The costs of transition of Spina Bifida Care in Ontario: A retrospective population based cohort study comparing outcomes and health care costs longitudinally from adolescence into adulthood between 2004 to 2021
Matthew Playfair, MBCHB1, J Andrew McClure, BA, MSc1, Britney Le, BSc, MSc2, Peter Wang, BSc, MD, MEd, FRCS1, Blayne Welk, MD, FRCSC, MSC1, Sumit Dave, MD, MCh, MSc, FRCSC1.
1Western University, London, ON, Canada, 2ICES – Institute for Clinical Evaluative Sciences, London, ON, Canada.
BACKGROUND: Transition from pediatric multidisciplinary to adult care results in a significant change in nature and intensity of care provided to complex spina bifida (SB) patients. The goal of this study is to track a single cohort of SB patients through this transition, describing planned and unplanned healthcare utilization in this population before and after transition.
METHODS: Through a retrospective population-based cohort study, newborn spina bifida patients requiring neurosurgery born in Ontario between from 1988- and 1999 requiring neurosurgery were studied using routinely collected data analysed at ICES. SB patients entered the study at 16 years and were longitudinally followed to 22 years. A composite primary outcome, including unplanned emergency room visits, hospitalizations and emergency surgical procedures, was compared for the same individual before and after transition to adult care. Secondary outcomes included these variables individually and measured the estimated total health care costs. Comparisons were made between the pediatric baseline year (age 16) to the first three years of adulthood (ages 19-21), with age 17-18 years being classified as years of transition.
RESULTS: In the 299 SB patients followed, no significant differences in health care utilization were noted from pediatric to adult care for the composite primary outcome (p=0.09). Emergency room visits (p=0.004) increased following transition into adult care with a mean of 0.98 (SD 1.9) visits, as compared to 0.7 visits (SD 1.43) in the baseline pediatric year (p=0.004). Similarly, unplanned surgery also increased with a mean of 0.02 (SD 0.1) vs a mean of <0.02 (SD 0.23) during the pediatric year (p=0.02). Despite this, the estimated individual total cost of care declined after transition of care, with a mean cost of $8,708/year (SD 18,858) versus the pediatric mean of $12,625/year (SD 38,176) (p=0.03). Further, multivariable analysis identified rural residence (RR 1.78, CI 1.30-2.44) and previous urologic surgery (RR 1.91, CI 1.41-2.57) as significant predictors of increased need for emergent care and overall healthcare costs respectively.
CONCLUSION: SB patients in Ontario have higher rates of emergency room usage and unplanned surgery after transition to adult care. Patient complexity and cost during pediatric care is likely a predictor of future healthcare utilization and cost, and may be an indication of need for specialist referral. While transition does not appear to drive an increase in healthcare costs, improvements in adult SB care, particularly for complex and rural patients with poor access to care, may decrease the requirement for emergent care.
|Table 1: Cohort Characteristics||Value||Overall|
|Rural residence *||63 (21.1%)|
|Primary care provider||Pediatrician||38 (12.7%)|
|Pediatrician and GP||68 (22.7%)|
|Age at time of Spina bifida procedure (days)||0 - 14||227 (75.9%)|
|15 - 30||11 (3.7%)|
|31 - 180||33 (11.0%)|
|181 - 365||18 (6.0%)|
|Previous urologic surgery||89 (29.8%)|
|Urinary tract drainage||<=5|
|Stoma revision||16 (5.4%)|
|Uretric reimplantation||40 (13.4%)|
|Stone surgery||22 (7.4%)|
|Bladder augmentation||25 (8.4%)|
|Bladder neck repair||9 (3.0%)|
|Urinary diversion||39 (13.0%)|
|Ureteral dilation||9 (3.0%)|
|Age at which care transitioned**||16||13 (12.3%)|
|20 or 21||9 (8.5%)|
|* Rural Residence missing for n=1 ** Percentage of patients with a pediatrician (n = 106)** Percentage of patients with a pediatrician (n = 106)|
|Table 2: Outcomes||Year 1 (age 16)Pediatric Care||Average of Years 4-6Adult Care|
|Outcome||Mean (SD)||Mean (SD)||p-value|
|Primary outcome||0.96 (1.94)||1.18 (2.15)||0.0918|
|Unplanned ER visits||0.7 (1.43)||0.98 (1.90)||0.0036|
|Hospital admissions||0.25 (0.74)||0.18 (0.44)||0.1096|
|Emergency surgical procedures||0.01 (0.23)||0.02 (0.1)||0.0171|
|GP visits||1.91 (3.43)||2.65 (3.04)||<.0001|
|Specialist consults||0.28 (0.57)||0.27 (0.4)||0.9453|
|Diagnostic imaging||0.07 (0.4)||0.09 (0.22)||0.0032|
|Urologic surgery||0.1 (0.65)||0.06 (0.27)||0.5115|
|Total cost of health care||12,624.64 (38,175.81)||8,708.22 (18,858.4)||0.0338|
|Table 3 – Multivariable Analysis:Primary outcome||Relative Risk||CI||p-value|
|Sex (ref= female)||0.90||0.65-1.24||0.5237|
|SB procedure within 14-days of birth||1.28||0.88-1.88||0.1968|
|Pediatrician primary care provider||1.27||0.91-1.77||0.1567|
|Number of primary outcome events in baseline year||1.16||1.11-1.22||<.0001|
|Sex (ref= female)||0.94||0.69-1.27||0.6691|
|SB procedure within 14-days of birth||1.82||1.12-2.96||0.016|
|Pediatrician primary care provider||2.14||1.53-2.99||<.0001|
|Total Healthcare cost (in 1000s) in baseline year||1.01||1.00-1.01||<.0001|
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