Statistical Brief #37Pediatric Hospital Stays for Cancer, 2005

General characteristics of pediatric hospital stays for cancer

Table 1 presents utilization and cost information for the treatment of pediatric cancer in U.S. community hospitals compared with all hospital stays for children and adolescents (excluding newborns). Relative to all pediatric hospitalizations, stays for cancer care were more than twice as expensive ($17,500 compared with $8,500 per stay) and about two days longer than the typical stay (6.4 versus 4.5 days). The high cost of cancer treatment was not solely due to longer hospital stays, but was also a result of more intensive treatment during each stay. The mean cost per day for pediatric cancer patients was nearly $1,000 more than the average per day hospital costs among all children and adolescents ($2,700 versus $1,900 per day).

Compared with adult cancer stays (table 2), pediatric cancer stays were, on average, more expensive ($17,500 versus $12,100) even though adult cancer patients averaged about the same amount of time, slightly over 6 days, in the hospital. The average cost per day of each child cancer stay was $700 more expensive than adult cancer stays, indicating more intensive treatment. The aggregate costs of inpatient cancer treatment for children and adolescents totaled $1.7 billion in 2005 compared with $22.3 billion for adult cancer care.

In terms of demographic characteristics, pediatric cancer patients were about 2 years older than the typical pediatric patient (8.4 versus 6.4 years old), and the likelihood of hospitalization did not vary significantly by gender. These stays originated in the emergency department far less frequently than all pediatric stays (8.8 versus 43.5 percent), but were just as likely to result in death at the hospital. In-hospital mortality for pediatric patients was rare, at less than 1 percent. The in-hospital death rate in adult cancer stays was comparable at 1 percent, but a larger portion of adults were admitted from the emergency department (22.0 percent).

Characteristics of two common pediatric cancers: leukemias and brain tumors

Table 3 provides detailed information about inpatient cancer care for the top 10 most common pediatric cancer conditions that required hospitalization. Among children and adolescents, the most common cancer stays were for leukemias and brain tumors. Collectively, leukemias and brain tumors accounted for about 16,200 stays, or over a third of all pediatric cancer stays (excluding stays that were principally for maintenance chemotherapy and radiation). The increasing volume of pediatric leukemia and brain tumor stays drove the aforementioned increase in total pediatric cancer stays from 2000 to 2005 with 76.2 percent and 83.4 percent increases, respectively (from 5,700 to 10,100 leukemia stays and 3,300 to 6,100 brain tumor stays) (figure 1). The increase in the average costs of leukemia and brain tumor stays was similar to that of all cancer stays (about 20 percent).

Leukemia, by far, was the most expensive pediatric cancer to treat (mean cost of $47,000 per stay) and had the longest average length of stay (16.1 days). Treatment costs for brain tumors were also high at $28,300 per stay, and patients remained in the hospital, on average, for 9.0 days. The total aggregate costs for treatment of these two cancers was over $653 million in 2005, accounting for 38.3 percent of the total costs for pediatric cancer care and 2.7 percent of the total costs for all hospital stays for children and adolescents.

Among adults, leukemias were the 16th most common cancer condition requiring hospitalization and brain tumors were the 18th (data not shown). Adult hospitalizations for these two conditions were much less expensive and shorter compared with child stays for the same conditions: $31,000 per leukemia hospitalization, with a mean length of stay of 14.4 days, and $16,700 per brain tumor hospitalization, with a mean length of stay of 7.3 days. While leukemias and brain tumors required the most hospital stays in children, hospitalizations for cancers of the uterus, lung, breast, and colon were much more common in adults.

Pediatric cancer stays, by age

Pediatric cancer patients were, on average, older than the typical pediatric patient. Cancer stays for children were most prevalent in the 1 to 4 year age group (representing 26.3 percent of stays) and the 10 to 14 age group (representing 24.5 percent of stays) (figure 2). This is in contrast to the typical non-newborn pediatric hospital stay for which the youngest children—under 1 year of age—accounted for the largest percentage of hospital stays (28.2 percent). This youngest age group accounted for only 8.2 percent of cancer stays.

Pediatric leukemia and brain tumor patients were, on average, about 8 years of age, which was comparable with the mean age of all pediatric cancer patients and over a year older than the average pediatric patient (6.4 years).

Pediatric cancer stays, by payer

Private insurance was billed for the largest portion of inpatient pediatric cancer care: 58.8 percent of stays in 2005 (figure 3). Medicaid was billed for about a third of pediatric cancer stays. A small percentage of hospitalizations (3.1 percent) were uninsured and the remaining stays (5.6 percent) were billed to “other” insurance types, such as TRICARE and Title V. Pediatric leukemia and brain tumor hospitalizations showed a similar pattern—private insurers were billed for about 60 percent and Medicaid for about 30 percent of cancer stays (data not shown). This is in contrast to billing practices for all pediatric hospital stays for which Medicaid and private insurance shared an equal responsibility of pediatric stays, with each insurer being billed for just over 45 percent of all child and adolescent hospitalizations in 2005.

For adult cancer stays, Medicare and private insurance were each billed for over 40 percent of stays (data not shown). However, government insurers played a more significant role in adult cancer stays, with an additional 8.3 percent of stays being billed to Medicaid. In total, about half of all adult cancer stays were billed to government payers, while only a third of child cancer stays were billed to the government.

Types of hospitals included in HCUP

HCUP is based on data from community hospitals, defined as short-term, non-Federal, general and other hospitals, excluding hospital units of other institutions (e.g., prisons). HCUP data include OB-GYN, ENT, orthopedic, cancer, pediatric, public, and academic medical hospitals. They exclude long-term care, rehabilitation, psychiatric, and alcoholism and chemical dependency hospitals, but these types of discharges are included if they are from community hospitals.

Unit of analysis

The unit of analysis is the hospital discharge (i.e., the hospital stay), not a person or patient. This means that a person who is admitted to the hospital multiple times in one year will be counted each time as a separate “discharge” from the hospital.

Costs and charges

Total hospital charges were converted to costs using HCUP cost-to-charge ratios based on hospital accounting reports from the Centers for Medicare and Medicaid Services (CMS).⁶ Costs will tend to reflect the actual costs of production, while charges represent what the hospital billed for the case. For each hospital, a hospital-wide cost-to-charge ratio is used because detailed charges are not available across all HCUP States. Hospital charges reflect the amount the hospital charged for the entire hospital stay and does not include professional (physician) fees.

Cost-to-charge ratios for 2005 will not be available until later this year. For the purposes of this Statistical Brief, the 2005 ratios were estimated by multiplying the 2004 ratio for each hospital by 0.96, which represents the average annual change exhibited in the cost-to-charge ratios over the past few years. Cost estimates for 2000 are reflected in 2005 dollars based on the Bureau of Labor Statistics Consumer Price Index All Urban Consumers (CPI-U) U.S. city average. All costs are reported to the nearest hundreds.

Payer

Payer is the expected payer for the hospital stay. To make coding uniform across all HCUP data sources, payer combines detailed categories into more general groups:

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Medicaid includes fee-for-service and managed care Medicaid patients. Patients covered by the State Children’s Health Insurance Program (SCHIP) may be included here. Because most state data do not identify SCHIP patients specifically, it is not possible to present this information separately.

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Private insurance includes Blue Cross, commercial carriers, and private HMOs and PPOs.

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Other includes Worker’s Compensation, TRICARE/CHAMPUS, CHAMPVA, Title V, and other government programs. Note: For this brief, when discussing pediatric stays Medicare is included in the “other” category due to the small number of children covered by the Medicare program. For adult stays, Medicare is reported as a separate category.

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Uninsured includes an insurance status of “self-pay” and “no charge.”

When more than one payer is listed for a hospital discharge, the first-listed payer is used.

Diagnoses, ICD-9-CM, and Clinical Classifications Software (CCS)

The principal diagnosis is that condition established after study to be chiefly responsible for the patient’s admission to the hospital. Secondary diagnoses are concomitant conditions that coexist at the time of admission or that develop during the stay. All-listed diagnoses include the principal diagnosis plus these additional secondary conditions.

ICD-9-CM is the International Classification of Diseases, Ninth Revision, Clinical Modification, which assigns numeric codes to diagnoses. There are about 12,000 ICD-9-CM diagnosis codes.

CCS categorizes ICD-9-CM diagnoses into 260 clinically meaningful categories.⁷ This “clinical grouper” makes it easier to quickly understand patterns of diagnoses and procedures.

For this report, pediatric cancer stays were defined as the following CCS diagnosis categories (italicized diagnoses are discussed in more depth in this brief):

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11: Cancer of head and neck

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12: Cancer of esophagus

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13: Cancer of stomach

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14: Cancer of colon

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15: Cancer of rectum and anus

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16: Cancer of liver and bile duct in liver

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17: Cancer of pancreas

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18: Cancer of other gastrointestinal organs and lining of abdominal cavity (peritoneum)

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19: Cancer of bronchial tubes and lung

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20: Other respiratory and chest cancers (intrathoracic)

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21: Cancer of bone

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22: Skin melanoma

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23: Skin cancer other than melanoma

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24: Breast cancer

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25: Cancer of uterus

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26: Cancer of cervix

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27: Cancer of ovary

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28: Other female genital cancer

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29: Prostate cancer

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30: Cancer of testicle

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31: Other male genital cancer

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32: Bladder cancer

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33: Kidney cancer

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34: Other urinary cancer

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35: Brain cancer and other nervous system cancer

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36: Thyroid cancer

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37: Hodgkin’s disease

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38: Non-Hodgkin’s lymphoma

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39: Cancer of blood (leukemia)

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40: Multiple myeloma

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41: Other and unspecified cancer

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42: Metastasis (spread of cancer or secondary cancer)

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43: Cancer without specification of site

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44: Tumors of unspecified nature or uncertain behavior

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45: Chemotherapy and radiation therapy

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46: Benign tumor of the uterus

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47: Other and unspecified benign tumor

Admission source

Admission source indicates where the patient was located prior to admission to the hospital. Emergency admission indicates the patient was admitted to the hospital through the emergency department.

Discharge status

Discharge status indicates the disposition of the patient at discharge from the hospital, and includes the following six categories: routine (to home), transfer to another short-term hospital, other transfers (including skilled nursing facility, intermediate care, and another type of facility such as a nursing home), home health care, against medical advice (AMA), or died in the hospital.