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Accident Analysis and Prevention 43 (2011) 595600

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Accident Analysis and Prevention


journal homepage: www.elsevier.com/locate/aap

Factors affecting hospital charges and length of stay from


teenage motor vehicle crash-related hospitalizations among
United States teenagers, 20022007
Corinne Peek-Asa a,b, , Jingzhen Yang a,c , Marizen Ramirez a,b , Cara Hamann a,d , Gang Cheng a,e
a
University of Iowa Injury Prevention Research Center, United States
b
The Department of Occupational and Environmental Health, University of Iowa, Iowa City, IA, United States
c
The Department of Community and Behavioral Health, University of Iowa, Iowa City, IA, United States
d
The Department of Epidemiology, University of Iowa, Iowa City, IA, United States
e
The Department of Biostatistics, University of Iowa, Iowa City, IA, United States

a r t i c l e i n f o a b s t r a c t

Article history: Motor vehicle crashes are the leading cause of death for all teenagers, and each year a far greater number
Received 15 April 2010 of teens are hospitalized with non-fatal injuries. This retrospective cohort study used the National Inpa-
Received in revised form 25 June 2010 tient Sample data to examine hospitalizations from the years 2002 to 2007 for 1518-year-old teenagers
Accepted 31 July 2010
who had been admitted due to a motor vehicle crash. More than 23,000 teens were hospitalized for
motor vehicle-related crash injuries each year, for a total of 139,880 over the 6-year period. Total hospi-
Keywords:
tal charges exceeded $1 billion almost every year, with a median hospital charge of more than $25,000.
Motor vehicle crash
Older teens, boys, those with fractures, internal injuries or intracranial injuries, and Medicaid/Medicare
Teenage driver
Hospitalization charges
as a payer were associated with higher hospital charges and longer lengths of stay. These high charges
Outcome study and hospitalization periods pose a signicant burden on teens, their families, and the health care
system.
2010 Elsevier Ltd. All rights reserved.

1. Introduction days for the parent, nancial strain, as well as the potential for
long-term physical disability and psychological trauma (Corso et al.,
Motor vehicle crashes are the leading cause of death for all chil- 2006; Gardner et al., 2007; Winston et al., 2002).
dren between the ages of 1 and 19 years, but crash and fatality rates In addition to nancial hardship for the family, these crashes
rise dramatically during the rst year of driving, usually between also pose a signicant burden to the health care system. The life-
the ages of 15 and 16 (Centers for Disease Control and Prevention, time costs for the motor vehicle injuries sustained in the United
2010a,b; Chen et al., 2000; Insurance Institute for Highway Safety, States in 2000 were estimated to exceed $89 billion dollars, with
2003, 2005; Shope and Bingham, 2008). Despite successful efforts more than $14 billion in medical care costs (Corso et al., 2006).
to reduce teen crash rates through policies such as Graduated However, few studies have evaluated the factors that affect these
Drivers Licensing legislation (Hartling et al., 2004; Hedlund and high hospital charges. One example, by Gardner et al. (2007), esti-
Compton, 2005; Rice et al., 2004; Simpson, 2003), death, injury, mated total charges for all pediatric (under 20 years of age) road
and crash rates remain markedly higher for teenagers than drivers trafc-related hospitalizations in the year 2003 as $2042 million,
of any other age group (Mayhew et al., 2003). with the highest individual charges for those 18 and 19 years of
In addition to the nearly 5500 deaths among teenagers due age. Gardner did not focus specically on teenagers and examined
to motor vehicle crashes each year, more than 20,000 are hos- all road users. Teenager drivers, which are recognized as a growing
pitalized and more than 400,000 receive emergency medical public health priority, may represent that highest hospitalization
attention (Centers for Disease Control and Prevention, 2010a,b). costs for motor vehicle occupants (Centers for Disease Control and
These injuries result in missed school days for the child, lost work Prevention, 2009).
We examine length of hospital stay and hospital charges for hos-
pitalizations for motor vehicle occupant injuries among teens aged
1518 for the years 20022007 in the United States to estimate the
Corresponding author at: University of Iowa, 100 Oakdale Campus, #114 IREH,
health care burden and to identify factors associated with increased
Iowa City, IA 52241, United States. Tel.: +1 319 335 4895; fax: +1 319 335 4225.
E-mail address: corinne-peek-asa@uiowa.edu (C. Peek-Asa). charges and hospital stays.

0001-4575/$ see front matter 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.aap.2010.07.019
596 C. Peek-Asa et al. / Accident Analysis and Prevention 43 (2011) 595600

Table 1
Hospitalizations for teenagers aged 1518 involved in motor vehicle trafc crashes, National Inpatient Sample, 20022007.

National estimatea Total hospital chargesb ($) LOS (days)

n % Mean Median Total charges (million) Mean Median

Total estimated cases 139,880 100 49,352 25,590 6819 5.1 2.3
Year
2002 23,158 16.6 42,594 21,556 975 4.7 2.1
2003 26,141 18.7 48,630 24,888 1255 5 2.2
2004 26,435 18.9 48,929 26,679 1283 5.2 2.4
2005 22,126 15.8 52,121 26,686 1146 5.2 2.2
2006 21,907 15.7 49,016 26,089 1065 5.2 2.3
2007 20,113 14.4 56,049 28,595 1095 5.6 2.4
Age
15 17,505 12.5 47,398 23,832 822 5.1 2.2
16 38,616 27.6 48,824 25,467 1868 5.2 2.4
17 39,774 28.4 47,473 25,423 1862 4.9 2.1
18 43,984 31.4 52,298 26,793 2268 5.3 2.3
Gender
Male 82,036 58.9 51,601 26,748 4183 5.3 2.2
Female 57,138 41.1 46,306 24,108 2615 5 2.3
Patient crash involvement
Driver of MV 56,742 40.6 49,521 26,143 2777 5.1 2.3
Passenger of MV 52,136 37.3 48,525 24,693 2505 5 2.2
Driver of motorcycle 7705 5.5 49,634 25,969 373 5.1 2.2
Passenger of motorcycle 912 0.7 62,308 29,379 56 7 2.6
Otherc 22,385 16 50,229 26,037 1107 5.5 2.3
Mortality status
Died 3738 2.7 85,531 59,561 316 2.9 0.7
Survived 135,914 97.3 48,188 24,980 6469 5.2 2.3
a
Weighted to discharges from all U.S. community, non-rehabilitation hospitals.
b
Total hospital charges were weighted for national estimates of total charges and adjusted to the year 2007 ination rates for in-hospital care.
c
Other includes railway, animal, bicycle, and pedestrian crashes in motor vehicle trafc.

2. Methods and materials injury. These were compared across patient characteristics includ-
ing year of hospitalization, age, gender, patient crash involvement
2.1. Data source (MV driver, passenger, motorcycle driver, passenger), and mortal-
ity status. Outcomes were also examined by injury characteristics
This retrospective cohort is composed of hospitalizations for including primary diagnosis, alcohol and drug comorbidity diag-
1518-year-old teenagers who had been admitted due to a motor noses, discharge status, and payer source. Primary diagnoses were
vehicle crash. Data were from the Nationwide Inpatient Sample identied using CCS diagnosis codes. Alcohol use and drug comor-
(NIS) of the Health Care Utilization Project (HCUP) provided by the bidities are included in the database as comorbidity codes (codes
Agency for Healthcare Research and Quality (AHRQ) for the years 2910 and 2913 for alcohol abuse and 6483064834 for drug depen-
20022007 (AHRQ, 2004). The NIS is the largest all-payer inpatient dency). Alcohol and drug toxicology reports that indicate use at
care database in the United States. Each year, the NIS provides infor- admission are not included in the NIS data.
mation on 58 million inpatient stays from approximately 1000
hospitals located in 35 states (AHRQ, 2004). 2.2. Analysis
The NIS is designed to approximate a 20-percent sample of
U.S. hospitals, dened as all nonfederal, short-term, general, and National estimates of hospitalizations were calculated using
other specialty hospitals, excluding hospital units of institutions discharge-level weighting provided by the HCUP (AHRQ, 2004).
(AHRQ, 2004). A stratied probability sample of hospitals was used Means and medians were examined for hospital length of stay (LOS)
with sampling probabilities proportional to the number of U.S. hos- and hospital charges. Medians were included because the data were
pitals in each stratum. The ve hospital characteristics used to heavily skewed. Hospital charges were adjusted to the year 2007
dene the strata were: ownership/control, bed size, teaching status, (last quarter) levels, using the consumer price index for inpatient
urban/rural location, and region (AHRQ, 2004). hospital services provided by the Bureau of Labor Statistics (Bureau
To select our study cases, we used the Clinical Classica- of Labor Statistics, 2008).
tions Software (CCS), a uniform and standardized coding system Linear regression models were used to assess patient and injury
developed by HCUP that classies diagnosis and procedures into characteristics associated with LOS and hospital charges per dis-
clinically meaningful categories based on the International Classi- charge. Models were adjusted for patient characteristics including
cation of Diseases, 9th Revision, Clinical Modication (ICD-9-CM) age, gender, primary diagnosis, and payer source and clustered on
(Clinical Classication Software, 2010). All patients aged 1518 hospital and variables used for hospital strata (ownership/control,
with a diagnosis of a motor vehicle trafc crash (CCS diagnosis bed size, teaching status, urban/rural location, and region). Log
of 2607) were included for analysis (which corresponds to ICD transformation was performed to account for the skewed dis-
codes: E810-E819, E9685, and E9885). This classication excludes tribution of LOS and hospital charges per discharge, and log
any transport, bicycle, or pedestrian injury that does not involve transformation increased the normality of the residuals from the
motor vehicle trafc. regression models.
The main outcomes were hospital length of stay in days and hos- The Cooks D statistic was used in the model diagnostics. The
pital charges per discharge. Hospital charges were obtained from cutoff Di > 4/n was used, where n was the sample size, to exclude the
the discharge data and reect the billing amount for the hospitaliza- inuential observations that do not t with the regression model.
tion. These charges may not reect total medical care costs for the The ndings reported from the linear regression models were based
C. Peek-Asa et al. / Accident Analysis and Prevention 43 (2011) 595600 597

Table 2
Injuries and injury among teenagers aged 1518 hospitalized for motor vehicle crashes, National Inpatient Sample, 20022007.

National estimatea Total hospital chargesb ($) LOS (days)

n % Mean Median Total charges (million) Mean Median

Total estimated cases 139,880 100 49,352 25,590 6819 5.1 2.3
Top 10 CCS primary diagnoses
233 Intracranial injury 33,261 23.8 68,834 28,381 2271 6.8 2
230 Fracture of lower limb 23,148 16.5 50,523 35,962 1153 5.1 3.1
234 Crushing injury or internal injury 18,682 13.4 50,547 27,648 933 5.6 3.3
231 Other fractures 17,135 12.2 42,682 23,827 721 4.8 2.8
229 Fracture of upper limb 9458 6.8 34,413 23,285 320 3.3 1.7
228 Skull and face fractures 7891 5.6 42,194 26,044 330 3.9 2
244 Other injuries/conditions from external causes 5408 3.9 22,220 14,416 120 1.8 0.6
235 Open wounds of head; neck; and trunk 4463 3.2 24,279 16,618 108 2.1 0.9
239 Supercial injury; contusion 3370 2.4 14,661 11,399 49 1.4 0.6
236 Open wounds of extremities 2960 2.4 43,186 22,805 126 4.8 1.9
All other primary diagnoses 14,103 10.1 49,860 19,290 689 6.3 2.2
Alcohol comorbidity diagnosis
Yes 7880 5.8 44,741 24,462 350 4.2 1.8
No 128,049 94.2 49,484 25,682 6255 5.2 2.3
Drug comorbidity diagnosis
Yes 6047 4.4 47,187 25,988 281 5.1 2.5
No 129,882 95.6 49,302 25,545 6324 5.2 2.3
Hospital disposition
Routine 112,331 80.3 34,350 21,574 3816 3.8 1.9
Short-term hospital 3437 2.5 91,832 42,561 313 6.4 2.2
Long-term care/other 24,112 17.2 113,640 66,848 2690 11.4 6.6
Payer source
Medicaid/Medicare 26,151 18.7 55,619 28,008 1440 6 2.6
Private/HMO 93,503 66.8 49,012 25,468 4517 5.1 2.3
Self-pay/no charge 11,424 8.2 36,154 22,135 411 3.7 1.7
Other 8801 6.3 51,510 24,965 452 5.1 2.2
a
Weighted to discharges from all U.S. community, non-rehabilitation hospitals.
b
Total hospital charges was weighted for national estimates of total charges and adjusted to the year 2007 ination rates for in-hospital care.

on reduced samples, with 5.5% of outlying observations removed teens died in the hospital, and these in-hospital deaths had median
(identied through model diagnostics) for LOS and hospital charges individual hospital charges of $59,561.
per discharge. These outliers largely inuenced the model tting
and reduced the degree of model interpretability. All the analyses
were conducted using SAS callable SUDAAN version 9.0 (Research 3.2. Injuries and injury characteristics among teenagers aged
Triangle Institute, 2004). 1518 hospitalized for motor vehicle crashes

The top 10 primary diagnoses accounted for 89.9% of all hos-


3. Results pitalizations (Table 2). Intracranial injuries were the primary
diagnosis for 23.8% of hospitalizations. The median charges for
3.1. Characteristics of teens hospitalized for motor vehicle crashes intracranial injuries were the second highest at $28,381, although
the mean charges ($68,834) were highest. Although all data for
Based on the National Inpatient Sample, a total of 139,880 teens LOS and charges were skewed, intracranial injuries were among
were hospitalized for motor vehicle-related crash injuries from the most skewed. This skewed distribution likely occurs because
2002 to 2007 (Table 1). The greatest number of hospitalizations milder intracranial injuries are released quickly with relative small
was in 2004 with 26,435 and the smallest in 2007 with 20,113 teens charges, while the more severe injuries lead to extensive stays
hospitalized. with very high costs. For all fracture locations combined, fractures
The cumulative estimated hospital charges for 1518-year olds were the primary diagnosis in 41.1% of hospitalizations. Fractures
involved in motor vehicle crashes for the 6-year period was nearly of the lower limb had the highest median charges at $35,962, and
$7 billion and exceeded $1 billion each year after 2002. The median crushing or internal injuries had the longest length of stay at 3.3
hospitalization charge was $25,590 and the mean was $49,352 days.
per discharge. Although the number of hospitalized teens gener- Of hospitalized teens in our sample, 5.8% were diagnosed with
ally decreased over the 6-year period, median charges increased an alcohol abuse comorbidity and 4.4% were diagnosed with a
from $21,556 in 2002 to $28,595 in 2007. The median hospital drug abuse comorbidity. Alcohol and drug use at the time of
stay was over two days and the mean hospital stay was 5.1 days. the crash was not known. Teens with alcohol comorbidities had
The median stay was 2.1 in 2002 and increased to 2.4 in 2007. lower charges and lengths of stay than teens without alcohol
The total days spent in the hospital for the 6-year period was comorbidities, although teens with drug comorbidities have higher
713,388. charges and lengths of stay than teens without drug comorbidi-
The number of teenagers hospitalized for motor vehicle crashes ties.
increased from age 15 to age 18 and were nearly a third higher for Over 80% of teens had a routine release, which for a teenager
males than females. Most of the hospitalizations were for motor is to the parent or custodian, while 2.5% were discharged to
vehicle occupants (77.9%), with slightly more drivers (40.6% of all short-term and 17.2% to long-term facilities. Charges for those
hospitalizations) than passengers (37.3%). Charges and LOS were discharged to short-term facilities were double those with rou-
highest for motorcycle passengers, with a median charge of $29,379 tine discharges, and those discharged to long-term facilities
and LOS of 2.6 days. For all hospitalizations, over 3700 (2.7%) of the had a median charge more than three times that for routine
598 C. Peek-Asa et al. / Accident Analysis and Prevention 43 (2011) 595600

Table 3
Regression model predicting hospital length of stay and hospital charge for teenagers aged 1518 involved in motor vehicle crashes, National Inpatient Sample, 20022007.a .

Chargeb , c , d , e LOSb , c , f

Predicted difference in average charge (95% CI) P-value Predicted difference in LOS (95% CI) P-value

Age <.001 0.003


15 Ref. Ref.
16 3049 (1494, 5082) <.001 0.22 (0, 0.50) 0.059
17 2264 (740, 3448) <.001 0.10 (0.31, 0.11) 0.290
18 4668 (3049, 6352) <.001 0.11 (0.10, 0.33) 0.261
Gender <.001 0.309
Male 3224 (2394, 4071) <.001 0.05 (0.05, 0.16) 0.309
Female Ref. Ref.
Patient crash involvement 0.002 0.697
Driver of MV Ref. Ref. Ref.
Passenger of MV 431 (850, 1307) 0.564 0.05 (0.11, 0.22) 0.487
Driver of motorcycle 1683 (3694, 431) 0.096 0.05 (0.31, 0.22) 0.683
Passenger of motorcycle 3112 (427, 6946) 0.087 0.39 (0.31, 1.2) 0.319
Other 1269 (2902, 431) 0.110 0.05 (0.11, 0.22) 0.573
Top 10 CCS primary diagnoses <.001
233 Intracranial injury 10,453 (8568, 12,113) <.001 1.65 (1.43, 1.93) <.001
230 Fracture of lower limb 18,017 (16,069, 20,064) <.001 1.93 (1.69, 2.18) <.001
234 Crushing injury or internal 14,217 (12,455, 16,451) <.001 3.00 (2.71, 3.3) <.001
injury
231 Other fractures 7373 (5667, 8874) <.001 1.74 (1.51, 1.93) <.001
229 Fracture of upper limb 8874 (7373, 10,778) <.001 0.75 (0.57, 0.94) <.001
228 Skull and face fractures 12,113 (10,131, 14,217) <.001 1.30 (1.09, 1.51) <.001
244 Other injuries due to external 2085 (3973, 0) 0.047 0.48 (0.66, 0.3) <.001
causes
235 Open wounds of head; neck; Ref. Ref.
and trunk/239 Supercial injury;
contusion/236 Open wounds of
extremities
Other 2305 (894, 3802) 0.001 1.56 (1.30, 1.88) <.001
Payer source 0.001 <.001
Medicaid/Medicare Ref. Ref.
Private/HMO 5045 (6596, 3016) <.001 0.59 (0.81, 0.36) <.001
Self-pay/no charge 6975 (9167, 5045) <.001 1.02 (1.32, 0.70) <.001
Other 4246 (6975, 883) 0.011 0.53 (0.86, 0.18) 0.003
a
769 patients who died in hospitals and 706 patients who transferred to short-term hospital were excluded.
b
Weighted to discharges from all U.S. community, non-rehabilitation hospitals.
c
The model was clustered on hospital and variables used for hospital weighting strata (ownership/control, bed size, teaching status, urban/rural location, and region).
d
The regression model was based on 25,123 observations after 1264 potentially inuential observations were removed. The response variable is log of length of stay and
the results was adjusted for year, drug, alcohol, and disposition.
e
Hospital charges were weighted for national estimates of total charges and adjusted to the year 2007 ination rates for in-hospital care.
f
The regression model was based on 24,947 observations after 1122 potentially inuential observations were removed. The response variable is log of total hospital charge
and the model was adjusted for length of stay, year, drug, alcohol, and disposition and clustered on hospital.

discharges. Hospital length of stay was similar between those age charges. Age, gender, and patient crash involvement, however,
with routine and short-term facility discharges, but those dis- were not signicantly associated with length of stay, which varied
charged to long-term facilities stayed in the hospital three times less than one day by age group. Compared with open wounds (the
longer. largest overall group), most other primary injuries had increased
Over two-thirds of the teens were covered by private insur- average charges and hospital stays. Fractures of the lower limb
ance, 18.7% were covered by Medicaid/Medicare, and 8.2% were averaged $18,017 (95% CI = 16,06920,064) more than the refer-
not insured. Compared with teens covered by private insurance ence group, and intracranial injuries, crushing/internal injury, and
(median charges = $25,468; LOS = 2.3 days), those covered by Med- skull and face fractures all had increased average charges of more
icaid/Medicare had signicantly higher median charges ($28,008) than $10,000. Crushing or internal injury to the abdomen or tho-
and lengths of stay (2.6 days), while those without insurance rax led to an average increased length of stay of three days (95%
had signicantly lower charges ($22,135) and lengths of stay (1.7 CI = 2.713.3). Fractures of the lower and upper limb, fractures to
days). the skull or face, and intracranial injuries all had average increases
of nearly two days of hospital stay compared with the reference
group of open wounds.
3.3. Predictors of increased hospital charges and hospital lengths
All payer categories had signicantly lower hospital stays and
of stay
charges when compared with Medicaid/Medicare. Private/HMO
averaged $5045 less and self-pay averaged $6975 less than Medi-
Compared with 15-year olds, older teens had signicantly
caid/Medicare, and self-pay patients averaged one-half to one less
higher hospital charges (Table 3). In particular, mean charges for
day in length of hospital stay.
18-year olds averaged $4668 more than 15-year olds. Hospitaliza-
tions for young men averaged $3224 more than for young women.
Compared with drivers of motor vehicles, passengers of motor- 4. Discussion
cycles had an average increased charge of $3112, although this
increase was not statistically signicant. Drivers of motorcycles The total number of days that 1518-year olds spent in the
and other road trafc users had non-signicant decreased aver- hospital as the result of motor vehicle crashes in 1 year is equiv-
C. Peek-Asa et al. / Accident Analysis and Prevention 43 (2011) 595600 599

alent to 3963 students missing an entire school year, or 4% of bidities. Since these data do not indicate intoxication at the time of
all U.S. teenagers missing one day of school. The most important the injury, the reasons for these trends are difcult to interpret.
limitation to these data is the under-estimation of motor vehi- In addition to the underestimate of motor vehicle crash-related
cle crash-related hospitalizations, making these estimates highly hospitalizations, there were several other limitations in this study.
conservative. Motor vehicle-related hospitalizations can only be The charges and hospital stays presented are for only the teenagers
identied in the National Inpatient Sample data through external involved in crashes. Occupants of other ages were likely to be
cause codes, which are missing for approximately 16% of entries involved in these crashes and were not considered in this analysis
(Greenspan et al., 2006). Our estimate for the number of teenagers (nor could individuals be tied to the same crash in these data). Crash
aged 1518 hospitalized for motor vehicle crashes is lower than characteristics are not included in these data, so crash risk factors
that provided through online queries of hospital discharge data for increased charges and hospital stays could not be examined.
provided through the CDC/National Center for Health Statistics Despite these limitations, this study is the rst to report on
(Centers for Disease Control and Prevention, 2010a). In 2007, the the national burden of hospitalizations for teens involved in motor
year with the greatest discrepancy, the NIS estimated 20,113 while vehicle collisions. These ndings add to a growing body of research
the online data provided an estimate of 27,900. For the 6-year literature that has identied teen driving safety as an important
period from 2002 to 2007, the NIS estimated a total of 139,800 public health priority.
while the online data estimated 162,554.
Despite the potential underestimate, the number, charges, and Acknowledgements
days spent in the hospital indicate a large burden on the health
care system, teenagers and their families. Total charges were This research was supported by the University of Iowa
estimated at over $1 billion per year, and nearly 27% of these Injury Prevention Research Center, funded by the National Cen-
hospitalized teens either had no insurance or were covered by Med- ter for Injury Prevention and Control (CDC) (grant number
icaid/Medicare. From 2002 to 2007, hospital charges increased by R49CCR703640).
nearly 25%, which could be due to increased costs in general or
increased injury severity from survivable crashes. Generally, the
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