title: Hospital Variation in Health Care Utilization by Children With Medical Complexity.
abstract: BACKGROUND
  Although children with medical complexity have high health care needs, little is known about the variation in care provided between centers. This information may be particularly useful in identifying opportunities to improve quality and reduce costs.
  
  
  METHODS
  We conducted a retrospective population-based observational cohort study using all payer claims databases for children aged 30 days to <18 years residing in Maine, New Hampshire, and Vermont from 2007 to 2010. We identified hospital-affiliated cohorts (n = 6) of patients (n = 8216) with medical complexity by using diagnostic codes from both inpatient and outpatient claims. Children were assigned to the hospital where they received the most inpatient days, or their outpatient visits if no hospitalization occurred. Outcomes of interest included patient encounters, medical imaging, and diagnostic testing. Adjusted relative rates were calculated with overdispersed Poisson regression models.
  
  
  RESULTS
  Adjusting for patient characteristics, the number of inpatient (relative rate 0.84 vs 2.28) and intensive care days (relative rate 0.45 vs 1.28) varied by more than twofold, whereas office (relative rate 0.77 vs 1.12) and emergency department visits (relative rate 0.71 vs 1.37) varied to a lesser extent. There was also marked variation in the use of imaging, and other diagnostic tests, with particularly high variation in electrocardiography (relative rate 0.35 vs 2.81) and head MRI (relative rate 0.72 vs 2.12).
  
  
  CONCLUSIONS
  Depending on where they receive care, children with medical complexity experience widely different patterns of utilization. These findings indicate the need for identifying best practices for this growing patient population.
authors.affiliation: Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Section of Pediatric Hospital Medicine, Children's Hospital at Dartmouth, Lebanon, New Hampshire; and shawn.l.ralston@hitchcock.org.
authors.forename: Shawn L
authors.initials: SL
authors.lastname: Ralston
authors.affiliation: Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire.
authors.forename: Wade
authors.initials: W
authors.lastname: Harrison
authors.affiliation: The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire.
authors.forename: Jared
authors.initials: J
authors.lastname: Wasserman
authors.affiliation: Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Section of Pediatric Hospital Medicine, Children's Hospital at Dartmouth, Lebanon, New Hampshire; and The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire.
authors.forename: David C
authors.initials: DC
authors.lastname: Goodman
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D009511:New England; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D010361:Patients / Q000145:classification*; D012189:Retrospective Studies