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

Ann Surg. 2018 Feb;267(2):392-400. 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.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adolescent
  • Child
  • Child, Preschool
  • Chronic Disease
  • Female
  • Healthcare Disparities / economics*
  • Healthcare Disparities / statistics & numerical data
  • Hospital Costs / statistics & numerical data
  • Hospital Mortality
  • Hospitals, Pediatric / economics
  • Humans
  • Infant
  • Length of Stay / economics
  • Length of Stay / statistics & numerical data
  • Male
  • Matched-Pair Analysis
  • Medicaid*
  • Practice Patterns, Physicians' / economics*
  • Practice Patterns, Physicians' / statistics & numerical data
  • Surgical Procedures, Operative / economics*
  • Surgical Procedures, Operative / statistics & numerical data
  • United States