Pediatric Sleep Disorders in Chronic Conditions Linked With Increased Healthcare Utilization, Hospitalizations

Pranshu A. Adavadkar, MD

A recently published Medicare claims study showed that sleep disorders in children with chronic medical conditions (CMCs) are associated with increased risk of heightened healthcare utilization (HU), with the risk varying based on certain sleep disorders. Overall, the presence of a sleep disorder was associated with a nearly 2-fold increase, further emphasizing the importance of a prioritized and targeted approach in sleep management to optimize health care resources.¹

The study included data on 16,325 children from the Coordinated Healthcare for Complex Kids (CHECK) project, with HU identified based on participants’ prior hospitalizations and emergency department (ED) visits in the 12 months prior to enrollment. Patients were deemed at low HU risk if they demonstrated no hospitalization or ED visits (n = 7486), medium if they incurred 1-2 hospitalizations or 1-3 ED visits (n = 8063), and at high risk if they had more than 3 hospitalizations or at least 4 ED visits (n = 776).

Led by Pranshu A. Adavadkar, MD, an associate professor of pediatrics and medicine at the University of Illinois, participants were divided into 5 age subgroups: infants and toddlers (0-2 years), preschoolers (3-5 years) elementary school children (6-10 years), middle school students (11-13 years), and high school students (14-17 years). For the analysis, the CMCs were grouped as follows: asthma/respiratory disorders, developmental disorders, ADHD, diabetes/metabolic disorders, overweight/obesity, prematurity, neurologic disorders, and mood disorders. Tonsillar hypertrophy was also included as a clinical feature for the analysis.

After controlling for other CMCs, sleep disorders, and demographic factors, children with asthma/respiratory disorders had an over 50% increased risk of being in the higher HU group (OR, 1.53; 95% CI, 1.40-1.67). Research also showed that the HU risks were doubled for prematurity (OR, 2.31; 95% CI, 1.94-2.76) and neurologic disorders (OR, 2.28; 95% CI, 1.87-2.78) and increased by 7% for mood disorders (OR, 1.75; 95% CI, 1.57-1.95). Notably, developmental disorders (OR, 0.49; 95% CI, 0.40-0.60) were associated with a decreased risk of HU. Investigators also found no increased HU risk for obesity and diabetes/metabolic disorders.

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On developmental disorders being associated with lower odds of increased HU, the authors wrote, "We speculate that the involvement of early intervention visits likely contributes to early detection and timely interventions, mitigating the development or progression of other medical conditions in children with developmental disorders. Also, outpatient care, which is likely a bigger component of HU in children with developmental disorders was not measured as an HU metric in our study."

In terms of demographic factors, children with Black race and Hispanic ethnicity were associated with an almost 50% lower risk of increased HU compared with White children (Black: OR, 0.58; 95% CI, 0.46-0.73; Hispanic/Latinx: OR, 0.57; 95% CI, 0.45-0.72). Furthermore, the risk of increased HU decreased as age increased (OR, 0.94; 95% CI, 0.94-0.95). It was noted that the discrepancy of HU risk between demographics may have been influenced by the minimal representation of White children in the cohort.

In terms of the specific sleep disorders, those with circadian rhythm sleep disorders were linked most strongly to the risk of being in an increased HU group (OR, 2.45; 95% CI, 1.07-5.64) compared with those without it. SDB (OR, 1.51; 95% Ci, 1.17-1.95) and insomnia (OR, 1.46; 95% CI, 1.06-2.02) were associated with an approximately 50% increase in elevated HU risk. Other sleep disorders such as hypersomnia, nocturnal enuresis, and sleep disordered breathing were not associated with the risk of increased HU. A small sample size for narcolepsy prevented interpretation of this patient population.

Those categorized with high HU demonstrated significantly higher rates of developmental disorders (28.6%), premature birth (9.9%), neurological disorders (34.1%), and mood disorders (12.8%) compared with the medium HU (23.9%, 6.2%, 27.0%, and 11.3%, respectively) and low HU (20.3%, 1.9%, 22.2%, and 9.1%, respectively) groups. The high HU group was also significantly younger than the lower HU groups, which investigators suggests that “the presence of more specialized health care needs in younger children, such as those with congenital anomalities and prematurity, likely contributes to this discrepancy."

Overall, Adavadkar et al concluded by saying that "While further examination of this association is needed, these findings offer yet another reason to screen children with CMCs for sleep disorders."

REFERENCES
1. Adavadkar PA, Brooks L, Pappalardo AA, Schwartz A, Rasinski K, Martin MA. Association between sleep disorders and health care utilization in children with chronic medical conditions: a Medicaid claims data analysis. Journ of Clin Sleep Med. 2024;20(4). doi:10.5664/jcsm.10936