Indian Pediatr 2016;53:639-641
Direct Medical Costs in
Children with Rotavirus and Non-rotavirus Diarrhea Admitted to a
Pediatric Intensive Care Unit and High Dependency Unit in Delhi
*Ann Mathew, Rajan Srinivasan, Srinivasan Venugopal
and Gagandeep Kang
From *Department of Pediatrics, St. Stephen’s
Hospital, Delhi; and Division of Gastrointestinal Sciences, Christian
Medical College, Vellore, Tamil Nadu; India.
Correspondence to: Dr. Ann Mathew, Department of
Pediatrics, St Stephen’s Hospital, Delhi, India.
Received: July 23, 2015;
Initial review: October 09, 2015;
Accepted: May 05, 2016
Objective: To estimate direct medical costs of
diarrheal hospitalization of children <5 years admitted in pediatric
intensive care unit (PICU) or high dependency unit (HDU).
Methods: Analysis of medical records and hospital
bills of 84 children during two time frames, 2005-08 and 2012-14.
Results: Direct medical costs in PICU increased
from INR 17,941 to INR 50,663 per child for rotavirus diarrhea and INR
11,614 to INR 27,106 for non-rotavirus diarrhea, and in HDU from
approximately INR 5,800 to INR 10,500 per child for all-cause diarrhea
between the two time frames.
Conclusions: Costs of PICU and HDU care are high
and should be included in cost-effectiveness analysis of vaccination.
Keywords: Diarrhea, Direct costs, Economic burden.
otavirus is the commonest cause of severe
diarrhea and is responsible for 25-40% of all diarrhea hospitalizations
in India [1,2]. Children with severe diarrhea may have co-morbidities
and complications [3-8] that may require more intensive care than that
provided in ward settings. The prevalence of underweight children in
India is high (39-75%) and confers an additional risk of deaths from
Rotavirus vaccines have the potential to alleviate
some of the burden associated with disease. Data on the cost of
treatment is required for assessment of economic cost- benefit of a
rotavirus vaccination program. Though previous costing studies of
rotavirus hospitalizations in India have shown that most costs were
direct medical costs [10,11], there has not been any published study
evaluating costs in intensive care settings. The purpose of this study
was to determine the direct medical costs of treatment of children with
rotavirus and non-rotavirus diarrhea who were hospitalized in the high
dependency unit (HDU) or pediatric intensive care unit (PICU).
The study was done at St. Stephen's Hospital – a 595
bedded not-for-profit, urban, referral hospital in Delhi. Based on
severity of illness and physician assessment, children with diarrhea
were admitted to the ward (37 beds), HDU (6 beds) or PICU (6 beds), and
treated according to standard guidelines. At our hospital, patients pay
for services, which are calculated for general patients on a no-profit
no-loss basis, and are revised annually by the hospital management. The
study was approved by the hospital Research and Ethics committee.
Data were analyzed for two periods, December 2005 to
December 2008 (36 months) and November 2012 to January 2014 (15 months).
During these periods, there was active rotavirus surveillance as part of
the Indian National Rotavirus Surveillance Network . Children aged <5
years with diarrhea admitted to the PICU or HDU, who had stool samples
tested for rotavirus by enzyme linked immunosorbent assay (ELISA) were
included, in the study. Children with an admission diagnosis other than
acute diarrhea were not included and six children with a co-primary
diagnosis of sepsis were excluded from analysis. Clinical and cost
details were obtained from the Hospital Information System (HIS) and
patient records. For costs not incurred by all children, the average
costs were calculated by dividing the total among all children receiving
the care, such as for ventilation where only some children needed to be
ventilated. Data were analyzed with SPSS v15. Cost data were presented
as median (IQR) and differences were calculated using Mann Whitney U
test. Costs were adjusted for the consumer price index (CPI)  for
assessment of whether the increase in INR costs paralleled the CPI.
Difference between proportions was evaluated by Chi square or Fisher
exact test. Nutritional status was graded using WHO growth tables .
A higher proportion of hospitalized children with
rotavirus diarrhea (50/571, 8.8%) as compared to non-rotavirus diarrhea
(34/816, 4.2%) required PICU and HDU care (P<0.001). History of
rotavirus vaccination was not obtained from the children.
The majority of children admitted to the HDU (27/35)
and the PICU (46/49) were infants, with mean duration of 3.4 days of
diarrhea at admission. Approximately a quarter (20/84) were referred
from elsewhere and three-quarters (63/84) had severe dehydration, with a
quarter (21/84) in shock. The proportion of children in PICU with severe
dehydration, acidemia, shock and hypokalemia was comparable in both
rotavirus and non-rotavirus diarrhea; hypernatremia and hypocalcemic
seizures were present in a higher proportion of rotavirus positive
children (data not shown). There was one death each in
rotavirus-positive and rotavirus-negative children. Underweight children
were more likely to have severe disease requiring PICU (OR 3.5, 95% CI
The direct medical costs per child in rotavirus and
non-rotavirus diarrhea in PICU and HDU are presented in
I. Overall, there was a substantial increase in direct medical
costs between the two time frames. The PICU costs for children with
rotavirus diarrhea were higher than non-rotavirus diarrhea, but the
differences were not statistically significant (P=0.056 in
2005-2008 and P=0.10 in 2012-2014). However, direct medical costs
had risen significantly (P=0.003) between the two time frames.
When adjusted for the change in the CPI, costs were 15% higher in the
latter period. For the HDU, direct medical costs were not different
between rotavirus and non-rotavirus diarrhea, but costs had increased
significantly between the two time frames, 2005-08 and 2012-14 (P=0.005),
and were 30% greater after adjusting for the CPI. For both PICU and HDU
most of the costs and increase in costs was due to bed costs, but
diagnostic costs more than doubled in the PICU and increased in the HDU
(Web Table I).
In this study, we describe the direct medical costs
of diarrheal hospitalizations in the PICU and HDU of a private
not-for-profit hospital, and documented no significant differences in
costs between rotavirus and non-rotavirus cases. When comparing the
first time frame of this study to two published studies in India that
reported a total cost of approximately INR 3200-3600 in a similar period
[10,11], the direct medical costs in the PICU were four times greater,
and in the HDU were one and half times greater. About 9% (50/571) of
children hospitalized with rotavirus diarrhea required this level of
care; this high proportion could be because a quarter of the children
were referred or previously treated elsewhere. The significant rise in
direct medical costs, despite adjustment for the CPI, could be because
management practices have changed over time, requiring more
investigations and use of equipment in higher- level care.
There are several limitations to this study. This was
a small study from a single center and may not represent treatment costs
at all types of facilities nationally. Direct non-medical costs and
indirect costs were not measured. Another limitation is that no history
of rotavirus vaccination was obtained. Data from in-patient wards in
India are available, but is now several years old and did not include
HDU or PICU admissions [10,11]. Updated data on costs in in-patients,
and additional data on out-patient costs as well as PICU and HDU costs
from other sites would be useful both in estimating the direct medical
costs of disease in different settings, and in evaluating the
cost-effectiveness of vaccination.
Acknowledgements: Dr JE Tate of the Centers for
Disease Control and Prevention, Atlanta, for her advice and review of
Contributors: AM: designed and conducted the
study, analyzed the data and wrote the paper; RS, SV: analyzed the data;
GK: analyzed and interpreted the data and reviewed the paper.
Funding: Indian Council for Medical Research
Competing Interest: None stated.
What This Study Adds?
• 9% of children admitted for rotavirus
gastroenteritis required high dependency unit and intensive care
unit admission and cost of such admissions are high even at a
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