PEDIATRICS Vol. 119 No. 4 April 2007, pp. e813-e820 (doi:10.1542/peds.2006-2140)
ARTICLE |
Patient and Hospital Characteristics Associated With Length of Stay and Hospital Charges for Pediatric Sports-Related Injury Hospitalizations in the United States, 2000–2003
a Injury Prevention Research Center
b Department of Community and Behavioral Health
c Occupational and Environmental Health
d Health Management and Policy
f Biostatistics
e Department of Pediatrics, Roy J. & Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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OBJECTIVES. The objectives of this study were to describe the patient and hospital characteristics of pediatric sports injury hospitalization and to determine the hospital characteristics that are associated with length of stay and total hospital charges (per discharge).
METHODS. Children who were aged 5 to 18 years and had a diagnosis of a sports injury in the Nationwide Inpatient Sample between 2000 and 2003 were included. National estimates of pediatric sports injury hospitalization, including the average and median of length of stay and total hospital charges, were computed. The relationship of hospital characteristics to length of stay and total hospital charges were assessed using linear regression, adjusting for patient characteristics and sample weight.
RESULTS. A total of 7979 pediatric sports injury hospitalizations among children who were aged 5 to 18 were identified during 4 years, approximately 10000 per year, nationwide. More than half of the hospitalizations were attributed to fractures. The mean and median of length of stay for pediatric sports injuries was 2.4 and 1.1 days, respectively. When weighted, the estimated total hospital charges for sports injury hospitalizations among 5- to 18-year-olds were $485 million during 4 years, with a steady increase each year. Urban hospitals had 46.1% higher total hospital charges than rural hospitals. Hospitals in the western United States had significantly greater total hospital charges than those in other regions.
CONCLUSIONS. The findings provide an empirical basis for future research on the magnitude of sports-related injuries that result in hospitalization among children. More research is needed to identify contributing factors that are associated with length of stay and total hospital charges for sports injury hospitalization. Intervention efforts also should be directed toward preventing severe sports injuries and to reducing the hospitalization and cost.
Key Words: length of stay • hospital charges • children • sports injury
Abbreviations: ED—emergency department • LOS—length of stay • NIS—Nationwide Inpatient Sample • E-code—external cause of injury code
Youth sports injuries pose a serious threat to the health and well-being of young people. At least 4.3 million sports and recreational injury episodes occur each year to school-aged children in the United States.1 For people who are aged 5 to 24 years, sport- and recreation-related injuries account for 1 of every 5 injury episodes.2
Although the number of sports-related injuries that result in hospitalization is relatively small compared with those that are treated in emergency departments (EDs) or outpatient clinics, it represents the more serious end of the spectrum of injuries.3 These injuries can have profound negative consequences for young people in terms of their physical, mental, and emotional health.4–6 They also can place a tremendous burden on the patient's family, the health care system, and society as a whole.7 A study of Massachusetts children ranked sports injuries second only to falls in per capita treatment expenditures.8 It is estimated that one fifth of school children are absent from school at least 1 day a year as a result of sports injuries,2 and annual treatment costs for youth sports injuries are estimated to be $1.8 billion dollars.9
Much of the previous research on sports-related injuries in children focused on injuries that were treated in emergency departments (ED) or outpatient clinics because most of these injuries do not require hospitalization.3 Little has been reported in the literature about the characteristics of pediatric sports injuries that result in hospitalization. There are no published national data describing patient and hospital characteristics related to hospital length of stay (LOS) and total hospital charges that result from sports-related injuries in the pediatric population.
In this study, we describe the patient and hospital characteristics of sports-related injuries that resulted in hospitalization among children who were aged 5 to 18 years in the United States between 2000 and 2003. We also examine the hospital characteristics that were associated with LOS and total hospital charges for sports-related injuries that resulted in hospitalization in this population.
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METHODS |
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Data Source
This study was a retrospective analysis of 4 years (2000–2003) of pediatric sports injuries that resulted in hospitalizations and was based on data from the Nationwide Inpatient Sample (NIS) of the Health Care Utilization Project provided by the Agency for Healthcare Research and Quality. The NIS is the largest all-payer inpatient care database in the United States. Each year, the NIS provides information on 5 to 8 million inpatient stays from
1000 hospitals located in 35 states.10 The NIS was designed to approximate a 20% sample of US hospitals, defined as "all nonfederal, short-term, general, and other specialty hospitals, excluding hospital units of institutions."10 A stratified probability sample of hospitals was used with sampling probabilities proportional to the number of US hospitals in each stratum. The 5 hospital characteristics that were used to define the strata were ownership/control, bed size, teaching status, urban/rural location, and region.10
Sample of Patients
All patients who were aged 5 to 18 years and had a diagnosis of a sports-related injury in the NIS between 2000 and 2003 were selected. Three International Classification of Diseases, 9th Revision, Clinical Modification, external cause of injury codes (E-codes) that were used for the patient selection were as follows: E886.0, tackles in sports that cause fall on same level from collision, pushing, or shoving, by or with other person; E917.0, striking against or struck accidentally by objects or persons in sports without subsequent fall; and E917.5, striking against or struck accidentally by objects or persons in sports with subsequent fall. Although other injuries may have been sports related, only these 3 E-codes were used specifically to identify sports injuries in this study. After 5 inpatient deaths were excluded, the sample included a total of 7979 pediatric sports injury hospitalizations.
Analysis
From the NIS sample, national estimates, along with 95% confidence intervals, were calculated using patient and hospital characteristics to identify the number of hospitalizations that met the study definition. The top 10 principal diagnoses and top 10 principal procedures were described for pediatric sports injuries that resulted in hospitalization. The discharge-level weights that were provided by the Health Care Utilization Project were applied in the calculation to account for sampling weights.10
The average and median of LOS and total hospital charges (per discharge) for the top 10 principal diagnoses were computed, excluding patients who were transferred to another hospital after being admitted to a hospital (n = 76; 0.95%). Hospital charges were adjusted to the year 2003 (last quarter) levels, using the consumer price index for inpatient hospital services that were provided by the Bureau of Labor Statistics.11
Linear regression models were used to assess hospital characteristics that were associated with LOS and total hospital charges per discharge, adjusting for patient characteristics including age, gender, type of injury, body site of injury, and admission source. For modeling total hospital charges per discharge, LOS was adjusted in addition to other covariates because LOS was a confounding variable that influenced the relationship between total hospital charges and patient's characteristics. A log transformation was performed on LOS and hospital charges per discharge to deal with the skewed distribution of these variables and to stabilize the variability of residuals from the regression models. Cook's D statistics were used in the model diagnostics to identify influential observations. The cutoff Di > 4/n was used, where n was the sample size, to exclude the observations that do not fit with regression model. The results reported from the linear regression models were based on reduced samples that removed outliers. For LOS and total hospital charges per discharge, respectively, 5.46% and 5.51% of observations were identified through model diagnostics as outliers that affected model fitting and reduced the degree of model interpretability. All of the analyses were conducted using SAS callable SUDAAN 9.0, accounting for cluster sampling and sample weights.12
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Characteristics of Sports-Related Injuries That Resulted in Hospitalization
A total of 7979 hospitalizations for pediatric sports injuries were identified in the sample of NIS data. When weighted, these represent an estimated total of 39010 pediatric sports injury hospitalizations nationwide among children who were aged 5 to 18 years between 2000 and 2003, with approximately 10000 pediatric sports injury hospitalizations each year (Table 1). Of all patients hospitalized for pediatric sports injuries, approximately one half (49.0%) were 15 to 18 years of age. Boys accounted for 86.5% (95% confidence interval: 85.7–87.3) of pediatric sports injury hospitalizations, or 6 times the number of comparable hospitalizations that occurred among girls. More than half (54.9%) of the pediatric sports injury hospitalizations were attributed to fractures. The most frequently injured body sites were the lower extremities (38.6%), the head and neck (24.2%), and the upper extremities (15.2%).
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The number of hospitalizations for pediatric sports injuries was higher in urban hospitals (86.5%), hospitals with high bed volume (59.9%), and teaching hospitals (54.3%). Most hospitalizations for sports-related injuries were admitted through the ED (73.3%) and discharged routinely after 24 to 48 hours of hospitalization (96.8%). The majority of the patients paid hospital charges through private insurance, including health maintenance organizations (78.3%). A total of 347 (4.4%) sampled patients, an estimated 1699 patients nationwide, were uninsured and paid hospital charges by themselves.
Top 10 Principal Diagnoses and Top 10 Principal Procedures
The most common principal diagnosis was lower extremity fracture, which accounted for nearly one third (31.7%) of all hospitalizations for sports-related injuries in this study, followed by upper extremity fractures (13.5%) and abdominal internal organ injuries (9.9%; Table 2). Five of the top 10 principal diagnoses were attributed to fractures. In addition, 4 of the top 10 principal diagnoses involved definite or possible traumatic brain injury.
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More than two thirds (68%) of patients underwent at least 1 procedure during their hospitalization. The most common principal procedure performed was open reduction and internal fixation of a lower leg fracture (11.4%; Table 2). The top 10 principal procedures performed accounted for a total of 2948 procedures, which translated to a weighted total of 14416 top 10 principal procedures performed nationwide from 2000 to 2003. Of these, approximately half (49%) were done for patients who were aged 15 to 18 and almost 9 (87%) of 10 for boys. Six of the top 10 procedures involved the lower extremities, and 3 involved the upper extremities. At least 4 of the top 10 principal procedures required surgery.
LOS and Total Hospital Charges
Overall, the average LOS for all pediatric sports injuries was 2.4 days with a median of 1.1 day (Table 3). For the top 10 principal diagnoses, the average hospitalization ranged from a little more than 1 day (eg, internal organ with possible traumatic brain injury, sprain and strain of lower extremity) to 4 days (eg, abdominal internal organ injury). Injury to the abdominal organs had a longer LOS compared with the other top 10 principal diagnoses, with a mean of 4.0 days and a median of 2.9 days.
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Nationwide, the estimated total hospital charges for sports injury hospitalizations among 5- to 18-year-olds was almost $0.5 billion dollars for 4 years (Table 3). The average hospital charges per discharge ranged from $7621 (eg, internal organ with possible traumatic brain injury) to $18814 (eg, fracture with definite traumatic brain injury) for the top 10 principal diagnoses. The total hospital charges for each of the top 10 principal diagnoses ranged from $7.4 million (eg, fracture with possible traumatic brain injury) to $167 million (eg, fracture of lower extremity). The total hospital charges for lower extremity fractures were more than one third of all hospital charges, as a result of a large number of hospitalizations.
Hospital Characteristics Associated With LOS and Total Hospital Charges
Overall, the average LOS for pediatric sports injury hospitalizations remained steady during the 4 study years. In contrast, the total hospital charges per discharge went up steadily and significantly during the 4 years even after adjustment for inflation rates in hospital care. Compared with the year 2000, the total hospital charges per discharge were 18.2% higher for the year 2002 and 20.4% higher for the year 2003 (P < .0001; Table 4). Children who were admitted into urban hospitals had 46.1% higher total hospital charges per discharge than those who were admitted into rural hospitals (P < .0001). Hospitals that are located in the western United States had significantly higher total hospital charges compared with hospitals in other regions (P < .0001). In particular, hospitals that are located in the western United States had 36.1% greater total hospital charges than hospitals in the Northeast.
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After adjustment for patient characteristics and injury type and site, children who were admitted into large or medium bed volume hospitals had longer LOS compared with those who were admitted into small bed volume hospitals, with a 9.5% and 7.7% increase in LOS, respectively (P = .0001). Children who were admitted into teaching hospitals also had significantly longer LOS, with a 7.9% (P < .0001) increase in LOS compared with children who were admitted to nonteaching hospitals. Uninsured patients tended to have shorter LOS (P < .0001) compared with insured patients even after adjustment for other patient characteristics.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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In this study, we analyzed the NIS data and found, nationwide, an estimated 39010 hospitalizations for sports-related injuries among children who were aged 5 to 18 years between 2000 and 2003. This translates into nearly 10000 sports injury hospitalizations for this age group each year, resulting in annual charges of $113 to $133 million. Although most sports-related injuries are minor, the NIS data demonstrate that a significant number of sports-related injuries have a major impact on the health and well-being of children. These injuries also constitute a substantial economic burden to the health care system as well as the patient's family. We found that although the number of hospitalizations did not increase during the study period, the total hospital charges increased significantly. This disparity indicates an increase in costs to families and third-party payers. To our knowledge, this is the first study to describe the extent and characteristics of pediatric sports injuries that result in hospitalization nationwide. Our findings provide an empirical basis for future research on the magnitude of sports-related injuries that result in hospitalization and suggest priorities for future intervention strategies. These findings are an underestimation of the total number of hospitalizations because only 3 E-codes that are very specific to sports injuries were used; many other sports injuries may have codes that do not specify the injury as being sports related.3
Consistent with previous findings from ED studies, boys and teenagers were more likely to sustain sports-related injuries.13–15 Our data also showed that the number of children who were admitted to hospitals for sports-related injuries was 6 times higher for boys than for girls. In addition, children in either the 10- to 14- or 15- to 18-year age groups had approximately 5 times as many hospitalizations for sports-related injuries than those who were aged 5 to 9. The age and gender differences that were observed in this study suggest that teenage boys not only may be at a greater risk for injury when playing sports but also tend to be more severely injured compared with girls and boys of younger ages. The higher sports exposure of a teenage boy may be partly responsible for such an elevated risk, although other behavioral (eg, willingness to take risks, thrill seeking) and physical (eg, increased muscle mass, larger force of impact) factors also may contribute to the observed differences.14 Additional investigation into why teenage boys are at an increased risk for pediatric sports injury hospitalization is warranted.
Although the proportion of all sports-related injuries that result in hospitalization is small, the absolute number of hospitalizations was high. Nationwide, at least 10000 children and adolescents aged 5 to 18 years are hospitalized each year as a result of sports-related injuries. This equates to daily averages of 23 boys, 8 new lower extremity fractures, and 4 new traumatic brain injuries that result in hospitalization from sports-related injuries from only the 3 E-codes included.
Our findings showed that children with sports injuries were more likely to be admitted to large, urban, teaching hospitals, and children in these hospitals also had longer hospital LOS and higher hospital charges. Participation of greater numbers of urban youth in organized sports may explain in part the larger proportion of urban hospitalizations.16 Other possible explanations may include the greater availability of medical resources, including trauma centers, in large urban hospitals; the referral of more severe injuries to large urban hospitals for treatment; the concentration of advanced diagnostic equipment and treatment techniques, including image testing and orthopedic surgeries, in large urban hospitals; and the limited sideline care at sporting events in rural communities. Another potential factor is increased use of E-codes that specifically identify sports injuries in large, teaching hospitals.
The average hospital LOS was 2.4 days, which likely represents more missed school days for the child and work days for the parents during hospitalization and recovery. A hospitalization can add tremendous stress to the patient's family and/or caregiver, both financially and psychologically. This could be even more burdensome for the rural family who must travel to a large urban hospital for necessary treatment of their injured child.
Our findings revealed that the most frequent injury diagnoses for pediatric sports injury hospitalizations involved fractures, a cause of serious physical damage and potentially permanent disability. The average hospital charges per fracture were almost $14000. Such charges may be devastating for a family without adequate health insurance, and even for those with insurance coverage, copayments may be high enough to be financially damaging.
It is not uncommon that an injured child has to modify his or her level of sporting activity after hospitalization. In some cases, the child may not be able to play a particular sport any more and may have to choose another sport. For many children, their participation in sports serves as, at least, a significant source of peer interaction, if not a major construct for their self-identity.17 The stress of removal from sports participation as a result of a severe injury likely compounds that of hospitalization and treatment.
Approximately half of all American children who are aged 5 to 18 years participate in organized sports.18 With the epidemic of obesity in the population, sports participation can be a valuable tool to promote physical activity and healthful living. Although participation in sports activities involves an inherent risk for injury, research has demonstrated that most of these injuries are preventable.2,19–21 Existing injury prevention programs have been successful in preventing the occurrence of sports injuries or reducing the severity of the injury, through the development and enforcement of safety rules, protective gear, and changes in sporting equipment and environments.22–24 This research objectively demonstrates the need for more investigation into the prevention of sports-related injuries. Other authors have suggested that without adequate sports safety measures, sports-related injuries and hospitalizations may become more widespread.20,21,25 Our research validates these concerns by illustrating the significant number of severe sports-related injuries that occur each year.
This study has several limitations. NIS data are derived from hospital discharge data, which lack informa tion on sports exposure. Therefore, we could not determine the rate of pediatric sports injury hospitalizations or compare the risk among different sports. The financial charge information provided by the NIS is based on hospital charges, not actual costs. In general, hospital charges are greater than actual costs. However, several charges (eg, physician professional fees, emergency transportation costs, subsequent rehabilitation costs) are not included as part of the hospital charge. Therefore, our estimation of total hospital charges may not reflect fully the financial impact of sports injury hospitalization on the patients and their families. Our case definition of sports injury hospitalization relied on 3 E-codes, which had high specificity but low sensitivity. In addition, not all hospitals in the United States were included in the NIS. Therefore, our projection of the number of sports injury hospitalizations could have been underestimated.
Despite these limitations, findings from our study demonstrate the significant morbidity and economic consequences that are associated with pediatric sports injury hospitalizations. Our findings will help to create a better understanding of the scope of and outcomes that are associated with pediatric sports injury hospitalizations so that intervention strategies can be developed to improve the quality of care, to maximize the recovery process, and to direct an effort to prevent future injuries.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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This study analyzed characteristics of sports-related injuries that resulted in hospitalization in children. The findings of the study are important because the physical damage and financial burden that result from such an injury could have a lifelong impact on the children and their families.26,27 Because participation in sports activity is widely promoted as part of a healthful lifestyle,28,29 pediatricians and other child health care providers can play a critical role in educating children, parents, and policy makers about injury prevention. More research is needed to identify risk factors that are associated with sports injury hospitalization. Prevention efforts also should address the severity of sports injury to reduce injury-related morbidity and the economic costs of treating these injuries.
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FOOTNOTES |
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Accepted Oct 11, 2006.
Address correspondence to Jingzhen Yang, PhD, MPH, Department of Community and Behavioral Health, College of Public Health, University of Iowa, 200 Hawkins Dr, E236 GH, Iowa City, IA 52242. E-mail: jingzhen-yang{at}uiowa.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics
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