Risk factors of death among children hospitalized with social insurance (BPJS): a cross sectional study using hospital claim data

Background: Hospital death rate is one of the indicators used to measure hospital performance and quality of care, especially the overall hospital death rate. This study aims to analyze the risk factors of death among children hospitalized with social insurance (BPJS) in one hospital in Jakarta. Method: This was a cross-sectional study conducted in one government hospital in Jakarta. The sample was all individual claim data of BPJS patients who were hospitalized during the period of January to December 2017. All BPJS patients aged below 18 years admitted into the pediatric wards were included in the analysis. The logistic regression was used to analyze the risks of children death Results: A total of 18.941 BPJS inpatients in the hospital was identified, out of the 3689 met the inclusion criteria. The proportion of death in children during one year was 7.3%. Illness severity level II had 11.51-fold [adjusted odds ratio (ORa)=11.51;CI=7.45-17.78; P=0.000]] meanwhile severity level III had 33.97-fold higher risk of children death (ORa=33.97; CI=19.93-57.91;P=0.000) compared to children with severity level I. Children who had ICU indicator increase risk of children death at 14.21 -fold (ORa=14.21;IK=9.1522.08;P= 0.000) compared to those who did not have. Furthermore the risk of children death in certain conditions originating in the perinatal period increases by 7.65–fold (ORa=7.65;IK=1.81-32.35;P=0.006) compared to diseases of the musculoskeletal system and connective tissue. Conclusion: Illness severity level, ICU indicator and diseases in certain conditions originating in the perinatal period are the most common risk factors for children death in the hospital. (Health Science Journal of Indonesia 2020;11(2):115-20)

A hospital inpatient ward is a place where necessary care is provided to patients whose health conditions require hospital admission for a certain time. 1 Inpatient care has become the core of services at the hospital and has a significant contribution to hospital revenue. 2 Therefore, the demands for excellent service and quality need to be managed properly. The information of inpatient productivity can be measured through several indicators. 3 Hospital death rate is one of the indicators used to measure hospital performance and quality of care, especially the overall hospital death rate. 4,5 It shows the proportion of patients who die during or immediately after the patients were admitted to the hospital. 6 Shihab et al reported that National Health Insurance (Jaminan Kesehatan Nasional/JKN) program increases the utilization of hospitalization both in the government and private hospitals. 7 It opens wider access to nationwide inpatient utilization. 7 The roll-out of JKN introduced in 2014 aims to extend financial coverage for health care to at least 95 % of the population by 2019. Nearly half of children (47%) have health insurance programs in 2015. Out of those with insurance, as many as 23% were covered by Badan Penyelenggara Jaminan Sosial (BPJS / Social Security Agency). 8 There is an increasing number of hospitalization in children, particularly in the urban areas and large community hospitals. 9 Improving the quality of care for seriously ill children is essential for reducing children death. Many factors were associated with the death rate in children such as mother's age at birth, mother's educational level, and mother's household socioeconomic, several diseases (malaria, diarrhea diseases, respiratory infections, and malnutrition), breastfeeding duration, total health care visits, low birth weight. 10,11 Beside that living in poor households, living in rural areas, birth rank, birth interval, previous death of a sibling, having other children under 5 years old, contraceptive, type of births, complications, history of previous mortality, antenatal care and place of delivery were also considered to contribute with childhood mortality. 12,13,14 Risk factors data for hospital death is widely assessed from socioeconomic factors, and the use of claim data for hospital evaluation is still limited in Indonesia. Although hospital-based mortality reviews may not reflect the multiple causes of all deaths in a large population, it can examine the causes that contribute to deaths occurring in hospital and identify inadequate care. The present study aimed to analyze the risk factors of death among children hospitalized with BPJS insurance in one hospital in Jakarta.

METHODS
This study was a cross-sectional study conducted in one government hospital in Jakarta. The sample was all individual claim data of BPJS patients who were hospitalized during the period of January to December 2017. The inclusion criteria was BPJS patients aged below 18 years admitted into the pediatric wards. The data with incomplete records was excluded from the analysis.
The outcome of the study was children death (death in children occurs both before and after 48 hours of admission over one year period). The independent variables of interest in this study were age, gender, hospital accommodation level, illness severity level, length of hospital stay (LOS), ICU indicator, ICU length of stay, and diseases category.
Age group was divided into two groups: less than 5 / under 5/ Balita and 5-17 (years). Gender was categorized into two groups: male and female. Hospital accommodation level was divided into three categories first class, second class and third class. Illness severity was grouped into severity level I(without complications or comorbidity), II(mild complications and comorbidity), III(major complications and comorbidity). 15 Illness severity level was automatically generated by the Indonesian Case Based Groups (INA-CBGs) software grouper application after entering the principal and secondary diagnosis. Length of hospital stay was categorized into 7 days or less and more than 7 days (the time from patient admission to the hospital until discharge), ICU indicator was grouped as yes (If the patient is admitted to the ICU during the treatment episode) and no. ICU length of stay was divided as 3 days or less and more than 3 days. Principal diagnosis was used to classify the diseases according to ICD 10 Category (2010). There were 20 disease groups identified in this study and several disease groups with a number of cases less than 100 cases were assigned to "other" groups. The diseases groups were certain infectious and parasitic diseases; diseases of the respiratory system; diseases of the digestive system, diseases of the musculoskeletal system and connective tissue; diseases of the genitourinary system, certain conditions originating in the perinatal period, symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified; injury, poisoning and certain other consequences of external causes; factors influencing health status and contact with health services; others (mental and behavioral disorders; diseases of the nervous system; diseases of the circulatory system; diseases of the skin and subcutaneous tissue; diseases of the ear and mastoid process; endocrine; nutritional and metabolic diseases; pregnancy, childbirth and the puerperium; diseases of the nervous system; diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism; neoplasms) The data was tabulated according to various factors included in this study and analyses were performed using the STATA version 9. The logistic regression model was used for multivariate analysis. Variable with a significance level (p-value) < 0.25 on bivariate analysis was kept in a multivariate model. Stepwise regression and likelihood ratio test was performed to select the final model.
This study was approved by The Ethics Committee, Faculty of Public Health, University of Indonesia with a letter number: 564/UN2.F10/PPM.00.02/2017. The confidentiality of the patient's information was ensured in such a way that the data will be used for the study purpose only.

RESULTS
A total of 18.941 BPJS inpatients in the hospital was identified, out of the 3689 met the inclusion criteria. The proportion of death in children during one year was 7.3% (271/3689). Table 1, compared to the respective reference groups, children under five years, LOS more than 7 days, children who had ICU indicator and ICU LOS more than 3 days were more likely to increase the risk of children death. The higher the severity level of diseases also seems to have a higher risk of death in children. Those who had the risk of death and did not have were similarly distributed in terms of gender and accommodation level (P > 0.05).

As shown in
In respect with diseases group based on ICD, children who had diseases of respiratory system, infectious and parasitic diseases, certain conditions originating in the perinatal period, congenital malformations, deformations and chromosomal abnormalities, as well as factors influencing health status and contact with health services were more likely to increase the risk of children death compared to those with the musculoskeletal system and connective tissue disease groups.
Table 2 the final model demonstrates severity level II had 11,51-fold while severity level III had 33.97fold higher risk of children death compared to children with severity level I. In addition, children who had ICU indicator increase risk of children death at 14.21-fold compared to those who did not have. Furthermore, the risk of children death in certain conditions originating in the perinatal period; symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified increase by 7.65-fold and 6.05-fold respectively compared to diseases of the musculoskeletal system and connective tissue.

DISCUSSION
This study showed that the greater the severity of illness, the greater the risk of death in children. The severity of illness is a condition of disorder in the organ system that can be assessed using demographic, clinical, physiological, and laboratory results. 16 The severely ill children have a clinical condition with severe organ systems dysfunction. If the condition was not treated properly and immediately, the risk of sequelae and death would have increased significantly. 17 In the case mix system, the severity is affected by the presence of a complication or comorbidity (secondary diagnosis). 18 The severity indicates how sick and what burden of illness has suffered by the patient. Patients often have additional diseases or medical condition which accompanies the main disease. Therefore, the existence of comorbidity is more likely to have worse initial well-being. Additional diseases will worsen the clinical course of the disease. Martins reported that the patients with one comorbidity have a higher mortality rate compared to patients without comorbidity. 19 However Chang LS et al in Chang-Gung Memorial Hospital-Kaohsiung, Taiwan, found the death in pediatric patients without comorbidities in several cases. 20 It was more common in younger children with the central nervous system and cardiovascular infections, consciousness change, and high liver enzyme levels at admission. 20 This study found when children were admitted to the ICU during the treatment episode, they had a greater risk of death 14.21-fold compared to those who did not. Most of the patients in ICU have at least one organ failure at the time of death. The death may take place suddenly or unexpectedly due to hemodynamic causes or occur later with many organ failures. 21 Children with ICU indicator was in critical condition or unstable or potentially unstable which poses a threat to the life of the patient. Intensive care provides integral management, optimum care with specialized personnel and equipment. Therefore, ICU allows the treatment for critically ill patients who need close vigilance and had potentially recoverable conditions. 22 The patients should be admitted to the ICU before achieving irreversible health conditions. This study demonstrated that certain conditions originating in the perinatal period had 7.65-fold for children death compared to the musculoskeletal system and connective tissue. Zhu et al in China reported that the majority of death occurred in infants (42%) over a 10 years period with pneumonia as the largest proportion for the immediate cause of death. 9 Lahmini et al in Marrakech mentioned that among pediatric patients, neonatal mortality was predominant followed by postnatal mortality (1 month to 1 year old). 23 Meanwhile the leading cause of pediatric mortality (at all ages) was neonatal pathologies. 23 The differences with this study may be due to the different data sources as well as different research designs and analyses.
This study has limitations, which did not represent the general population. Several determinants were not available in the claim data such as signs and symptoms, laboratory results, medications prescribed by physicians, and referred from other facilities.  In conclusion, illness severity level, ICU indicator and diseases in certain conditions originating in the perinatal period are the most common risk factors for children death in the hospital. The clinical pathways could be implemented to standardize patient management and improve hospital cost efficiency, however this must be followed by conducting an audit of clinical pathway compliance as quality control. Expansion of neonatal or pediatric intensive care unit (NICU/PICU) and improvement of the skill of its staff to reduce mortality caused by certain conditions originating in the perinatal period.