Determination of Highly Resource-Intensive Pediatric Patients: Opportunity for Innovation.

Abstract

To assess the most resource-intensive diagnosis-related groups in children's hospitals and determine the associated patient outcomes and payor distribution patterns. This retrospective cohort study analyzed 359 616 pediatric inpatient encounters across 39 tertiary-care children's hospitals using the Pediatric Health Information System database from January to December 2023. After excluding encounters primarily for physical therapy, pain management, diagnostic services, and routine primary care services, resource-intensive care was identified by evaluating length of stay, billed charges, and cost-to-charge ratios. The top twenty diagnosis-related groups for each metric were classified as most resource-intensive. Secondary outcomes included clinical complications and payor patterns. The cohort (median age 4.0 years; 52.8% male) showed resource-intensive diagnosis groups were predominantly perinatal syndromes (57.5%), followed by oncologic conditions (5.8%) and musculoskeletal disorders (4.4%). Resource-intensive encounters demonstrated significantly higher rates of complex chronic conditions (72%-94% vs 52% overall; P < .001) and complications (both medical and surgical) compared with the general population. Children's Health Insurance Program-covered patients (relative risk [RR] = 1.39 [95% CI 1.23-1.59]) and those with commercial preferred provider organization insurance (RR = 1.09 [95% CI 1.03-1.14]) had higher risks of resource-intensive care, yet Medicaid Managed Care and commercial health maintenance organization plans (both RR = 0.89, P < .001) had protective effects. Perinatal syndromes, oncologic conditions, and musculoskeletal disorders were the most resource-intensive pediatric diagnoses, with significantly higher complication rates than the general inpatient population. Insurance type was associated with resource utilization, suggesting targeted care management for high-resource diagnoses could improve the value of pediatric hospital care.