Management trends of infantile hemangioma: A national perspective

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Abstract

Introduction

The primary management of infantile hemangioma (IH) has changed since 2008, with the initiation of propranolol. The change that propranolol has affected on resource utilization is unknown.

Materials and methods

The Kids' Inpatient Database (KID) in 2003, 2006, 2009, and 2012 was queried for ICD-9 codes for IH in children under age three. The number of patients undergoing the following procedures of interest: tracheostomy, tracheoscopy and laryngoscopy with biopsy, and excision of skin lesion were evaluated. Data was analyzed for demographics and details on the admission. Trends were identified. Weighted statistical analyses were performed with SAS 9.4.

Results

The number of qualified admissions significantly increased over the years (9271 in 2003–12029 in 2012, OR 1.042 per year increase, p < 0.001). The mean age at admission ranged from 26 to 28 days but did not vary over time (p = 0.54). The percentage undergoing tracheostomy significantly decreased from 1.05% in 2003 to 0.27% in 2012 (p = 0.0055), and the percentage undergoing tracheoscopy and laryngoscopy with biopsy significantly decreased from 7.29% in 2003 to 4.20% in 2012 (p = 0.011) among those with IH of unspecified or other sites. The percentage undergoing skin lesion excision also significantly decreased from 1.87% in 2003 to 1.03%, in 2012 (p = 0.0038) among those with IH of skin and subcutaneous tissue. These findings suggest a potential impact of propranolol. After adjusting for inflation, the total hospital charges increased from a mean of $17,838 in 2003 to an adjusted mean of $41,306 in 2012 (p < 0.0001).

Conclusions

Total admissions and hospital charges in children with IH has increased from 2003 to 2012. The percentage of patients undergoing tracheostomy, tracheoscopy and laryngoscopy with biopsy, and skin lesion excision significantly decreased in 2012 compared to 2003, suggesting a potential impact of propranolol. Further studies are needed to examine these changes more closely.

Introduction

Infantile hemangiomas (IHs) are common, benign vascular tumors. They are the most common tumors in infants and children and affect about 4% of children [1]. These neoplasms undergo a rapid proliferative stage followed by involution with the majority of hemangiomas resolving by age seven without treatment [2].

About 60% of IHs are located in the head and neck region with most being solitary cutaneous and/or subcutaneous neoplasms [1]. In addition to occurring in the skin and subcutaneous tissue, IHs can also occur in the airway, leading to airway obstruction. About 1-2% of patients with cutaneous IHs will also have a lesion in the subglottis [3]. Additionally, IH in the V3 distribution will have upper airway involvement in 29%, and in patients with PHACE syndrome – a subset of patient with IH accompanied by structural anomalies of the brain, cerebral vasculature, eyes, sternum, and/or aorta – 52% will have upper or lower airway involvement [4], [5], [6].

The primary management of IH is observation if there is no functional or dramatic cosmetic deficit. If there is such a deficit, management options include surgical resection, pulsed dye laser, corticosteroids, and vincristine. Additionally, and most recently, in 2008, it was discovered that propranolol, a nonselective β-adrenergic blocker, can be used to reduce the growth of these neoplasms [7]. Since this time, the management of IH has largely shifted to off-label use of propranolol for primary treatment. This change in management has likely affected trends in practices and resource utilization, including the number of procedures performed on these children, number of hospital admissions, and total hospital charges.

Section snippets

Materials and methods

The Kids' Inpatient Database (KID) – a set of publically available pediatric healthcare databases – part of the Healthcare Utilization Project (HCUP), created by the Agency for Healthcare Research and Quality (AHRQ) through a Federal-State-Industry partnership – was reviewed [8]. This national database contains data on admissions for patients under the age of 21 years from more than 4100 hospitals across the United States every 3 years since 1997.

The KID database in the years 2003, 2006, 2009,

Demographics, number of procedures, and risk stratification

The number of qualified admissions, age at admission, gender, and length of stay are shown in Table 1. The number of procedures per admission, and percentages of patients undergoing certain procedures of interest are described in Table 2. When comparing the percentage of patients with IH of unspecified or other sites undergoing airway procedures in 2003 versus 2012, the percentage undergoing tracheostomy significantly decreased from 1.05% in 2003 to 0.27% in 2012 (p = 0.0055), and the

Discussion

From 2003 to 2012, the total number of qualified admissions significantly increased from 9271 to 12,029 with a 4.2% increase in the odds of having a qualified admission per year. Both the number of qualified admissions for patients with hemangioma of unspecified or other sites and the number of qualified admissions for those with hemangioma of skin and subcutaneous tissue increased significantly. There was no significant difference from 2003 to 2012 in the gender distribution or mean age at

Conclusions

Total admissions, length of stay, admissions in teaching hospitals, and hospital charges in children with IH has increased from 2003 to 2012. The percentage undergoing tracheostomy and tracheoscopy and laryngoscopy with biopsy among those with IH of unspecified or other sites significantly decreased in 2012 compared to 2003, and the percentage undergoing skin lesion excision among those with IH of skin and subcutaneous tissue also decreased. These findings suggest a potential impact of

Conflicts of interest

None.

Acknowledgements

HCUP Data Partners that contribute to HCUP:

Alaska, Arizona, Arkansas, California, Colorado, Connecticut, District of Columbia, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah,

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