north, southwest, or Toronto, Ontario) and the mean volume of inpatient encounters per year were also identified.

Statistical Analysis

For each hospital condition, we determined the condition-specific prevalence over the study period using the number of hospital encounters associated with the condition as the numerator and the total number of encounters associated with all conditions as the denominator. We calculated the prevalence per 1000 patient encounters. The median and mean cost per encounter and the cumulative cost of encounters for each condition were also calculated. Hospital conditions were ranked from highest to lowest based on the total volume of encounters (called prevalence rank) and based on cumulative cost.

For the 25 medical conditions with the highest cumulative cost, we determined the variation in cost per encounter across hospitals. We focused on the conditions with the highest cumulative cost because they would either be highly prevalent or highly costly per encounter.16 The condition-specific variation in cost across hospitals was adjusted for known factors associated with variation in cost, including age, sex, number of CCCs present, material deprivation, and rural vs urban classification to minimize confounding from other factors that may have biased the extent of variation in cost across hospitals.16,34,35,36

To alleviate skewness, hospital encounter costs were log transformed before conducting the analysis of variation in cost. The variation in cost per encounter was assessed using 2 methods16: intraclass correlation coefficient (ICC) and number of outlier hospitals. To assess variation in cost per encounter using the ICC method, for each condition, the variation in cost (using cost per encounter) across hospitals was divided by the total variation in cost per encounter (which included within-hospital and across-hospital variation in costs). The ICC was calculated using a mixed-effects model with random intercepts for each hospital and patient characteristics as fixed effects.16 To assess variation in cost per encounter using the number of outlier hospitals, for each condition, the number of hospitals with more than 30% of encounters in the highest or lowest quintile of overall cost per encounter was calculated. The ICC was a single measure that quantified the extent of variation in cost across hospitals, whereas the number of outlier hospitals provided granularity regarding the number of hospitals that met the low-cost and/or high-cost outlier hospital criteria for the condition.16 To ensure we had an adequate sample of hospitals and encounters per hospital for the analysis of variation in cost, we restricted this analysis to conditions (from the 25 highest-cost medical conditions) that had data available from at least 10 hospitals with more than 25 encounters per hospital for the corresponding condition.37 Secondary analysis examined the variation in cost per encounter for each condition across general hospitals alone. This analysis was not performed separately across pediatric hospitals because of the small number of pediatric hospitals.

Additional analyses identified the 25 most prevalent and 25 most costly conditions in pediatric vs general hospitals. These analyses were conducted as differences in the volume, cost, and characteristics of pediatric hospitalizations reported between hospital types.17 Analyses were performed using SAS Enterprise Guide software, version 7.1 (SAS Institute Inc).

Results

In total, there were 1 361 712 hospital encounters among children in Ontario between April 1, 2014, and March 31, 2019. After exclusions (437 166 of which were normal newborn births), 627 314 inpatient encounters among children were included from 157 general hospitals and 8 pediatric hospitals (eFigure in the Supplement). The total hospital cost was $3.3 billion, with 408 003 hospitalizations (65.0%) and $1.4 billion (43.8%) in total costs occurring at general hospitals.

Of the included encounters, 281 230 (44.8%) were among children younger than 30 days, 332 494 (53.0%) were among boys, and 571 437 (91.1%) were among children residing in urban areas (Table 1). Children with at least 1 CCC represented 141 653 inpatient encounters (22.6%). A total of 471 440 encounters (75.2%) occurred because of medical conditions, 94 727 encounters (15.1%) occurred because of surgical conditions, and 61 147 encounters (9.7%) occurred because of medical/surgical conditions. The median length of stay was 2 days (IQR, 1-4 days). The median annual hospital volume of inpatient encounters was 73.0 (IQR, 4.6-1003.2).

Table 1. Patient, Encounter, and Hospital Characteristics Among Children With Inpatient Encounters in Ontario, Canada, From 2014 to 2019.

Characteristic No. (%)
Patients
Total inpatient encounters, No. 627 314
Age at time of encounter, median (IQR), y 0 (0-8.0)
Age range at time of encounter
<30 d 281 230 (44.8)
≥30 d to <1 y 53 827 (8.6)
1 to 4 y 93 217 (14.9)
5 to 12 y 92 730 (14.8)
13 to <18 y 106 310 (16.9)
Sex
Female 294 820 (47.0)
Male 332 494 (53.0)
Rurality of residence
Rural 41 548 (6.6)
Urban 571 437 (91.1)
Missing 14 329 (2.3)
No. of complex chronic conditions present
0 485 661 (77.4)
1 74 685 (11.9)
2 26 537 (4.2)
≥3 40 431 (6.4)
Material deprivation, quintile
1 (Least deprived) 123 336 (19.7)
2 119 456 (19.0)
3 113 473 (18.1)
4 115 571 (18.4)
5 (Most deprived) 142 832 (22.8)
Missing 12 646 (2.0)
Encounters
Type of condition
Medical 471 440 (75.2)
Medical/surgical 61 147 (9.7)
Surgical 94 727 (15.1)
Length of stay, median (IQR), d 2.0 (1.0-4.0)
Hospitals
Total hospitals, No. 165
Type of hospital
Pediatric 8 (4.8)
General 157 (95.2)
Region
Southwest 35 (21.2)
Central south 12 (7.3)
Central west 15 (9.1)
Central east 19 (11.5)
Toronto 14 (8.5)
East 27 (16.4)
North 43 (26.1)
Annual volume of inpatient encounters, median (IQR) 73.0 (4.6-1003.2)
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Prevalence and Cost

The 50 most prevalent and 50 most costly conditions (of 68 total conditions) ranked by cumulative cost are shown in Table 2. The top 10 most costly conditions accounted for 55.5% of all costs and 48.6% of all encounters among the 68 conditions. Extreme immaturity of newborn had the highest median cost per encounter ($21 702; IQR, $3698-$40 779). Low birth weight had the highest prevalence (86.2 per 1000 encounters). Several mental health conditions had the highest prevalence and highest cost among children; these conditions included major depressive disorder (20.7 per 1000 encounters; $78.3 million), adjustment disorders (12.1 per 1000 encounters; $40.9 million), anorexia nervosa (2.8 per 1000 encounters; $31.5 million), anxiety disorders (8.0 per 1000 encounters; $30.7 million), other mental health disorders (5.1 per 1000 encounters; $19.3 million), schizophrenia and psychotic disorders (2.4 per 1000 encounters; $17.2 million), and attention-deficit/hyperactivity disorder (3.5 per 1000 encounters; $16.3 million). Diagnoses within the condition category other mental health disorders are shown in eTable 1 in the Supplement.

Table 2. Prevalence and Cost for the 50 Most Costly and 50 Most Prevalent Conditions Among Children With Inpatient Encounters in Ontario, Canada, From 2014 to 2019.

Conditiona Type of condition Rank Inpatient encounters, No. Cost, $b
Based on total cost Based on No. of encountersc Totald Prevalencee Total Per encounter, median (IQR)
Low birth weight Medical 1 1 54 100 86.2 676 292 381 2924 (1236-13 777)
Preterm newborn Medical 2 4 23 821 38.0 137 377 386 2468 (1255-6011)
Major depressive disorder Medical 3 9 12 975 20.7 78 303 976 5780 (5306-6735)
Pneumonia Medical 4 5 17 143 27.3 71 566 538 2929 (2709-4029)
Other perinatal conditions Medical 5 2 42 674 68.0 65 791 674 1036 (1026-1236)
Bronchiolitis Medical 6 6 15 950 25.4 54 581 261 2602 (2392-2700)
Surfactant deficiency disorder Medical 7 43 3015 4.8 50 023 527 6645 (2148-15 952)
Neonatal hyperbilirubinemia Medical 8 3 30 048 47.9 46 670 627 1447 (1064-1500)
Adjustment disorders Medical 9 17 7621 12.1 40 888 157 5114 (4675-6314)
Transient tachypnea of newborn Medical 10 7 14 287 22.8 40 298 745 1653 (1428-3383)
Chemotherapy Medical 11 14 7905 12.6 37 529 210 4238 (2634-4490)
Drug withdrawal syndrome in newborn Medical 12 39 3291 5.2 37 016 433 9473 (8713-13 274)
Anorexia nervosa Medical 13 66 1758 2.8 31 464 629 18 398 (16 329-18 752)
Anxiety disorders Medical 14 26 5010 8.0 30 680 583 6448 (5395-7030)
Asthma Medical 15 8 13 449 21.4 28 454 191 1723 (1623-2081)
Acute appendicitis without peritonitis Surgical 16 12 9978 15.9 27 902 739 2655 (2519-2832)
Feeding difficulties Medical/surgical 17 22 6560 10.5 25 848 677 1531 (1036-4105)
Urinary tract infections Medical 18 18 7088 11.3 25 645 046 3112 (2831-3466)
Other congenital anomalies Surgical 19 42 3077 4.9 25 600 029 2474 (930-4716)
Infectious gastroenteritis Medical 20 10 11 373 18.1 25 591 365 1735 (1706-1897)
Respiratory distress of newborn Medical 21 16 7738 12.3 23 641 152 1541 (1428-2796)
Acute lymphoid leukemia Medical 22 119 894 1.4 23 453 440 17 271 (12 208-29 469)
Necrotizing enterocolitis Medical/surgical 23 174 459 0.7 23 045 352 17 821 (9370-47 819)
Acute appendicitis with peritonitis Surgical 24 29 4400 7.0 22 170 824 4006 (3852-4755)
Complications of surgical procedures or medical care Medical/surgical 25 30 4164 6.6 21 916 650 2393 (1438-4175)
Extreme immaturity of newborn Medical 26 147 580 0.9 20 925 776 21 702 (3698-40 779)
Scoliosis Surgical 27 101 1053 1.7 20 547 895 18 884 (12 943-19 834)
Intrauterine hypoxia and birth asphyxia Medical 28 57 2326 3.7 20 469 981 3385 (1528-10 694)
Other mental health disorders Medical 29 41 3168 5.1 19 272 426 2843 (2320-6185)
Sepsis of newborn Medical 30 52 2638 4.2 18 806 085 4985 (2961-6845)
Neutropenia Medical 31 44 3010 4.8 18 704 373 4240 (3703-6717)
Septicemia Medical 32 61 1890 3.0 18 688 859 4630 (4117-8729)
Fracture of lower limb Surgical 33 35 3776 6.0 18 566 246 3953 (3328-4926)
Respiratory failure Medical 34 138 677 1.1 18 550 691 11 766 (4800-36 001)
Newborn respiratory failure Medical 35 20 6642 10.6 18 328 994 1268 (1123-2335)
Neonatal hypoglycemia Medical 36 15 7844 12.5 18 226 564 1078 (1030-2400)
Tetralogy of Fallot Medical/surgical 37 147 580 0.9 17 923 567 17 303 (4047-28 984)
Schizophrenia and psychotic disorders Medical 38 72 1519 2.4 17 244 815 10 768 (9374-11 384)
Transposition of great vessels Medical/surgical 39 173 461 0.7 16 416 666 20 067 (3217-44 862)
Attention-deficit/hyperactivity disorder Medical 40 58 2199 3.5 16 337 289 7046 (6367-7823)
Viral infection Medical 41 21 6632 10.6 16 158 659 1918 (1829-2131)
Hypertrophy of tonsils and adenoids Surgical 42 13 8166 13.0 15 948 718 1842 (1828-1907)
Intracranial injury Medical 43 90 1156 1.8 15 775 600 3945 (2673-11 482)
Gastroschisis and exomphalos Surgical 44 219 319 0.5 15 639 964 21 307 (1113-65 445)
Congenital tracheoesophageal disorders Surgical 45 236 277 0.4 15 518 709 10 313 (2035-47 866)
Sleep apnea Surgical 46 23 6358 10.1 15 498 436 1842 (1828-1907)
Hypoplastic left heart syndrome Medical/surgical 47 253 238 0.4 15 261 396 14 977 (1595-54 180)
Screening for suspected conditions Medical 48 11 10 817 17.2 14 444 254 1065 (1030-1236)
Cystic fibrosis Medical 49 120 856 1.4 14 429 112 14 179 (12 436-16 173)
Seizures with and without intractable epilepsy Medical 50 33 3913 6.2 14 356 766 1903 (1801-2754)
Cellulitis Medical 51 31 4114 6.6 14 298 664 3055 (2482-3596)
Acute upper respiratory infection Medical 52 25 5023 8.0 14 272 166 2057 (1967-2181)
Other lower respiratory disease Medical 53 38 3533 5.6 14 126 940 2213 (1939-2791)
Fever of unknown origin Medical 54 28 4693 7.5 12 746 513 2284 (2167-2529)
Infant of diabetic mother Medical 55 19 6707 10.7 12 569 146 1078 (1030-1236)
Other aftercare Medical/surgical 57 27 4738 7.6 11 353 620 1275 (1187-1554)
Fracture of upper limb Surgical 61 32 3953 6.3 11 037 979 2931 (1984-3034)
Supracondylar fracture of humerus Surgical 63 36 3713 5.9 10 643 826 2943 (2856-2974)
ABO hemolytic disease Medical 81 34 3814 6.1 8 375 305 1858 (1682-2190)
Influenza Medical 86 50 2865 4.6 8 212 883 2072 (1970-2393)
Diabetic ketoacidosis Medical 87 46 2988 4.8 8 126 963 2607 (2272-2838)
Congenital genitourinary anomalies Surgical 90 40 3171 5.1 7 717 287 930 (891-1629)
Neonatal tachycardia Medical 93 48 2929 4.7 7 258 219 1078 (1030-1558)
Other convulsions Medical 103 47 2954 4.7 6 568 239 1882 (1796-2198)
Respiratory problems after birth, other Medical 110 49 2882 4.6 5 901 470 1526 (1428-1677)
Tongue-tied Surgical 112 24 5128 8.2 5 892 461 1036 (1026-1078)
Birth trauma Medical/surgical 118 45 3002 4.8 5 344 774 1065 (1026-1236)
Croup Medical 124 37 3612 5.8 5 067 750 1148 (1103-1292)
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Abbreviation: ABO, ABO blood group system.

a

Sixty-eight total conditions.

b

Costs adjusted for inflation to 2018 US dollars (mean 2018 exchange rate: $0.77 US dollars = $1.00 Canadian dollar).

c

Also known as prevalence rank in this study.

d

Total number of encounters for the condition over the study period.

e

Condition-specific prevalence per 1000 encounters.

Of the 68 conditions, 7 were highly prevalent and costly: low birth weight (86.2 per 1000 encounters; $676.3 million), preterm newborn (38.0 per 1000 encounters; $137.4 million), major depressive disorder (20.7 per 1000 encounters; $78.3 million), pneumonia (27.3 per 1000 encounters; $71.6 million), other perinatal conditions (68.0 per 1000 encounters; $65.8 million), bronchiolitis (25.4 per 1000 encounters; $54.6 million), and neonatal hyperbilirubinemia (47.9 per 1000 encounters; $46.7 million) (Table 2; data for other perinatal conditions are shown in eTable 1 in the Supplement). The 25 most costly medical conditions were categorized into cancer (2 conditions: acute lymphoid leukemia and chemotherapy), newborn (10 conditions: drug withdrawal syndrome in newborn, extreme immaturity of newborn, intrauterine hypoxia and birth asphyxia, low birth weight, neonatal hyperbilirubinemia, other perinatal conditions, preterm newborn, respiratory distress of newborn, surfactant deficiency disorder, and transient tachypnea of newborn), mental health (5 conditions: adjustment disorders, anorexia nervosa, anxiety disorders, major depressive disorder, and other mental health disorders), infectious (6 conditions: infectious gastroenteritis, neutropenia, pneumonia, sepsis of newborn, septicemia, and urinary tract infections), and respiratory (2 conditions: asthma and bronchiolitis) (Figure 1). Most of the prevalent and costly medical conditions were newborn conditions (low birth weight, preterm newborn, and other perinatal conditions).

Figure 1. Volume and Cost of Encounters for the 25 Highest-Cost Medical Conditions Among Children With Inpatient Encounters in Ontario, Canada, From 2014 to 2019.

Figure 1.

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Total costs (in millions) are presented in Canadian dollars. To convert Canadian dollars to US dollars (adjusted for inflation to 2018 US dollars), multiply values by 0.77. The x- and y-axes are presented using a log2 scale.

The variation in cost per encounter across hospitals was examined for 23 of the 25 most costly medical conditions that had an adequate number of hospitals and/or encounters (Table 3). Two mental health conditions (other mental health disorders [ICC, 0.28] and anxiety disorders [ICC, 0.19]) and 3 newborn conditions (intrauterine hypoxia and birth asphyxia [ICC, 0.27], other perinatal conditions [ICC, 0.17], and surfactant deficiency disorder [ie, respiratory distress syndrome in newborn; ICC, 0.17]) had the highest variation in cost across hospitals using the ICC method. The outlier hospital method, which was also used to evaluate variation in cost, revealed that more than 50% of the hospitals examined had a high proportion of high- or low-cost hospitalizations for 3 conditions (chemotherapy [25 of 30 hospitals], intrauterine hypoxia and birth asphyxia [14 of 24 hospitals], and other mental health disorders [18 of 30 hospitals]) (Table 3). The variation in cost per encounter across general hospitals was examined for 21 of the 25 most costly medical conditions (eTable 2 in the Supplement). The variation in cost (measured using ICC) for most conditions was similar to the variation found when examined across all hospitals. However, for some conditions, such as intrauterine hypoxia and birth asphyxia (ICC, 0.06) and other perinatal conditions (ICC, 0.06), the ICCs were substantially lower across general hospitals.

Table 3. Variation in Cost per Encounter Across Hospitals for the 25 Medical Conditions With the Highest Cumulative Cost Among Children in Ontario From 2014 to 2019.

Condition Hospitals included, No.a ICCb Outlier hospitals, No.b
Low cost High cost Totalc
Newborn
Intrauterine hypoxia and birth asphyxia 24 0.27 11 3 14
Other perinatal conditions 81 0.17 4 15 19
Surfactant deficiency disorder 39 0.17 13 4 17
Low birth weight 70 0.14 26 5 31
Preterm newborn 67 0.11 16 6 22
Transient tachypnea of newborn 65 0.11 17 6 23
Respiratory distress of newborn 58 0.11 10 9 19
Drug withdrawal syndrome in newborn 35 0.07 5 5 9
Neonatal hyperbilirubinemia 76 0.03 7 4 11
Extreme immaturity of newbornd NA NA NA NA NA
Mental health
Other mental health disorders 30 0.28 9 9 18
Anxiety disorders 29 0.19 6 2 8
Major depressive disorder 34 0.05 3 2 5
Adjustment disorders 28 0.05 2 3 5
Anorexia nervosa 11 0.03 2 0 2
Infectious
Septicemia 22 0.10 5 3 8
Sepsis of newborn 33 0.07 3 6 9
Neutropenia 14 0.07 2 1 3
Pneumonia 52 0.06 8 4 12
Infectious gastroenteritis 46 0.03 5 2 5
Urinary tract infections 45 0.01 0 1 1
Respiratory
Bronchiolitis 48 0.03 6 3 9
Asthma 46 0.02 0 1 1
Cancer
Chemotherapy 30 0.12 22 11 25
Acute lymphoid leukemiad NA NA NA NA NA
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Abbreviations: ICC, intraclass correlation coefficient; NA, not applicable.

a

Number of hospitals in Ontario with >25 encounters for each corresponding condition during the study. Analysis of variation in cost was performed using encounter data from these hospitals only.

b

The ICCs and number of outlier hospitals were calculated using costs that were adjusted for patient age, sex, number of complex chronic conditions present, material deprivation, and rural vs urban classification.

c

Total number of distinct outlier hospitals for each condition. For some conditions, the total number does not equal the sum of low- and high-cost outlier hospitals because some of these hospitals were reported as both low- and high-cost outlier hospitals.

d

Analysis of variation in cost was not performed for extreme immaturity of newborn and acute lymphoid leukemia because there were <10 hospitals with >25 encounters for each of the conditions.

Prevalence and Cost by Hospital Type

At general hospitals, the median annual volume of encounters was 53.6 (IQR, 4.0-757.2), whereas in pediatric hospitals, the median annual volume was 4117.1 (IQR, 1924.9-7704.4). The volume and cost of inpatient encounters among children in pediatric and general hospitals are shown in eTable 3 in the Supplement.

The rank order of the 25 most prevalent and 25 most costly conditions differed slightly between pediatric and general hospitals (eTable 4 and eTable 5 in the Supplement). In pediatric hospitals, the conditions with the highest prevalence and cost were low birth weight (68.2 per 1000 encounters; $348.1 million) and chemotherapy (28.4 per 1000 encounters; $34.2 million). In general hospitals, the most prevalent and costly conditions were low birth weight (95.9 per 1000 encounters) and other perinatal conditions (89.7 per 1000 encounters), and the most costly were low birth weight ($328.1 million) and preterm newborn ($112.3 million). The percentages of hospital costs and encounters that occurred in pediatric vs general hospitals for all conditions in total and for the most costly and/or most prevalent conditions identified in both hospital types are shown in Figure 2. Overall, inpatient encounters at general hospitals represented 65.0% of all hospital encounters and 43.8% of all hospital costs among children. With regard to the most costly and/or prevalent conditions in both hospital types, most of the hospital costs (59.2%) and encounters (77.0%) occurred in general hospitals.

Figure 2. Costs and Encounters of the Most Costly and Prevalent Conditions in Pediatric and General Hospitals in Ontario, Canada, From 2014 to 2019.

Figure 2.

Open in a new tab

Percentage of hospital costs and encounters for all conditions and for the most costly and/or prevalent conditions (based on the top 25 most prevalent conditions and the top 25 most costly conditions identified for each hospital type in eTable 4 and eTable 5 in the Supplement). Costs were adjusted for inflation to 2018 US dollars (mean 2018 exchange rate: $0.77 US dollars = $1.00 Canadian dollar).

Discussion

This population-based cross-sectional study of health administrative data from Canada’s most populous province identified pediatric hospital conditions with high prevalence, cost, and/or variation in cost from 2014 to 2019. The study included 627 314 hospitalizations among children at all general and pediatric hospitals, finding that 65.0% of encounters and 43.8% of costs occurred at general hospitals. Several mental health and newborn conditions (low birth weight, preterm newborn, major depressive disorder, other perinatal conditions, and neonatal hyperbilirubinemia) had the highest prevalence, cost, and variation in cost across hospitals. Findings from this study can be combined with research priorities identified by patients, caregivers, and clinicians38 to develop a research agenda for investigators and funders conducting research involving hospitalized children. Furthermore, the findings may be used to prioritize hospital quality improvement efforts.

A separate study recently examined the prevalence and cost of conditions in US pediatric hospitals.18 Although it is difficult to compare the current study with the previous US study18 because of differences in health care systems,39 coding systems used (ICD-10-CA vs ICD-10-CM), and hospital types included, we observed several differences in the rank order of conditions. Newborn conditions such as low birth weight, which were ranked higher in cumulative cost in the current study, were ranked lower in cumulative cost in US pediatric hospitals,18 which likely reflects the large role of nonpediatric hospitals in neonatal care as well as potential ICD-10 coding differences. The US study18 also identified fewer mental health conditions as prevalent and costly (2 mental health conditions within the top 50 list compared with 7 mental health conditions in the present study). In 1 study conducted in Ontario between 1991 to 1992 and 1997 to 1998,20 respiratory conditions, such as bronchiolitis and asthma, were the primary reasons for medical hospitalization among children younger than 15 years. In the current study, bronchiolitis was ranked sixth and asthma ranked eighth in the list of most prevalent conditions.

Several mental health conditions were identified among the 50 most prevalent and costly conditions, consistent with recent reports40,41 identifying mental disorders as one of the most common reasons for pediatric hospitalization. A recent study41 reported a 60% increase in hospitalizations for mental disorders among children and youths in Canada from 2008 to 2009 and 2018 to 2019. Beyond the health care system burden, 2 mental health conditions (anxiety disorders and other mental health disorders) also had high variation in cost across hospitals, with the broad category of other mental health disorders having the highest ICC (0.28) of all costly medical conditions (specific mental health diagnoses are available in eTable 1 in the Supplement). The high cost and prevalence of mental health conditions in pediatric hospitalization may be owing to a lack of effective interventions and the presence of barriers to accessing mental health services, including long waiting times for counseling and therapy, lack of available mental health professionals, and challenges regarding access to community-based mental health services.42,43,44,45 In Ontario, rates of outpatient visits have modestly increased, whereas emergency department visits and hospitalizations for mental health among children have substantially increased between 2009 and 2017.46 This difference suggests the presence of barriers to outpatient mental health care and an increase in the prevalence43 and burden of mental illnesses that are severe enough to require hospitalization.46 Our study findings highlight the need to improve care standardization across hospitals and evaluate new mental health interventions for children to identify those that are most cost-effective.

Newborn conditions, such as low birth weight and preterm newborn, were also the most prevalent and costly conditions among hospitalized children. We found that almost one-half (44.8%) of the inpatient encounters occurred among children younger than 30 days. Similar findings were observed in previous Canadian studies.20,40,47 Over the last few decades, research in the field of neonatology has produced advancements in neonatal care, which has been associated with improvements in survival and outcomes among infants.48,49 The high cost and prevalence of newborn conditions observed in our study suggests the need for research to identify cost-effective interventions for this population. In addition to high cost and prevalence, several newborn conditions (eg, intrauterine hypoxia and birth asphyxia) had high variation in cost across hospitals. These conditions represent areas in which better understanding of clinical practice variation is needed to identify whether future research or quality improvement initiatives are required to address them.

Most pediatric hospitalizations in Ontario (65.0%) occurred in general hospitals, which is similar to the 70% previously reported in the US.17 The high prevalence and cost of encounters observed in general hospitals suggest the need for future research to focus on ways to better manage these conditions among children admitted to general hospitals and to prioritize quality improvement efforts toward these areas. Most published studies on hospital use or ways to improve hospital care among children have only included pediatric hospitals.18,30,50,51,52 The lack of inclusion of general hospitals (including community hospitals) in research leaves important clinical care questions in these hospitals unanswered.53 Furthermore, because of differences in hospital characteristics (eg, practice settings), quality improvement initiatives based on research conducted in pediatric hospitals may not be applicable to general hospitals.53 It is important that general hospitals be included in research involving hospitalized children to ensure findings are generalizable and reflect the hospital setting in which most children receive care.53

Limitations

This study has several limitations. First, errors may have occurred when coding the discharge diagnosis, which may have resulted in misclassification of conditions. Second, hospitalization costs were estimated using provincial mean unit costs, and the amount of resources consumed was estimated using the patient’s resource intensity weight. Therefore, the costs do not reflect the actual costs of the resources used and may underestimate the extent of the cost variation.26,54 Third, unmeasured factors (eg, disease severity) may have accounted for a portion of the variation in cost across hospitals. Fourth, a few nonspecific conditions, such as other mental health disorders, had high prevalence, cost, and/or variation in cost across hospitals. Future condition-specific research could focus on examining the specific diagnostic codes underlying these nonspecific conditions. Fifth, our system-level analysis did not examine the condition-specific sources of cost or variation in cost (eg, length of stay). Future condition-specific studies could examine these sources. Sixth, the data used in this study were reported before the COVID-19 pandemic.

Conclusions

This population-based cross-sectional study used health administrative data from Ontario, Canada, to identify conditions with high prevalence, cost, and/or variation in cost as priorities for future research. Several newborn and mental health conditions (low birth weight, preterm newborn, major depressive disorder, other perinatal conditions, and neonatal hyperbilirubinemia) were identified as having the highest prevalence, cost, and variation in cost across hospitals. Findings from this study can be used by investigators and funders to develop a research agenda that includes general hospitals, with the goal of improving the evidence base and outcomes for hospitalized children. Furthermore, the findings may help prioritize hospital quality improvement initiatives to ensure high-quality hospital care is provided to children.

Supplement.

eFigure. Flow Diagram of Cohort Construction

eTable 1. Top 10 ICD-10-CA Most Responsible Diagnosis Codes That Led to Hospital Encounters for Each Nonspecific Pediatric Condition Identified in Children With Inpatient Encounters (From Table 2) in Ontario, 2014-2019

eTable 2. Variation in Cost per Encounter Across General Hospitals for the 25 Conditions With the Highest Cumulative Cost Among Children in Ontario, 2014-2019

eTable 3. Volume and Cost of Inpatient Encounters in Pediatric Hospitals and General Hospitals, 2014-2019

eTable 4. Prevalence and Cost of the 25 Most Costly and 25 Most Prevalent Conditions Among Children With Inpatient Encounters in Pediatric Hospitals in Ontario, 2014-2019

eTable 5. Prevalence and Cost for the 25 Most Costly and 25 Most Prevalent Conditions Among Children With Inpatient Encounters in General Hospitals in Ontario, 2014-2019

Click here for additional data file. (288.1KB, pdf)

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement.

eFigure. Flow Diagram of Cohort Construction

eTable 1. Top 10 ICD-10-CA Most Responsible Diagnosis Codes That Led to Hospital Encounters for Each Nonspecific Pediatric Condition Identified in Children With Inpatient Encounters (From Table 2) in Ontario, 2014-2019

eTable 2. Variation in Cost per Encounter Across General Hospitals for the 25 Conditions With the Highest Cumulative Cost Among Children in Ontario, 2014-2019

eTable 3. Volume and Cost of Inpatient Encounters in Pediatric Hospitals and General Hospitals, 2014-2019

eTable 4. Prevalence and Cost of the 25 Most Costly and 25 Most Prevalent Conditions Among Children With Inpatient Encounters in Pediatric Hospitals in Ontario, 2014-2019

eTable 5. Prevalence and Cost for the 25 Most Costly and 25 Most Prevalent Conditions Among Children With Inpatient Encounters in General Hospitals in Ontario, 2014-2019

Click here for additional data file. (288.1KB, pdf)

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