Secondary Logo

Institutional members access full text with Ovid®

Share this article on:

Practice Style Variation in Medicaid and Non-Medicaid Children With Complex Chronic Conditions Undergoing Surgery

Silber, Jeffrey, H., MD, PhD*,†,‡,§,¶; Rosenbaum, Paul, R., PhD¶,||; Wang, Wei, PhD*; Calhoun, Shawna, R., MPH*; Reiter, Joseph, G., MS*; Even-Shoshan, Orit, MS*; Greeley, William, J., MD, MBA

doi: 10.1097/SLA.0000000000002061

Objectives: With differential payment between Medicaid and Non-Medicaid services, we asked whether style-of-practice differs between similar Medicaid and Non-Medicaid children with complex chronic conditions (CCCs) undergoing surgery.

Summary of Background Data: Surgery in children with CCCs accounts for a disproportionately large percentage of resource utilization at major children's hospitals.

Methods: A matched cohort design, studying 23,582 pairs of children with CCCs undergoing surgery (Medicaid matched to Non-Medicaid within the same hospital) from 2009 to 2013 in 41 Children's Hospitals. Patients were matched on age, sex, principal procedure, CCCs, and other characteristics.

Results: Median cost in Medicaid patients was $21,547 versus $20,527 in Non-Medicaid patients (5.0% higher, P < 0.001). Median paired difference in cost (Medicaid minus Non-Medicaid) was $320 [95% confidence interval (CI): $208, $445], (1.6% higher, P < 0.001). 90th percentile costs were $133,640 versus $127,523, (4.8% higher, P < 0.001). Mean paired difference in length of stay (LOS) was 0.50 days (95% CI: 0.36, 0.65), (P < 0.001). ICU utilization was 2.8% higher (36.7% vs 35.7%, P < 0.001). Finally, in-hospital mortality pooled across all pairs was higher in Medicaid patients (0.38% vs 0.22%, P = 0.002). After adjusting for multiple testing, no individual hospital displayed significant differences in cost between groups, only 1 hospital displayed significant differences in LOS and 1 in ICU utilization.

Conclusions: Treatment style differences between Medicaid and Non-Medicaid children were small, suggesting little disparity with in-hospital surgical care for patients with CCCs operated on within Children's Hospitals. However, in-hospital mortality, although rare, was slightly higher in Medicaid patients and merits further investigation.

*Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, PA

The Department of Pediatrics, The University of Pennsylvania School of Medicine, Philadelphia, PA

Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA

§Department of Health Care Management, The Wharton School, The University of Pennsylvania, Philadelphia, PA

The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA

||Department of Statistics, The Wharton School, The University of Pennsylvania, Philadelphia, PA.

Reprints: Dr Jeffrey H. Silber, MD, PhD, Center for Outcomes Research, The Children's Hospital of Philadelphia, 3535 Market Street, Suite 1029, Philadelphia, PA 19104. E-mail:

Reprints: Reprints will not be available from the authors.

Funding Source: All phases of this study were supported by an Agency for Healthcare Research and Quality grant, U18-HS020508.

The authors have no financial relationships relevant to this article to disclose.

The authors have no conflicts of interest to disclose.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.