Standardizing Pediatric Somatic Symptom and Related Disorders Care: Clinical Pathway Reduces Health Care Cost and Use

Abstract

BACKGROUND: Pediatric somatic symptom and related disorders (SSRDs) are common with high health care costs and use because of lack of standardized, evidence-based practice. Our hospital implemented a clinical pathway (CP) for SSRD evaluation and management. Our study objective was to evaluate health care cost and use associated with the organization’s SSRD CP in the emergency department (ED) and inpatient settings hypothesizing lower cost and use in the CP group relative to controls. METHODS: We conducted a retrospective analysis of costs and use before and after implementation of the SSRD CP. Data were collected from the hospital’s electronic health record and the Pediatric Health Information System database. Participants included pediatric patients on the CP (“P” group) and control groups with an SSRD diagnosis and mental health consultation either the year before the CP (“C” group) or during the CP study period (“T” group). Primary outcomes included costs, length of stay, diagnostic testing, imaging, subspecialty consultation, and readmission rates. RESULTS: The ED P group had more lower-cost imaging, whereas the inpatient T group greater higher-cost imaging than other groups. The inpatient P group had significantly shorter length of stay, fewer subspecialty consults, and lower costs. There were no significant group differences in readmission rates. The CP reduced median total costs per patient encounter by $51 433 for the inpatient group and $6075 for the ED group. CONCLUSIONS: The CP group showed significant reductions in health care cost and use after implementation of a CP for SSRD care. In future work, researchers should explore patient and practitioner experience with the SSRD CP and long-term outcomes.

Clinical progress note: Management of somatic symptom and related disorders in pediatric inpatients

“…1,7,11 Clinical pathways are an evidence-based means shown to help improve consistency, safety, and efficacy of patient care, and have been associated with decreases in hospital length of stay, in-hospital complications, and costs. 6,12 Giudice et al described an SSRD clinical pathway implemented in a children's hospital that begins by identifying patients with suspected SSRDs (mostly neurologic symptoms) in the emergency department, including example provider language. 7 If specific admission criteria are met, initial inpatient management emphasizes early involvement of subspecialists, including psychiatry, other relevant medical subspecialties, ancillary support, and an electronic functional plan order set that promotes daily mobility and sleep hygiene.…”

“…A growing number of North American institutions over the past several years have developed and implemented clinical pathways to address and standardize care for those with suspected SSRDs 1,7,11 . Clinical pathways are an evidence‐based means shown to help improve consistency, safety, and efficacy of patient care, and have been associated with decreases in hospital length of stay, in‐hospital complications, and costs 6,12 …”

“…SSRDs have a substantial impact on the healthcare system, accounting for 20% of U.S. healthcare expenditures 1 . Pediatric SSRDs are associated with prolonged hospitalization, family and provider dissatisfaction, and excessive resource utilization 6,7 . This includes diagnostic testing, overuse of pain medication, frequent acute care utilization, and most significantly, an estimated 37.7% readmission rate within 1 year 6–8 .…”

“… 1 Pediatric SSRDs are associated with prolonged hospitalization, family and provider dissatisfaction, and excessive resource utilization. 6 , 7 This includes diagnostic testing, overuse of pain medication, frequent acute care utilization, and most significantly, an estimated 37.7% readmission rate within 1 year. 6 , 7 , 8 Mean index hospitalization duration after SSRD diagnosis rises with patient age, from 6.9 days in school‐age youth to 11.5 days in young adults.…”

“… 6 , 7 This includes diagnostic testing, overuse of pain medication, frequent acute care utilization, and most significantly, an estimated 37.7% readmission rate within 1 year. 6 , 7 , 8 Mean index hospitalization duration after SSRD diagnosis rises with patient age, from 6.9 days in school‐age youth to 11.5 days in young adults. 8 Limited literature comparing pediatric and adult SSRDs suggests that visceral hyperalgesia in functional abdominal pain is influenced by early life events and often leads to disability.…”