title: Value Narratives: A Novel Method for Understanding High-Cost Pediatric Hospital Patients.
abstract: To delineate the drivers of cost associated with the most-costly inpatients in a tertiary pediatric hospital.
  
  
  
  We identified the 10% most-costly inpatients treated at a large regional children's hospital in 2010. From this group we randomly selected, within representative specialties, 2 groups of 50 inpatients for detailed chart review. By using daily cost data and clinical records, 2 independent reviewers examined the clinical course of each patient to identify events that drove cost beyond that expected for standard of care. By using an iterative process, these events were grouped into themes or "cost drivers." Linear regression was used to measure the association of number of cost drivers and total 2010 inpatient cost.
  
  
  
  We identified 7 cost drivers: medical complications (49%), futile treatment (6%), failure to identify family care preferences (9%), system errors (65%), preventable admissions (21%), complex family dynamics (11%), and expensive diagnosis with no other cost driver (15%). Cost drivers were associated with increased total costs.
  
  
  
  We developed a novel method for understanding high-cost inpatients. This method allowed a more detailed understanding of cost drivers than could be achieved with administrative data alone. Many of these cost drivers were related to problems with communication.
authors.affiliation: Department of Pediatrics, University of Utah, Salt Lake City, Utah; and andrew.gerald.smith@hsc.utah.edu.
authors.forename: Andrew
authors.initials: A
authors.lastname: Smith
authors.affiliation: Primary Children's Hospital, Intermountain Health Care, Salt Lake City, Utah.
authors.forename: Seth
authors.initials: S
authors.lastname: Andrews
authors.affiliation: Department of Pediatrics, University of Utah, Salt Lake City, Utah; and.
authors.forename: Victoria
authors.initials: V
authors.lastname: Wilkins
authors.affiliation: Department of Pediatrics, University of Utah, Salt Lake City, Utah; and.
authors.forename: Theodore
authors.initials: T
authors.lastname: De Beritto
authors.affiliation: Department of Pediatrics, University of Utah, Salt Lake City, Utah; and.
authors.forename: Stephen
authors.initials: S
authors.lastname: Jenkins
authors.affiliation: Department of Pediatrics, University of Utah, Salt Lake City, Utah; and.
authors.forename: Christopher G
authors.initials: CG
authors.lastname: Maloney
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003365:Costs and Cost Analysis / Q000379:methods; D003625:Data Collection; D003953:Diagnosis-Related Groups / Q000191:economics*; D005260:Female; D017721:Hospital Costs / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000191:economics; D006776:Hospitals, Pediatric / Q000458:organization & administration / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007297:Inpatients / Q000706:statistics & numerical data; D008297:Male; D019300:Medical Errors / Q000191:economics*; D018447:Medical Futility; D011368:Professional-Family Relations; D011897:Random Allocation; D062606:Tertiary Care Centers / Q000458:organization & administration / Q000706:statistics & numerical data; D014589:Utah