Geographic Financial Analysis of Craniosynostosis Surgery in the United States

Abstract

Background: The purpose of this study was to investigate the financial implications of demographic and socioeconomic factors upon the cost of surgical procedures for craniosynostosis. Methods: A retrospective cohort study was conducted of admissions for craniosynostosis surgery in the United States from 2015 through 2020 using the Pediatric Health Information System. Patient demographics, case volume, and surgical approach were analyzed in context of hospital charges. Results: During the study interval, 3869 patients were admitted for surgery for craniosynostosis. In multivariate regression accounting for demographic and socioeconomic factors, hospital admission charges were significantly higher in patients with longer hospital length of stay (P < 0.001), longer ICU length of stay (P < 0.001), living in an underserved area (P = 0.046), preoperative risk factors (P = 0.016), and those undergoing open procedures (P < 0.001); hospital admission charges were significantly lower in patients with White race (P = 0.020) and those treated at high-volume centers (P < 0.001). In multivariate regression, ICU length of stay was significantly higher in patients with preoperative risk factors (P < 0.001), undergoing open procedures (P < 0.001), government insurance (P = 0.018), and not treated at high-volume centers (P = 0.005). There were significant differences in admission charges (P < 0.001), charge-to-cost ratios (P < 0.001), and likelihood of being treated at high-volume craniofacial centers (P < 0.001) across geographic regions of the country. Conclusions: In the United States, there is significant sociodemographic variability in charges for craniosynostosis care, with increased hospital charges independently associated with non-White race, preoperative risk factors, and living in an underserved area.

Scoping Review of Healthcare Disparities in Treatment of Craniosynostosis: Assessing Impacts of Race, Insurance, and Socioeconomic Status

“…Access to craniosynostosis evaluation and surgical care varied based on patient race, insurance status, and socioeconomic status (Table 1). Seventeen of the 28 studies analyzed differences in time to craniosynostosis diagnosis, referral, or surgical intervention (7 single-institution cohort reviews, 10 national database reviews, and 2 dual-institution cohort revi ews) 3,4,[6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] . Ten 3,4,[7][8][9]11,13,15,17,19 of the 17 studies investigated racial disparities in access to care, all of which found that non-white patients were more likely to experience a delay to at least one step of the diagnostic process (i.e., diagnosis, referral, or intervention) compared to White patients.…”

“…3,15 Six studies investigated the consequences of presenting for surgery at an older age. 6,10,14,16,18,20 Of these, one national database review found that older age at the time of surgical intervention was associated with increased surgical complication rate and increased hospital length of stay. 10 Five studies (3 national database reviews and 2 single-institution cohort reviews) found that older patients were more likely to undergo open surgical approaches than those who presented at younger ages.…”

Choosing a Multidisciplinary Cleft and Craniofacial Team: Medical, Surgical, and Social Considerations

“…Recent work discussing craniosynostosis care suggests higher-volume centers (80th percentile or above) yield superior patient outcomes including significantly lower hospital admission charges, shorter intensive care unit (ICU) length of stay, and lower ICU charges. 8 High-volume craniosynostosis surgery centers also performed endoscopic procedures twice as often as open procedures. 8 Although the election for endoscopic versus open procedures is certainly a multifaceted one, emerging literature highlights the favorable peri- and postoperative profile of endoscopic approaches for several craniofacial operations, including reduced blood loss, 13 decreased operative time, 13 and shorter ICU length of stay.…”

“…8 High-volume craniosynostosis surgery centers also performed endoscopic procedures twice as often as open procedures. 8 Although the election for endoscopic versus open procedures is certainly a multifaceted one, emerging literature highlights the favorable peri- and postoperative profile of endoscopic approaches for several craniofacial operations, including reduced blood loss, 13 decreased operative time, 13 and shorter ICU length of stay. 14,15 Additionally, academic institutions often have multiple clinicians in any given specialty from which knowledge bases can be tapped to maximize patient care.…”

“…5,6 The American Cleft Palate-Craniofacial Association (ACPA) established criteria to optionally achieve "ACPA Team Approval" status, outlining parameters regarding team composition, team management, communication, cultural competence, psychological/social services, and outcomes assessment. 7 While these criteria certainly chaperone families and caregivers in selecting an optimal cleft and craniofacial team, approval status does not reflect the quality or clinical outcomes, and recent literature has suggested additional factors such as center volume, 8 center geography, 9 prenatal services, 10 surgical planning, 11 and social services 12 may impact cleft and craniofacial patient outcomes and caretaker experience, and thus are salient considerations for identifying the optimal team. Importantly, it should be acknowledged early in our discussion that for a substantial proportion of families, access and location barriers preclude the option of choosing between teams.…”