ABSTRACT
BACKGROUND: There is a lack of uniformity across hospitals in applying inpatient versus observation status for short-stay (<48 h) pediatric hospitalizations, with negative financial implications associated with observation. Children with medical complexity (CMC) represent a growing population and incur high costs of care. The financial implications of inpatient and observation status for CMC have not been studied. OBJECTIVES: To compare costs and reimbursement for short-stay hospitalizations for CMC by inpatient and observation status, overall and stratified by payor. METHODS: We performed a cohort study of short-stay hospitalizations for CMC from 2016 to 2021 at 10 children's hospitals reporting reimbursement in the Pediatric Health Information System and Revenue Management Program. The primary outcome was the cost coverage ratio (CCR), defined as an encounter's reimbursement divided by the estimated cost. RESULTS: There were 89,282 encounters included. The median costs per encounter were similar across observation ($5206, IQR $3604-$7484) and inpatient ($6547, IQR $4725-$9349) encounters. For government payors, the median CCR was 0.6 (IQR 0.2-0.9) for observation encounters and 1.2 (IQR 0.8-1.9) for inpatient. For nongovernment payors, the median CCR was 1.6 (IQR 1.3-1.9) for observation and 1.6 (IQR 1.4-2) for inpatient. Government reimbursement was associated with increased risk for financial loss (OR 13.91, 95% CI 7.23, 26.77) and with a median net loss of $985,952 (IQR $389,871-$1,700,041) per hospital annually for observation encounters. CONCLUSIONS: Government-paid observation encounters for CMC are associated with significant financial loss at children's hospitals. This reimbursement model may pose a threat to children's hospitals' ability to care for CMC.
ABSTRACT
Globally, study of factors contributing to the street-migration of the tens of millions of street-involved children focus almost exclusively on children's perspectives. In this study, we assess household and maternal factors associated with street-migration of children through self-report of 1974 randomly selected women in semi-rural Kenya. Contributing new perspectives on this global phenomenon, data show a statistically significant association between increased maternal childhood adversities and street-migration of children (p<0.001). Higher household wealth (p<0.01) and maternal education (p<0.05) were associated with lower odds of street-migration of children. Social support, reporting HIV+, school enrollment of biologically-related children, overall health, reported alcohol use, and functional literacy significantly mediated these pathways. Protecting children from street-migration in the next generation requires reducing childhood adversities in the present generation.
