Less surgery, but more admissions for infantile hemangioma

Use of the oral beta blocker propranolol for treatment of infantile hemangioma is likely behind sizeable increases in resource utilization, including hospital admissions and associated costs, according to studypublished in the International Journal of Pediatric Otorhinolaryngology this month.

However, while healthcare utilization increased, the need for surgical procedures decreased among these children, researchers reported.

“There is value in having less surgery and less risk of anesthesia, especially in young children,” according to study author Robert Chun, M.D., associate professor and associate pediatric otolaryngology fellowship director, Children's Hospital of Wisconsin, Medical College of Wisconsin, in Milwaukee.

Infantile hemangiomas are the most common tumors in infants and children. While most hemangiomas resolve on their own, there are cases in which the benign vascular tumors should be treated, including when the tumors impact a vital function, such as breathing or vision, or if there’s a permanent risk to appearance. Surgical resection, pulsed dye laser, corticosteroids and vincristine were among the widely used management options for infantile hemangiomas. But, in 2008, primary management of infantile hemangioma shifted to propranolol, which has been used for many years to treat hypertension, migraine and more. The FDA approved propranolol (Hemangeol, Pierre Fabre Dermatologie), shown to result in complete or nearly complete resolution of target hemangiomas, in March 2014.

To determine how the treatment shift has impacted healthcare resource utilization, Medical College of Wisconsin researchers analyzed the Kids' 0Inpatient Database (KID) in 2003, 2006, 2009, and 2012 for children younger than three years, who had ICD-9 codes for infantile hemangioma. They identified trends for children with infantile hemangioma undergoing tracheostomy, tracheoscopy and laryngoscopy with biopsy, and skin lesion excision, according to the study.

The researchers found that qualified admissions increased from 9, 271 in 2003 to 12,029 in 2012. That’s a 4.2 percent increase in the odds of a qualified admission each year, according to the study.

Children’s average ages at admission, which were from 26 to 28 days, did not notably change in the study period.

The authors noted significant decreases in the percentages of pediatric patients undergoing each of the procedures they studied. Tracheostomy used decreased from 1.05 percent in 2003 to 0.27 percent in 2012. Tracheoscopy and laryngoscopy with biopsy, for treatment of infantile hemangiomas of unspecified or other sites, fell from 7.29 percent of patients in 2003 to 4.20 percent in 2012. And the percentage of patients having skin lesion excision for infantile hemangiomas of the skin and subcutaneous tissue decreased across all time points, from 1.87 percent at the study’s start to 1.03 percent in 2012.

“… the change in management of infantile hemangiomas with the discovery of propranolol in 2008 may be responsible for the decrease in procedures on children with cutaneous hemangiomas,” the authors write.

The percentage of patients admitted with a comorbid diagnosis of other anomalies of the larynx, trachea and bronchus increased from 0.73 percent in 2003 to 1.55 percent in 2012.

The authors found an increase in patients covered by Medicaid or Medicare and a decrease in patients covered by private insurance during the study period. Those with private insurance had more procedures at each point during the study than those with Medicare or Medicaid.

Admissions to urban teaching hospitals increased from the beginning to end of the study, while admission to rural and urban non-teaching hospitals increased. There was no significant change in the number of hospital admissions by region.

A large increase of the total cost of each admission could be related to propranolol use, according to the authors. The increase was significant, even after adjusting for healthcare inflation. The authors note that increased hospital charges could be due to propranolol pretreatment testing and post-treatment admission for observation.

“In 2008, Siegfried et al. proposed baseline echocardiography and 48-h hospitalization or home nursing visits to monitor vital signs and blood glucose levels after propranolol treatment, as the major side effects of propranolol include bradycardia, hypotension, hypoglycemia and bronchospasm,” the authors write.

More recent guidelines recommend extensive pretreatment testing and post-treatment observation, so admission cost increases make sense, they write.

While the findings suggest propranolol use is driving the increased utilization, more studies are needed to look more closely at the changes and factors behind it, according to the study.

REFERENCES

Espahbodi M, Yan K, Chun RH, McCormick ME. “Management trends of infantile hemangioma: A national perspective,”International Journal of Pediatrics Otorhinolaryngology, January 2018. DOI: 10.1016/j.ijporl.2017.10.044.