Long-Term Health Care Utilization After Cardiac Surgery in Children Covered Under Medicaid
Sarah CrookKacie DraganJoyce WooMatthew NeidellPengfei JiangStephen C. CookEdward L. HannanJane W. NewburgerMarshall L. JacobsEmile BachaChristopher J. PetitRobert VincentKathleen Walsh-SpoonhowerRalph S. MoscaT. K. Susheel KumarNeil DevejianSteven A. KamenirGeorge M. AlfierisMichael F. SwartzDavid MeyerE. PaulJohn BillingsBrett R. Anderson
Key result
Pediatric cardiac surgery is linked to ~22-fold higher monthly healthcare expenditures in the first year.
- n=10,463
Why the study?
Understanding the longitudinal burden of healthcare expenditures and utilization after pediatric cardiac surgery is needed to counsel families, improve care, and reduce outcome inequities.
Does pediatric cardiac surgery increase long-term healthcare expenditures and utilization compared to matched non-cardiac children in a Medicaid population, and what are the predictors of this utilization?
Key Points
- To evaluate longitudinal healthcare expenditures and multidimensional healthcare utilization among Medicaid-insured children following pediatric cardiac surgery compared to matched non-cardiac controls.
- Linked the New York State CHS-COLOUR clinical registry (2006–2019) with longitudinal Medicaid claims through 2019 for 5,241 children aged ≤18 years undergoing cardiac surgery and matched non-cardiac comparators.
- Modeled healthcare expenditures and utilization across inpatient admissions, emergency department visits, primary care, and subspecialist visits using log-linear and Poisson regression models.
- Monthly expenditures for cardiac surgical patients exceeded non-cardiac comparators in year 1 ($15.5K [SD $62.0K] vs. $0.7K [SD $6.6K]) and remained elevated in year 5 ($1.6K [SD $9.1K] vs. $0.3K [SD $2.2K]).
- Children spent an average of 52.9 days in hospitals and doctors' offices during postoperative year 1 and 90.5 days over 5 years.
- Compared to non-Hispanic White children, Hispanic children had more emergency visits (51% [CI 30–76%] more) and inpatient admissions (44% [CI 18–76%] more) in years 2-to-5, but 25% (CI 18–32%) fewer primary care visits.
Study Design
Type
Cohort (n=10,463)
Multicenter
Yes
Structured PICO
Does pediatric cardiac surgery increase long-term healthcare expenditures and utilization compared to matched non-cardiac children in a Medicaid population, and what are the predictors of this utilization?
P
Population
10,463 Medicaid-enrolled children aged ≤18 years in New York State, including 5,247 who underwent initial cardiac surgery and 5,216 matched comparators, followed longitudinally to assess healthcare utilization.
E
Exposure
Pediatric cardiac surgery (including all cardiopulmonary bypass and non-cardiopulmonary bypass cardiovascular surgeries).
C
Comparator
1:1 matched cohort of Medicaid-enrolled children without cardiac surgical disease (matched on date of birth, age first Medicaid-enrolled, county of residence, gender, race/ethnicity, and duration of Medicaid enrolment).
O
Outcome
Total healthcare expenditures (adjusted to 2019 dollars) and multidimensional measures of healthcare utilization (number and duration of inpatient admissions, emergency room visits, and outpatient primary care and subspecialty visits) at 1 and 2-to-5 years post-surgery.
Main Result
Absolute Event Rate: 15.5% vs 0.7%
Children undergoing cardiac surgery have substantial, persistent longitudinal healthcare needs and expenditures, with significant racial and ethnic disparities in how outpatient and emergency care is utilized.
Limitations
- Susceptible to sample selection bias in longitudinal claims data
- Results might not be generalizable to privately insured patients or outside New York State
- Potential unmeasured confounding not captured in surgical registries
- Accuracy of race/ethnicity data from administrative and registry sources
- Variable accuracy of presenting diagnoses or indications for clinical care in administrative data
- Did not capture out-of-pocket expenses, lost wages, or other costs associated with care
- Sample selection bias due to patients entering and leaving longitudinal claims cohorts
- Limited generalizability to privately insured patients or those outside New York State
- Potential inaccuracies in self-reported race/ethnicity and unmeasured confounding in registry data
- Lack of data on specific indications for healthcare visits
- Does not include out-of-pocket expenses, lost wages, or other indirect costs
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“We've brought together congenital heart surgeons, fetal and pediatric cardiologists, pediatricians, public health experts, health economists, biostatisticians, and medical anthropologists to tackle these complex issues. From our earlier work, we know that children from different backgrounds often see different providers-even when they have similar insurance. Now we're asking how families connect with these providers and how the health care system can work more effectively to ensure better outcomes for all children.”
“Bringing together data, surgical and public health leaders, and innovative quantitative and qualitative expertise from across the country, we will be able to develop a deeper knowledge of how patients navigate insurance, prenatal care, and birth center selection; how they choose and access the pediatricians, cardiologists, and surgeons they see; and how these factors influence downstream care and outcomes across the life course.”
“Dr. Anderson's work exemplifies Mount Sinai's commitment to driving improved health outcomes for all children through data-driven science. By linking robust clinical information with real-world health care data, this project has the power to change how we as providers and policymakers structure and deliver care for children with heart disease nationwide.”
Implication
High longitudinal costs after pediatric cardiac surgery warrant care coordination planning; leaves open whether targeted interventions reduce expenditures in Medicaid populations.
Abstract
Background: Understanding the longitudinal burden of healthcare expenditures and utilization after pediatric cardiac surgery is needed to counsel families, improve care, and reduce outcome inequities. Objectives: To describe and identify predictors of healthcare expenditures and utilization for Medicaid-insured pediatric cardiac surgical patients. Methods: All Medicaid enrolled children ≤18 years undergoing cardiac surgery in the New York State CHS-COLOUR database, 2006–2019, were followed in Medicaid claims data through 2019. A matched cohort of children without cardiac surgical disease was identified as comparators. Expenditures and inpatient, primary care, subspecialist, and emergency department utilization were modeled using log-linear and Poisson regression models to assess associations between patient characteristics and outcomes. Results: In 5,241 New York Medicaid-enrolled children, longitudinal healthcare expenditures and utilization for cardiac surgical patients exceeded non-cardiac surgical comparators (cardiac surgical children 15.5K [SD $62.0K] per month in year 1, $1.6K [SD $9.1K] per month year 5 vs. non-cardiac surgical children: $0.7K [SD $6.6K] per month in year 1, $0.3K [SD $2.2K] per month in year 5). Children after cardiac surgery spent 52.9 days in hospitals and doctors’ offices in the first postoperative year and 90.5 days over 5 years. Being Hispanic, compared with non-Hispanic White, was associated with having more emergency department visits, inpatient admissions and subspecialist visits in years 2-to-5, but fewer primary care visits and greater 5-year mortality. Conclusions: Children after cardiac surgery have significant longitudinal healthcare needs, even among those with less severe cardiac disease. Healthcare utilization differed by race/ethnicity, though mechanisms driving disparities should be investigated further.
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Cite This Study
Crook et al. (2023) conducted a cohort in Pediatric cardiac surgery (n=10,463). Pediatric cardiac surgery vs. Matched children without cardiac surgical disease was evaluated on Mean Medicaid expenditures per month in year 1 (in thousands of USD). Pediatric cardiac surgery was associated with significantly higher longitudinal healthcare expenditures, averaging $15,500 per month in the first year compared to $700 for matched comparators.