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. Author manuscript; available in PMC: 2023 Jul 1.
Published in final edited form as: Neurogastroenterol Motil. 2021 Nov 19;34(7):e14288. doi: 10.1111/nmo.14288

United States Healthcare Burden of Pediatric Functional Gastrointestinal Pain Disorder Hospitalizations from 2002 to 2018

John M Hollier 1,2, Jason L Salemi 3,4, Robert J Shulman 1,2,5
PMCID: PMC9117572  NIHMSID: NIHMS1752570  PMID: 34796594

Abstract

Background:

The healthcare burden of pediatric functional gastrointestinal pain disorders (FGIDs) is unclear. Our study aimed to characterize the burden of these hospitalizations in the United States (US).

Methods:

We utilized the US National Inpatient Sample from 2002 to 2018 to capture pediatric hospitalizations (ages 4 to 18 years old) with a primary discharge diagnosis of abdominal pain, constipation, irritable bowel syndrome, dyspepsia, abdominal migraine, cyclic vomiting syndrome, or fecal incontinence. We calculated the FGID hospitalization prevalence rate, length-of-stay (LOS), and inflation-adjusted costs annually and assessed for statistically significant trend changes using joinpoint analyses.

Key Results:

22.3 million pediatric hospitalizations were captured, and 1 in 64 pediatric hospitalizations were attributed to a primary FGID hospitalization. The overall FGID hospitalization prevalence rate initially remained stable but decreased significantly from 2013 to 2018. Constipation and abdominal pain hospitalization rates, respectively, increased and decreased significantly over time. Constipation hospitalizations were more prevalent for younger non-Hispanic Blacks and Hispanics. FGID hospitalization rates stratified by sex were similar. Mean LOS was 2.3 days; average LOS increased significantly from 2002 to 2013 and then stabilized. FGID hospitalization costs averaged $6,216 per admission and increased significantly for all FGIDs except dyspepsia. Endoscopic procedures were the most common interventions.

Conclusions & Inferences:

FGID hospitalization prevalence rates decreased recently, possibly due to national healthcare policy implementation. Nonetheless, constipation admissions increased. LOS was stable in recent years but associated costs-per-hospitalization were increasing over time, probably due to endoscopic procedures. More studies are needed to explain these prevalence and cost trends.

Keywords: constipation, abdominal pain, irritable bowel syndrome, costs, prevalence

Overall Pediatric Functional Gastrointestinal Pain Disorder Hospitalization Prevalence Decreased Significantly after Implementation of the Affordable Care Act

INTRODUCTION

Functional gastrointestinal pain disorders (FGIDs) are a set of chronic abdominal conditions, most of which are associated with abdominal pain; they cannot be attributed to an organic etiology (e.g., urinary tract infection or celiac disease).1–3 These disorders are highly prevalent, affecting about 20% of children and adolescents worldwide.4–12 FGIDs are associated with increased psychosocial distress like anxiety and depression and decreased health-related quality-of-life.4,7,8,13–16 Unfortunately, about 60% of affected children will transition to adults with similar abdominal pain conditions, which costs our healthcare system about $20–30 billion annually in direct and indirect medical costs.17–23

The current healthcare and economic impact of pediatric FGIDs in the United States (US) remains unclear. It is estimated that 2% to 4% of pediatric primary care visits and up to 50% of pediatric gastroenterology specialty office visits are attributable to FGIDs.24,25 A US study of adolescents with chronic pain (which many patients with FGIDs have) estimates a mean cost of about $12,000 per patient, which generalizes to about $19.5 billion annually.26 A Dutch study estimated that children with irritable bowel syndrome (IBS) or functional abdominal pain cost their healthcare system the equivalent of about 550 million US dollars annually (approximately $2,800 per patient).27 Clear estimates of the US healthcare and economic burden of childhood FGIDs are needed.

Most FGID presentations are managed in the outpatient setting, but some affected children may be hospitalized for further medical investigation or pain control.28 Park and colleagues conducted a study covering the years 1997 to 2009 that examined the US healthcare burden of FGID hospitalizations in children and adolescents, noting a temporal increase in hospitalization costs.29 To our knowledge, this previous study was the first to highlight the FGID inpatient economic burden of children in the US. However, it did not include professional fees or adjustments for inflation. The study included children under four years of age, which is not ideal, because younger children have different criteria for diagnosis of a FGID and separate differential diagnoses to consider than do older children.2,30

Given the increasing societal costs for medical care and public expectation of efficient, high-quality care, it is imperative that institutional administrators, third-party payers, policymakers, physicians, and patients have the most accurate and up-to-date information to understand current healthcare utilization trends better. This study provides an updated estimate of the US inpatient burden of childhood FGIDs from 2002 to 2018, stratified by FGID types, patient demographics, and institutional characteristics. We aimed to assess trends in FGID hospitalization prevalence rates, length-of-stay (LOS), and costs including professional fees and adjustments for inflation.

MATERIALS AND Methods

National Inpatient Sample Database Description and Sampling Design

We conducted a cross-sectional, serial secondary analysis of a national inpatient database sponsored by the Agency for Healthcare Research and Quality as part of their Healthcare Cost and Utilization Project (HCUP). Our analysis utilized HCUP’s National Inpatient Sample (NIS), the largest all-payer hospitalization database in the US. The NIS samples nonfederal, non-rehabilitation, short-term community hospitalizations from 22 geographically diverse states, representing about 7 million de-identified patient hospitalizations (35 million weighted) annually. Each hospitalization encounter includes clinical (e.g., discharge diagnoses, LOS, procedures) and nonclinical data like hospitalization costs. The NIS sampling strategy strived to ensure that US hospitalization encounters were generalizable and captured individual facility characteristics (e.g., bed size, ownership, teaching status, urban/rural location, and census region). Before 2012, the NIS used two-stage cluster sampling, first selecting hospitals as the primary sampling units and then including all hospitalizations from selected hospitals in stage two. Starting in 2012, the sampling strategy changed to sample 20% of hospitalizations for all participating hospitals. Our analysis incorporated HCUP-supplied NIS-Trends files to confirm that sampling weights and data elements were defined consistently over time despite the change in sampling design. This study was exempt from our institutional review board’s (IRB) oversight after protocol review.

Patient Selection and Study Outcomes

Our study included hospitalized pediatric patients with FGIDs ages 4 to 18 years. The lower cutoff of 4 years was selected as the minimum age in order to follow pediatric Rome criteria for diagnosis and treatment in children as opposed to infants and toddlers.31 We analyzed annual trends in hospitalization prevalence rates, LOS, and costs from 2002 to 2018. We captured all pediatric patients with a primary FGID discharge diagnosis as identified by the International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9) coding system. Beginning October 1, 2015, we used the Tenth Revision codes (ICD-10) due to the coding change for inpatient settings nationwide. Those FGID admissions with both primary and secondary FGID diagnoses were only analyzed by the primary FGID diagnosis code and the secondary FGID diagnosis code was ignored.

Rome II FGID criteria were published in 1999, and Rome III criteria were published in 2006. All Rome II FGIDs are included in the Rome III criteria, including an additional category that does not have a corresponding ICD-9 or ICD-10 billing code (functional abdominal pain syndrome).1,2 Rome IV criteria were published in 2016; this iteration includes all Rome III types except functional abdominal pain syndrome and changed the Rome III “functional abdominal pain” diagnosis to “functional abdominal pain—not otherwise specified.”2,3 We elected to forgo functional nausea and functional vomiting, which only are in the Rome IV criteria. The Park et al. paper included abdominal pain, constipation, and fecal incontinence, so we also included these diagnoses. FGID types captured by ICD-9 and ICD-10 codes were abdominal pain, constipation, IBS, dyspepsia, abdominal migraine, cyclic vomiting syndrome, and non-retentive fecal incontinence (respective codes are listed in Supplemental Table S1).

National Database Variables

All annual NIS database entries included patient demographics (i.e., age, gender, race/ethnicity, ZIP Code-level income, and hospitalization disposition) and institutional characteristics (i.e., emergency services utilized, patient transferred in or out of the institution, geographic region, hospital size, and type). Study outcomes were comprised of patient-level hospitalization data, including ICD-9 or ICD-10 discharge codes (depending on the observation year), LOS, and associated costs.

Data Analysis

We calculated the average overall (all years) and annual primary FGID hospitalization prevalence rates, LOS, and costs for all FGID diagnoses throughout the observation period. These outcomes were then stratified by the patient demographics and institutional characteristics listed above. These analyses were conducted in SAS 9.4 for Windows (Cary, NC, USA).

Joinpoint regression models assessed whether a statistical trend change occurred during our study timeframe for each outcome. This statistical approach uses a series of straight lines on a log scale to fit the independent outcome trends and identifies specific time points in which the observed trend changes. Our analysis was applied to FGID hospitalization prevalence rates, LOS, and costs as separate dependent variables, and the independent variables were those noted above (i.e., demographics, institutional characteristics). The Monte Carlo permutation method determined the optimal number of joinpoints for each model. The annual percentage change (APC) and its 95% confidence interval for each study outcome were computed using generalized linear modeling.32 These analyses were conducted using the Joinpoint Trend Analysis Software desktop version 4.7.0.0 (Statistical Methodology and Applications Branch, Surveillance Research Program, US National Cancer Institute).

The hospitalization cost data includes direct hospitalization professional fees associated with the hospitalization. Professional fees were included in FGID hospitalization costs through the use of calculated professional fee ratios.33 Professional fee ratios were extrapolated for periods before 2004 and after 2012. Cost estimates were then further adjusted for inflation by utilizing the Producer Price Index for hospitals. All cost data are noted in 2018 US dollars. Percentage of the most common procedures conducted during primary FGID hospitalizations was tabulated to provide insight into observed cost trends.

RESULTS

Overall FGID Hospitalization Prevalence Rates

Pediatric hospitalizations ranged from 1.1 to 1.6 million annually for a total of 22.3 million hospitalizations during the study timeframe. Primary FGID hospitalizations occurred once in every 64 pediatric hospitalizations. FGID hospitalization prevalence rates are summarized in Table 1 and Figure 1. Joinpoint analysis confirms stable overall FGID hospitalization prevalence rates from 2002 to 2013, followed by a significant decrease from 2013 to 2018 (APC2013–2018: −6.8 [95% CI: −9.3,−4.2]).

Table 1.

Primary Pediatric Functional Gastrointestinal Pain Disorder Hospitalization Prevalence Rates from 2002 to 2018 by Patient Demographics and Facility Characteristics

Overall Primary FGID Abdominal Pain Constipation IBS Dyspepsia Abdominal migraine Cyclic Vomiting Syndrome Fecal Incontinence
n Cases per 10K cases n Cases per 10K cases n Cases per 10K cases n Cases per 10K cases n Cases per 10K cases n Cases per 10K cases n Cases per 10K cases n Cases per 10K cases
Overall 350,986 157.3 200,855 90.0 103,152 46.2 9,101 4.1 4,276 1.9 5,305 2.4 24,568 11.0 3,730 1.7
Ages (years old)
 4–6 49,491 163.1 20,601 67.9 22,124 72.9 229 0.8 653 2.2 331 1.1 4,544 15.0 1,009 3.3
 7–9 70,248 220.0 33,714 105.6 28,226 88.4 777 2.4 558 1.7 802 2.5 5,011 15.7 1,161 3.6
 10–12 75,232 232.7 42,271 130.7 23,770 73.5 1,734 5.4 791 2.4 1,176 3.6 4,546 14.1 945 2.9
 13–15 66,827 164.2 41,874 102.9 15,723 38.6 2,561 6.3 859 2.1 1,332 3.3 4,034 9.9 444 1.1
 16–18 89,186 101.6 62,394 71.1 13,309 15.2 3,800 4.3 1,415 1.6 1,665 1.9 6,433 7.3 171 0.2
Race/ethnicity
 NH-White 171,141 180.6 95,154 100.4 50,340 53.1 5,467 5.8 2,418 2.6 3,140 3.3 12,784 13.5 1,839 1.9
 NH-Black 36,421 106.6 17,615 51.5 14,270 41.8 736 2.2 341 1.0 523 1.5 2,606 7.6 331 1.0
 Hispanic 59,560 152.8 36,384 93.3 17,573 45.1 881 2.3 531 1.4 588 1.5 3,042 7.8 560 1.4
 NH-Other 21,160 144.6 11,834 80.9 6,182 42.3 453 3.1 234 1.6 293 2.0 2,003 13.7 161 1.1
Sex
 Male 151,325 156.4 79,717 82.4 51,984 53.7 3,137 3.2 1,644 1.7 1,793 1.9 10,483 10.8 2,568 2.7
 Female 195,390 156.6 117,953 94.6 50,347 40.4 5,896 4.7 2,613 2.1 3,442 2.8 13,986 11.2 1,152 0.9
Payer
 Government 141,538 135.2 73,849 70.5 50,872 48.6 2,737 2.6 1,503 1.4 1,461 1.4 9,249 8.8 1,867 1.8
 Private 182,232 181.6 110,087 109.7 45,271 45.1 5,685 5.7 2,501 2.5 3,522 3.5 13,537 13.5 1,628 1.6
 Other 27,215 150.5 16,918 93.5 7,009 38.8 679 3.8 271 1.5 322 1.8 1,782 9.9 234 1.3
Zip code-level income
 Lowest 97,035 139.9 55,870 80.6 29,567 42.6 2,116 3.1 953 1.4 1,132 1.6 6,320 9.1 1,077 1.6
 2nd 84,452 152.4 48,423 87.4 25,422 45.9 1,864 3.4 1,024 1.8 1,142 2.1 5,516 10.0 1,061 1.9
 3rd 83,536 168.4 46,506 93.7 25,367 51.1 2,453 4.9 1,070 2.2 1,430 2.9 5,907 11.9 804 1.6
 Highest 79,012 180.9 45,728 104.7 21,039 48.2 2,482 5.7 1,124 2.6 1,532 3.5 6,412 14.7 695 1.6
Disposition
 Died 44 6.5 14 2.1 29 4.3 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0
 Routine 337,482 163.3 192,436 93.1 100,433 48.6 8,861 4.3 3,867 1.9 5,177 2.5 23,106 11.2 3,603 1.7
 Transfer 11,730 79.3 7,016 47.4 2,583 17.5 224 1.5 391 2.6 124 0.8 1,270 8.6 121 0.8
 DAMA 1,693 201.4 1,363 162.2 101 12.0 16 1.8 17 2.1 5 0.5 192 22.8 0 0.0
Emergency services
 No 137,154 115.8 63,900 53.9 52,082 44.0 3,926 3.3 2,219 1.9 2,301 1.9 9,564 8.1 3,162 2.7
 Yes 213,832 204.4 136,955 130.9 51,070 48.8 5,175 4.9 2,057 2.0 3,004 2.9 15,003 14.3 568 0.5
Any transfer in
 Yes 21,994 110.3 12,071 60.6 7,194 36.1 658 3.3 254 1.3 359 1.8 1,352 6.8 106 0.5
 No 328,991 161.9 188,783 92.9 95,958 47.2 8,442 4.2 4,022 2.0 4,947 2.4 23,215 11.4 3,624 1.8
Any transfer out
 Yes 8,220 98.5 6,075 72.8 1,034 12.4 166 2.0 86 1.0 60 0.7 780 9.3 20 0.2
 No 342,765 159.6 194,780 90.7 102,118 47.5 8,935 4.2 4,190 2.0 5,245 2.4 23,788 11.1 3,710 1.7
Any transfer in/out
 Yes 29,831 111.0 17,970 66.9 8,109 30.2 800 3.0 329 1.2 414 1.5 2,088 7.8 121 0.4
 No 321,154 163.7 182,884 93.2 95,043 48.4 8,301 4.2 3,947 2.0 4,891 2.5 22,480 11.5 3,609 1.8
Hospital census region
 Northeast 69,675 167.6 42,270 101.7 18,557 44.6 1,647 4.0 698 1.7 1,021 2.5 4,949 11.9 535 1.3
 Midwest 76,569 151.7 43,098 85.4 22,687 45.0 2,293 4.5 1,153 2.3 1,072 2.1 5,224 10.4 1,042 2.1
 South 119,611 142.0 65,713 78.0 36,926 43.8 3,620 4.3 1,481 1.8 2,165 2.6 8,625 10.2 1,080 1.3
 West 85,130 181.7 49,773 106.2 24,982 53.3 1,541 3.3 944 2.0 1,047 2.2 5,771 12.3 1,072 2.3
Hospital bed size
 Small 51,244 165.0 30,386 97.8 14,383 46.3 1,200 3.9 553 1.8 672 2.2 3,662 11.8 387 1.2
 Medium 89,124 161.0 52,013 94.0 24,833 44.9 2,181 3.9 877 1.6 1,289 2.3 6,992 12.6 938 1.7
 Large 209,607 154.5 117,888 86.9 63,684 46.9 5,699 4.2 2,827 2.1 3,307 2.4 13,808 10.2 2,394 1.8
Hospital type
 Rural 34,882 172.0 26,547 130.9 4,825 23.8 596 2.9 195 1.0 262 1.3 2,285 11.3 171 0.8
 Urban, non-teaching 83,707 157.0 61,579 115.5 12,942 24.3 1,868 3.5 566 1.1 1,092 2.0 5,269 9.9 392 0.7
 Urban, teaching 231,386 155.8 112,162 75.5 85,133 57.3 6,617 4.5 3,496 2.4 3,914 2.6 16,909 11.4 3,155 2.1
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DAMA, Discharged against medical advice; IBS, irritable bowel syndrome; NH, Non-Hispanic

Incomplete case totals are due to missing data

Figure 1. Mean Annual Functional Gastrointestinal Pain Disorder Hospitalization Prevalence Rates.

Figure 1.

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FGID, functional gastrointestinal pain disorder; IBS, irritable bowel syndrome

Abdominal pain and constipation were the most common FGIDs throughout the observation period (Table 1). Joinpoint analysis confirmed a significant decrease in abdominal pain hospitalizations (APC2002–2014: −3.9 [95% CI: −4.6,−3.2] and APC2014–2018: −16.1 [95% CI: −20.1,−11.8], Figure 1) and a significant increase in constipation hospitalizations over time (from 24.5 hospitalizations per 10,000 admissions in 2002 to 77.6 per 10,000 in 2018, APC2002–2009: 7.1 [95% CI: 3.0, 11.3]; Figure 1). These analyses also discovered a significant marginal increase in dyspepsia hospitalizations (from 1.5 to 3.5 per 10,000 admissions, APC2002–2018: 2.1 [95% CI: 0.5, 3.7], Figure 1) and an increasing trend for fecal incontinence admissions (from 0.9 to 2.4 per 10,000 admissions; Figure 1). Abdominal migraine admissions increased significantly from 2002 to 2014 (APC: 5.3 [95% CI: 1.9, 8.7], Figure 1) but then decreased significantly from 2014 to 2018 (APC: −17.9 [95% CI: −31.4, −1.6]; Figure 1). Similarly, cyclic vomiting syndrome admissions increased significantly from 2002 to 2014 (APC 4.1 [95% CI: 1.7, 6.6], Figure 1) but subsequently decreased significantly from 2014 to 2018 (APC −21.6 [95% CI: −29.4, −13.0]; Figure 1). IBS annual admission prevalence rates were relatively stable throughout the observation period; the prevalence rate ranged from 3.5 to 4.7 hospitalizations per 10,000 admissions annually (Figure 1).

Prevalence Rates by Age and Gender

Patients ages 10 to 12 years carried the largest burden of FGID hospitalizations compared to other age groups for all years (Table 1 and Supplemental Figure 1). Abdominal pain was the most common discharge FGID diagnosis for all age groups except for the 4- to 6-year-old group where constipation was the most common (Table 1 and Supplemental Figure 1). FGID hospitalization rates significantly increased marginally over time for children ages 4 to 6 years (APC2002–2018: 1.5 [95% CI: 0.5, 3.7]) and were stable for the 7- to 9-year-old age group over time (Supplemental Figure 2). For the 10- to 12-year-old age group, the FGID hospitalization rate was stable until 2013 and decreased significantly afterward (APC2013–2018: −6.8 [95% CI: −10.8, −2.5]; Supplemental Figure 2). Similarly, the 13- to 15-year-old group hospitalization rate was stable from 2002 to 2014 with a significant decrease afterward (APC2014–2018: −11.7 [95% CI: −16.0, −7.3]; Supplemental Figure 2). Lastly, the 16- to 18-year-old group hospitalization rates from 2002 to 2013 did not change but subsequently decreased significantly (APC2013–2018: −10.1 [95% CI: −12.7, −7.4]; Supplemental Figure 2).

There were no sex differences observed for overall FGID hospitalization rates from 2002 to 2013. Thereafter, the hospitalization rates decreased significantly for both males and females (APC2013–2018: −6.1 [95% CI: −9.2, −3.0] and (APC2013–2018: −7.4 [95% CI: −10.2, −4.5], respectively).

Prevalence Rates by Race/Ethnicity

We compared FGID hospitalization prevalence rates by race/ethnicity groups. This figure was calculated by dividing the frequency of FGID admissions for a specific race/ethnicity group by the total number of admissions for the same race/ethnicity group. Non-Hispanic Whites were admitted more often to the hospital with a FGID diagnosis (180.6 non-Hispanic White FGID admissions per 10,000 non-Hispanic White admissions), and non-Hispanic Blacks were admitted least often (106.6 non-Hispanic Black FGID admissions per 10,000 non-Hispanic Black admissions; Table 1 and Supplemental Figure 3). All race/ethnicity groups except the Other race/ethnicity category had non-significant fluctuations in FGID admissions until 2013 when the annual prevalence rate decreased (Supplemental Figure 3). The Other race/ethnicity group had a similar trend until 2014 with a significant precipitous decrease in FGID hospitalizations subsequently (Supplemental Figure 3).

Prevalence Rates by Race/Ethnicity and Age

Our data were stratified by race/ethnicity and age categories to assess whether the FGIDs’ distribution differed (Supplemental Figure 4). Fecal incontinence hospitalizations were a higher proportion of FGID admissions in younger children compared to adolescents (Supplemental Figure 4). Non-Hispanic Blacks had a higher proportion of constipation hospitalizations among all FGID hospitalizations for both the 4- to 6-year-olds and 10- to 12-year-olds compared to other race/ethnicity groups (Supplemental Figure 4). Hispanics had a higher proportion of constipation admissions for the 7- to 9-year-old group (Supplemental Figure 4).

Prevalence Rates by Income

We observed other patient-level factors that affected FGID hospitalization prevalence rates. Higher zip code-level incomes were associated with higher hospitalization rates for overall FGIDs and each type except fecal incontinence (Table 1). As expected, mortality was rare during their hospitalizations, and most hospitalization discharges were routine (Table 1). Most hospitalized patients received emergency department services and were not transferred in or out of the initial treating facility (Table 1).

Prevalence Rates by Insurance Payer Type

FGID admissions were more common for pediatric patients with private insurance than government or Other payer types (Table 1). Government insurance admissions fluctuated throughout our observation period. The prevalence rate stabilized from 2002 to 2009, and then a steady, significant increase was observed (APC2009–2013: 7.7 [95% CI: 0.7, 15.1). From 2013 onward, a significant decrease in FGID hospitalizations was observed (APC2013–2018: −5.2 [95% CI: −7.3, −3.0]). FGID admission rates covered by private insurance remained stable from 2002 to 2014 with a significant decrease afterward (APC2014–2018: −9.9 [95% CI: −14.2, −5.4). FGID hospitalizations covered by Other payer types remained stable throughout the observation period (APC2002–2018: −1.7 [95% CI: −2.6, −0.6]).

Prevalence Rates by Facility Characteristics

There were notable trends between hospital characteristics and FGID hospitalization rates. Hospitals located in the West and Northeast regions had higher FGID hospitalization rates than the rest of the country (181.7 and 167.6 per 10,000 among all regional admissions, respectively; Table 1). The Western region admitted more FGID patients with abdominal pain and constipation (Table 1). No other significant differences by region were noted for any of the FGID subgroups. There were significant decreases in the FGID hospitalization rate towards the latter years in the Midwest (APC2012–2018: −6.2 [95% CI: −8.6, −3.8]) and West (APC2013–2018: −6.5 [95% CI: −11.6, −1.1]). Small and rural hospitals had more FGID hospitalizations compared to other hospital types (Table 1). The constipation hospitalization rate for urban teaching hospitals was more than double that of rural and urban, nonteaching hospitals (57.9 versus 23.8 versus 24.3 per 10,000 hospitalizations among all specific hospital type admissions, respectively; Table 1).

FGID Hospitalization Length-of-Stay (LOS)

The average LOS for a primary FGID hospitalization throughout the observation period was 2.3 days (Table 2). Mean LOS for each FGID is outlined in Table 2 and Figure 2. Joinpoint analyses noted a significant increase in average LOS for all FGID diagnoses from 2002 to 2013 (APC2002 to 2013: 2.5 [95% CI: 1.2, 2.5]) with no significant change onwards. Dyspepsia hospitalizations were consistently longer than other FGIDs (average 5.5 days [range from 3.8 to 7.4 days annually]; Table 2 and Figure 2).

Table 2.

Primary Pediatric Functional Gastrointestinal Pain Disorder Hospitalization Length-of-Stay from 2002 to 2018 by Patient Demographics and Facility Characteristics

Overall Primary FGID Abdominal Pain Constipation IBS Dyspepsia Abdominal migraine Cyclic Vomiting Syndrome Fecal Incontinence
Overall 2.3 2.0 2.4 3.7 5.5 2.9 3.2 2.9
Age, years
 4–6 2.2 1.6 2.3 4.2 6.3 2.6 2.9 2.6
 7–9 2.1 1.7 2.2 3.5 6.0 2.8 3.1 3.0
 10–12 2.2 1.9 2.4 3.6 5.0 2.8 3.3 2.7
 13–15 2.5 2.2 2.6 3.7 5.9 2.9 3.4 3.1
 16–18 2.6 2.3 2.7 3.7 5.1 3.3 3.4 4.5
Race/Ethnicity
 Non-Hispanic Whites 2.4 2.1 2.4 3.5 5.2 2.9 3.2 2.9
 Non-Hispanic Blacks 2.6 2.2 2.5 3.9 8.9 3.5 3.5 3.8
 Hispanics 2.2 1.9 2.3 4.4 6.0 3.0 2.9 2.8
 Non-Hispanic Other 2.3 2.0 2.4 4.5 5.2 3.3 3.2 2.2
Sex
 Male 2.3 1.9 2.4 4.2 6.1 2.7 3.0 2.9
 Female 2.4 2.2 2.4 3.5 5.2 3.1 3.4 3.0
Payer
 Government 2.4 2.1 2.5 3.8 6.8 3.1 3.5 3.0
 Private 2.3 2.0 2.3 3.6 4.6 2.9 3.1 2.7
 Other 2.2 1.9 2.3 4.4 7.0 2.6 2.8 3.6
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Numbers represent duration of primary FGID hospitalizations in days

FGID, functional gastrointestinal pain disorders; IBS, irritable bowel syndrome

Figure 2. Mean Annual Functional Gastrointestinal Pain Disorder Hospitalization Length of Stay.

Figure 2.

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FGID, functional gastrointestinal pain disorder; IBS, irritable bowel syndrome

FGID Hospitalization Costs

The average inflation-adjusted cost for a primary FGID hospitalization was $6,292 during the observation period. Annual cost data for primary FGID admissions is summarized in Table 3 and Figure 3. Our analysis showed that all FGIDs except dyspepsia admission costs increased significantly from 2002 to 2018 and the APC ranged from 1.7 to 4.3 (Supplemental Table 2). Cost trends for non-FGID admissions initially did not change but then increased from 2009 to 2018 (APC: 3.5 [95% CI: 2.2, 4.8]). Dyspepsia mean hospitalization cost was $13,826 and was higher than other FGID admissions throughout the observation period (range from $9,686 to $21,627, Table 3 and Figure 3). The average IBS hospitalization cost was $9,504 and ranged from $7,261 to $14,579 annually during this timeframe (Table 3 and Figure 3).

Table 3.

Primary Pediatric Functional Gastrointestinal Pain Disorder Hospitalization Costs from 2002 to 2018 by Patient Demographics and Facility Characteristics

Overall Primary FGID Abdominal Pain Constipation IBS Dyspepsia Abdominal migraine Cyclic Vomiting Syndrome Fecal Incontinence
Overall 6,216 5,893 5,879 9,685 13,826 6,983 7,250 7,796
Ages, years
 4–6 5,261 4,404 5,264 12,628 14,498 7,446 6,921 6,583
 7–9 5,302 4,783 5,160 8,830 17,542 6,415 6,721 8,513
 10–12 5,915 5,479 5,824 9,431 12,031 6,138 7,700 6,896
 13–15 6,686 6,256 6,705 9,578 14,913 6,739 7,247 8,462
 16–18 7,367 7,009 7,539 9,854 12,354 7,987 7,586 13,425
Race/Ethnicity
 Non-Hispanic Whites 6,361 6,035 6,161 8,853 13,220 6,548 6,920 8,059
 Non-Hispanic Blacks 6,262 6,080 5,496 9,746 18,931 8,908 7,934 10,776
 Hispanics 6,000 5,550 5,859 14,351 15,248 7,735 7,499 7,285
 Other 6,589 6,083 6,020 14,496 13,536 7,573 8,524 6,960
Sex
 Male 5,947 5,387 5,877 11,184 15,717 6,626 6,938 7,418
 Female 6,450 6,255 5,908 8,934 12,673 7,209 7,488 8,573
Payer
 Government 6,032 5,745 5,610 9,561 16,032 7,015 7,502 7,502
 Private 6,394 6,055 6,227 9,224 12,184 7,025 7,101 7,839
 Other 6,023 5,512 5,648 13,932 16,019 6,419 7,022 9,805
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Hospitalization costs figures are reflected in 2018 United States Dollars

Figure 3. Mean Annual Functional Gastrointestinal Pain Disorder Hospitalization Inflation-Adjusted Costs.

Figure 3.

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Costs are inflation-adjusted to 2018 United States dollars. FGID, functional gastrointestinal pain disorder; IBS, irritable bowel syndrome; US, United States

FGID hospitalization costs increased with older patients, particularly in the 16- to 18-year-old group (Table 3). Regarding race/ethnicity, admission costs for the Other race/ethnicity group were most expensive (Table 3). Hospitalizations for female patients were more expensive than for males for all FGIDs ($6,412 females versus $5,528 males), and hospitalizations supported by private insurance payers were more expensive than government-sponsored payer programs ($6,217 private versus $5,864 government; Table 3).

Procedure Frequency during FGID Hospitalizations

The most common procedures from 2002 to third-quarter 2015 indicated by ICD-9 procedure codes were esophagogastroduodenoscopy with closed biopsy, closed [endoscopic] biopsy of the large intestine, and computerized axial tomography of the abdomen (Table 4). IBS and dyspepsia admissions more commonly utilized upper endoscopy (55% and 38%, respectively) and lower endoscopy (52% and 7%, respectively) compared to other FGIDs (Table 4). The frequency of procedures conducted during primary FGID hospitalizations from the fourth quarter of 2015 to 2018 (based on ICD-10 procedure billing codes) is outlined in Table 5. Of the 15 most frequent procedures conducted for all FGID admissions, 13 were related to endoscopic procedures (Table 5). As high as 69% of IBS admissions and 41% of dyspepsia admissions had an endoscopic procedure performed.

Table 4.

Most Frequent ICD-9 Procedure Codes for Primary Functional Gastrointestinal Pain Disorder Hospitalizations from Year 2002 to Third Quarter 2015

ICD-9 Procedure Code ICD-9 Procedure Code Description All FGIDs Abdominal Pain Constipation IBS Dyspepsia Abdominal Migraine Cyclic Vomiting Syndrome Fecal Incontinence
4516 EGD with closed biopsy 22.47 23.4 11.16 55.21 37.56 18.51 38.82 4.58
4525 Closed [endoscopic] biopsy of large intestine 13.74 13.49 11.49 52.46 7.24 4.98 4.87 4.58
8801 Computerized axial tomography of abdomen 11.92 17.23 6.07 4.07 2.26 1.78 2.44 1.15
4701 Laparoscopic appendectomy 9.47 16.23 0.35 0.24 0 0.36 0.35 0.57
8876 Diagnostic ultrasound of abdomen and retroperitoneum 6.6 8.77 4.58 2.51 2.04 1.07 3.05 0
9607 Insertion of other (naso-) gastric tube 6.42 0.94 20.54 1.44 2.49 0.36 1.57 15.19
4824 Closed [endoscopic] biopsy of rectum 5.45 3.91 8.03 17.6 2.04 1.78 2.35 4.87
4709 Other appendectomy 5.17 8.82 0.31 0 0.23 0.36 0 0.29
9929 Injection or infusion of other therapeutic or prophylactic substance 4.28 4.62 3.5 2.87 2.04 3.56 7.22 2.01
4523 Colonoscopy 3.85 2.63 6.62 9.7 1.13 0.36 0.87 4.58
8939 Other nonoperative measurements and examinations 3.35 0.64 9.55 0.72 7.47 0.71 1.83 8.31
4513 Other endoscopy of small intestine 3.18 3.6 1.08 6.11 9.73 2.14 4.7 0.29
9638 Impacted feces removal 3.09 0.05 10.94 0.24 0.23 0 0.44 8.6
5421 Laparoscopy 2.73 3.91 1.27 1.2 0.9 0.36 0.26 2.87
966 Enteral infusion of concentrated nutritional substances 2.7 0.79 4.54 0.72 14.03 2.14 10.44 0.86
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Numbers represent the percentage of specific FGID discharge hospitalizations that had a specific procedure

EGD, esophagogastroduodenoscopy; FGIDs, functional gastrointestinal pain disorders; IBS, irritable bowel syndrome; ICD-9, International Classification of Diseases, Ninth Edition

Table 5.

Most Frequent ICD-10 Procedure Codes for Primary Functional Gastrointestinal Pain Disorder Hospitalizations from Fourth Quarter 2015 to 2018

ICD-10 Procedure Code ICD-10 Procedure Code Description All FGIDs Abdominal Pain Constipation IBS Dyspepsia Abdominal Migraine Cyclic Vomiting Syndrome Fecal Incontinence
0DB98ZX Excision of Duodenum, Via Natural or Artificial Opening Endoscopic, Diagnostic 28.01 42.95 14.45 68.97 36.46 26.47 37.58 2.94
0DB68ZX Excision of Stomach, Via Natural or Artificial Opening Endoscopic, Diagnostic 25.61 39.32 12.51 65.52 40.63 26.47 33.33 2.94
0DBB8ZX Excision of Ileum, Via Natural or Artificial Opening Endoscopic, Diagnostic 15.27 23.18 10.05 47.7 4.17 0 3.03 1.47
0DB38ZX Excision of Lower Esophagus, Via Natural or Artificial Opening Endoscopic, Diagnostic 14.83 22.05 7.58 33.91 20.83 20.59 24.24 2.94
0DBP8ZX Excision of Rectum, Via Natural or Artificial Opening Endoscopic, Diagnostic 12.23 16.25 7.97 47.7 4.17 0 4.24 2.94
0DBN8ZX Excision of Sigmoid Colon, Via Natural or Artificial Opening Endoscopic, Diagnostic 11.69 14.66 8.1 46.55 5.21 0 3.64 0
0DB58ZX Excision of Esophagus, Via Natural or Artificial Opening Endoscopic, Diagnostic 11.59 18.3 5.96 28.16 15.63 8.82 13.94 0
0DBL8ZX Excision of Transverse Colon, Via Natural or Artificial Opening Endoscopic, Diagnostic 10.07 14.43 5.44 45.4 3.13 0 2.42 1.47
0DBH8ZX Excision of Cecum, Via Natural or Artificial Opening Endoscopic, Diagnostic 9.66 13.41 6.68 32.76 3.13 0 2.42 1.47
0DBK8ZX Excision of Ascending Colon, Via Natural or Artificial Opening Endoscopic, Diagnostic 8.68 12.84 5.25 32.76 2.08 0 1.82 1.47
0DBM8ZX Excision of Descending Colon, Via Natural or Artificial Opening Endoscopic, Diagnostic 8.58 12.16 5.44 33.91 1.04 0 1.21 1.47
0DH673Z Insertion of Infusion Device into Stomach, Via Natural or Artificial Opening 7.43 0.45 13.42 1.72 1.04 0 0 7.35
0DB18ZX Excision of Upper Esophagus, Via Natural or Artificial Opening Endoscopic, Diagnostic 5.68 8.86 2.98 11.49 8.33 2.94 8.48 1.47
0DB28ZX Excision of Middle Esophagus, Via Natural or Artificial Opening Endoscopic, Diagnostic 5.34 7.05 3.18 13.22 3.13 11.76 10.3 0
0D9670Z Drainage of Stomach with Drainage Device, Via Natural or Artificial Opening 5.1 0.8 9.07 0.57 1.04 0 0 2.94
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Numbers represent the percentage of specific FGID discharge hospitalizations that had a specific procedure

EGD, esophagogastroduodenoscopy; FGIDs, functional gastrointestinal pain disorders; IBS, irritable bowel syndrome; ICD-10, International Classification of Diseases, Tenth Edition

DISCUSSION

Our study quantified the healthcare and economic burden of FGID hospitalizations among US children over a recent 17-year time span. Our approach expanded on a previous study that evaluated costs up to 2009: inpatient prevalence rates, average hospitalization LOS, and average hospital charges associated with FGID admissions.29 First, we focused on pediatric patients 4 to 18 years of age to coincide with expert guidelines for diagnosing and treating children with FGIDs.31 Second, we incorporated professional fees and adjusted overall hospitalization costs for inflation over time. Third, we utilized specific Rome II, III, and IV criteria for diagnosing FGIDs and their respective ICD-9 and ICD-10 billing codes, when available, for capturing primary FGID hospitalizations.2,34,35 These processes cumulatively permit a thorough analysis of well-vetted national inpatient data for an accurate and current assessment of pediatric inpatient FGID healthcare and economic burdens.

The overall FGID hospitalization prevalence rates were relatively stable over time with a significant decrease occurring from 2014 to 2018. This observation remained even when the data were stratified by age, sex, FGID type, zip code-associated income levels, insurance type, and hospital country regions.

The decline in hospitalizations may be related to provider-level factors. For example, the transition from ICD-9 to ICD-10 billing codes could influence the coding behavior and patterns of clinicians managing these patients; however, this rationale does not explain the observed change completely considering the ICD-9 to ICD-10 transition occurred in the latter portion of 2015. Dissemination of clinical guidelines for FGIDs may have influenced clinical decision-making, but the most recent clinical guidelines for FGIDs and constipation were published in 2006 and 2014, respectively.31,36 Despite the common inflection point of 2014, constipation prevalence rates ironically increased consistently despite the dissemination of the guideline. This observation may be due to known poor dissemination and implementation of clinical guidelines in general.37

Implementation of changes in national healthcare policy may be partially responsible for the observed trend. Most importantly, the Affordable Care Act (ACA) was passed in 2010 but not fully implemented until January 2014. This legislation improved access to health insurance for low-income adults by expanding Medicaid and the Children’s Health Insurance Program (CHIP). Opportunities for parents to enroll through Medicaid expansion indirectly increased enrollment of their previously eligible but unenrolled children to Medicaid or CHIP coverage.38,39 Increasing access to these government-sponsored safety-net health insurance programs and compelling middle-class Americans to obtain health insurance could have affected inpatient healthcare utilization for FGIDs by offering greater access to outpatient evaluation. The classic RAND Health Insurance Experiment revealed patients increase healthcare expenditures as their cost-sharing decreases for medical services without consequence to health status for the average person.40 However, the relationship between inpatient and outpatient utilization on healthcare expenditures is unclear. The RAND Health Insurance Experiment and other studies suggest outpatient and inpatient healthcare utilization are positively associated with total medical expenditures (e.g., outpatient and inpatient utilization increase together [complementation]).40,41 Other adult studies note a negative association between inpatient and outpatient care on medical expenditures (e.g., inpatient utilization increases as outpatient utilization decreases [substitution]).42–44 Further research is needed to explore the possible role of the ACA and other healthcare policy initiatives on pediatric FGID hospitalizations and ambulatory care utilization.

FGID hospitalization prevalence rates for people of color in the US were consistently lower than for non-Hispanic Whites, especially for non-Hispanic Blacks. This differential in FGID hospitalizations may reflect intrinsic patient-level or extrinsic system-level factors. We can speculate that affected non-Hispanic White children may be more susceptible to more severe abdominal pain episodes requiring inpatient evaluation or have better access to insurance and healthcare compared to other race/ethnicity groups. Alternatively, clinician adherence to FGID guidelines that discourage unnecessary healthcare utilization may be practiced more often for affected minorities.31 However, we also cannot ignore that implicit bias can impact clinician decision-making and downstream healthcare utilization outcomes, especially for pain. Implicit bias is defined as “attitudes or stereotypes that impact understanding, actions, and decisions in an unconscious manner.”45 Inherent stereotypes may affect knowledge and the delivery of healthcare. A previous study discovered non-Hispanic White medical trainees held false biological beliefs when comparing pain of non-Hispanic Whites versus non-Hispanic Blacks.46 Goyal et al. revealed differential clinical management by race/ethnicity in the emergency room setting for children who presented with long bone fractures and appendicitis; minorities were less likely to receive opioids and optimal pain reduction.47,48 More studies are needed to delineate whether innate characteristics, barriers to healthcare, proper application of clinical guidelines, or other factors explain these observed prevalence trends.

Primary FGID hospitalization average LOS was stable towards the latter portion of the observation period, yet hospitalization costs outpaced non-FGID hospitalizations despite adjustments for medical-related inflation. Park et al. also detected a stable average LOS and increasing hospitalization charges up to 2009.29 Our study shows dyspepsia and IBS hospitalizations were associated with longer LOS and more frequent endoscopic procedures compared to other FGIDs, which coincides with the most expensive average annual hospitalization costs. Future work is needed to explore what factors account for these findings. This knowledge could raise awareness about critical factors that may influence medical care and prevent unnecessary procedures for this vulnerable chronic pain population.

Constipation admission rates are increasing annually despite a 2014 clinical guideline that provides treatment recommendations.36 We are concerned that the dissemination of these guidelines may not have changed clinical practice.49 Physician resistance to change clinical practice is influenced by knowledge, attitude, and perceptions of new evidence-based guidelines.50 This constipation guideline may be perceived as ineffective, which would prevent long-term practice change. There also may be caregiver hesitation to use polyethylene glycol 3350 as a maintenance medication to treat constipation. This now first-line treatment was reported to the Food and Drug Administration last decade for a possible association with neuropsychiatric events in children, such as seizures, aggression, and mood swings. However, this myth was debunked through a clinical trial, but negative public perception of polyethylene glycol 3350 may persist.51,52

National healthcare utilization databases have limitations. We cannot validate whether the FGID hospitalizations captured met clinical criteria for a Rome II, III, or IVFGID. Further, we cannot validate whether included primary FGID hospitalizations with symptoms like abdominal pain, constipation, or fecal incontinence were attributed to an organic etiology. Towards the end of our observation period, the medical billing coding changed from ICD-9 to ICD-10 and coding by discharge attending physicians could have been affected by the new coding scheme. Nonetheless, our ICD-9 and ICD-10 billing codes were comprehensive and represented the key Rome II, III, and IV FGIDs. Our hospitalization cost data included professional fees, which were calculated using a professional fee ratio.33 These ratios were extrapolated for years before 2004 and after 2012. However, we are confident these professional fee extrapolations are fair estimates of the overall FGID cost burden. Strengths of our study include the use of the most comprehensive database available; the use of pediatric Rome criteria applied to the appropriate age groups (i.e., four years of age and up); and accounting for inflation and professional fees.

In summary, the healthcare burden of pediatric FGID hospitalizations may be decreasing in recent years, but the inflation-adjusted costs of these hospitalizations are increasing significantly despite stable LOS. There also are discrepancies in hospitalizations based on race/ethnicity and socioeconomic status. More studies exploring potential contributing factors at the patient, provider, and national policy level are needed to assure appropriate levels of hospitalization and medical testing in this vulnerable patient population.

Supplementary Material

fS2

Supplemental Figure 2. Mean Annual Functional Gastrointestinal Disorder Hospitalization Prevalence Rates by Age. FGID, functional gastrointestinal pain disorder; IBS, irritable bowel syndrome

fS3

Supplemental Figure 3. Mean Annual Functional Gastrointestinal Pain Disorder Hospitalization Prevalence Rates by Race/Ethnicity. FGID, functional gastrointestinal pain disorder; IBS, irritable bowel syndrome

fS1

Supplemental Figure 1. Distribution of Functional Gastrointestinal Pain Disorder Hospitalizations by Age from 2002 to 2018. FGID, functional gastrointestinal pain disorder; IBS, irritable bowel syndrome

tS1
tS2
fS4

Supplemental Figure 4. Distribution of Functional Gastrointestinal Pain Disorder Hospitalizations by Age and Race/Ethnicity from 2002 to 2018. FGID, functional gastrointestinal pain disorder; HISP, Hispanics; IBS, irritable bowel syndrome, NHB, non-Hispanic Blacks; NHW, non-Hispanic Whites

Acknowledgments

The authors would like to thank Beverly Porter, who assisted with devising a strategy to capture and characterize ICD-9 and ICD-10 hospital and procedure codes for FGID admissions. Drs. David R. Lairson and Wenyaw Chan graciously provided insight into health economic perspectives applied to our research findings.

Funding

All phases of this study was supported by NIH grant, K23 DK120928 (JMH), R01 NR013497 (RJS), R01 NR005337 (RJS), and the Daffy’s Foundation (RJS). This study also was supported by Baylor College of Medicine’s Center of Excellence in Health Equity, Training, and Research through a grant sponsored by the Health Resources and Services Administration (Grant No. D34HP31024) and P30 DK056338, which funds the Texas Medical Center Digestive Disease Center. One author was supported by the US Department of Agriculture/ARS under Cooperative Agreement 58-3092-0-001 (RJS). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. This work is a publication of the USDA/ARS Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital. The contents do not necessarily reflect the views or policies of the USDA, nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government.

Footnotes

Disclosures: All authors do not have any disclosures or conflicts of interest to report.

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Associated Data

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

Supplementary Materials

fS2

Supplemental Figure 2. Mean Annual Functional Gastrointestinal Disorder Hospitalization Prevalence Rates by Age. FGID, functional gastrointestinal pain disorder; IBS, irritable bowel syndrome

NIHMS1752570-supplement-fS2.tif (53.8KB, tif)
fS3

Supplemental Figure 3. Mean Annual Functional Gastrointestinal Pain Disorder Hospitalization Prevalence Rates by Race/Ethnicity. FGID, functional gastrointestinal pain disorder; IBS, irritable bowel syndrome

NIHMS1752570-supplement-fS3.tif (71.8KB, tif)
fS1

Supplemental Figure 1. Distribution of Functional Gastrointestinal Pain Disorder Hospitalizations by Age from 2002 to 2018. FGID, functional gastrointestinal pain disorder; IBS, irritable bowel syndrome

NIHMS1752570-supplement-fS1.tif (355.5KB, tif)
tS1
NIHMS1752570-supplement-tS1.docx (12.6KB, docx)
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NIHMS1752570-supplement-tS2.docx (12.4KB, docx)
fS4

Supplemental Figure 4. Distribution of Functional Gastrointestinal Pain Disorder Hospitalizations by Age and Race/Ethnicity from 2002 to 2018. FGID, functional gastrointestinal pain disorder; HISP, Hispanics; IBS, irritable bowel syndrome, NHB, non-Hispanic Blacks; NHW, non-Hispanic Whites

NIHMS1752570-supplement-fS4.tif (429.3KB, tif)

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