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Multimorbidity and Condition Clustering in Children & Adolescents: Resource Use, Expenditures & Quality
thesisposted on 06.08.2019 by Rachel L Harrington
In order to distinguish essays and pre-prints from academic theses, we have a separate category. These are often much longer text based documents than a paper.
The goal of this dissertation was to describe the patterns of multimorbidity among children in the United States, and to examine the role multimorbidity plays in pediatric healthcare resource utilization and quality of care. This work was conceptualized and executed as four separate studies, two in the general pediatric population, and two among early survivors of pediatric cancer (children under 18 who were a minimum of 2 years out from end of active therapy). All studies were conducted in a national, commercially-insured, cohort of children identified in the Truven Marketscan Commercial Claims and Encounters Database (2009-2014). The first study examined healthcare resource utilization associated with multimorbidity among children with chronic illness. Latent class analysis was used to identify eight comorbidity groups. The “Attention Deficit” group was the largest (22.1%), while the highest resource utilization was observed among children belonging to the “Developmental Disorder” group (mean annual expenditures of $24,606). The second study examined differences in quality of care in the same population. Only 55% of children achieved quality benchmarks (scores ≥75%). Compared to children with one chronic condition, the lowest quality was experienced by the “Mood Disorders” group (Odds Ratio [OR]: 0.6, Confidence Interval [CI]: 0.5-0.6), while highest was the “Chronic Otitis Media” group (OR: 1.9, CI: 1.9-2.0). The third study focused on early survivors of pediatric cancer, the number of chronic conditions they experienced, and associated resource utilization. Over 20% of survivors had at least one chronic condition, and 36.3% had multiple. Compared to survivors without chronic conditions, the presence of multimorbidity significantly increased the odds of an emergency department visit (OR: 1.7, CI: 1.4-2.1), and of a hospitalization (OR: 3.8, CI: 2.5-5.5). The fourth study built on this work by identifying five comorbidity groups among the early survivor population to further explore differences in utilization. Compared to survivors without chronic conditions, membership in the “Central Nervous System” (CNS) group was significantly associated with the highest expenditures ($25,370), while membership in “CNS with Endocrine” had the highest odds of hospitalization (OR: 5.0, CI: 2.3-10.7). Overall, this dissertation provides a new way of conceptualizing and evaluating the burden of chronic conditions in the pediatric population. By linking epidemiologic, resource utilization and quality evidence in this population, results of this work highlight the existence of subgroups of children for whom additional clinical care and policy interventions may be warranted in the current environment of value-based healthcare.