Household food insecurity is associated with increased hospitalizations and health care expenditures among infants

In recent years, household food insecurity (HFI) has been shown to predict increased health care utilization (including hospitalizations) and costs among Canadian working-age adults.[i] Additionally, a 2018 study has shown food insecure US adults had significantly greater estimated mean annualized health care expenditures ($6,072 vs. $4,208), an extra $1,863 in health care expenditure per year, or $77.5 billion in additional health care expenditure annually.[ii] These Canadian and US findings raise the question whether HFI may also be correlated with increased hospitalizations and health care expenditures among children, including infants, a relationship supported by evidence from research on young children (ages <48 months) in the United States.[iii],[iv],[v]

Researchers from Children’s HealthWatch sought to answer this question. In the 2018 issue of the Journal of Applied Research on Children: Informing Policy for Children at Risk, the Children’s HealthWatch study “Household food insecurity positively associated with increased hospital charges for infants” compared the number of hospitalizations, estimates of mean days hospitalized per year, charges per day, and total charges per year for hospitalizations among infants from food-secure and food-insecure households. These data were obtained by linking two bodies of data – Children’s HealthWatch cross-sectional survey data (1998-2005) and annual inpatient hospitalization charges derived from actual hospital billing data. This study provides the first evidence of which we are aware that household food insecurity may be associated with increased charges for infant hospitalizations and with increased number and longer duration of hospital stays among infants.

While the average length of non-neonatal stays for all infants ages <12 months hospitalized in 2009 was 3.76 days, the average length of stay for Medicaid-enrolled infants in this age group was 4.00 days.[vi] Overall average cost per stay for infants <12 months of age funded by Medicaid in 2009 was $4,564, while mean charges for those infant stays was $14,561.[vii] The large proportion of hospital stays, greater lengths of stay and higher costs and charges among infants <12 months of age covered by Medicaid suggest that identifying and addressing the potentially preventable social determinants of those stays could play an important role in reducing public health care expenditures. Thus the goal of this study was to examine whether hospital charges for inpatient stays among low-income infants (<12 months of age) were associated with their household’s concurrent food security status.

Of 793 infants <12 months of age hospitalized with at least one diagnosis plausibly related to food insecurity (e.g., respiratory or intestinal infections on the basis of their plausible relationship to immune function and nutrition), 158 (20%) lived in households that reported HFI. Among all infants, 24% of those from food-insecure households vs. 16% from food-secure households had two or more hospital admissions over the 12 study months. Median length of stay per admission was 3 days for infants from food-insecure households compared to 2 days for infants from food-secure households. Overall mean annual hospitalization charges for the sample were $6,474 per patient. Adjusted average annual charges for infants exposed to HFI were statistically significantly higher than charges for infants not exposed to HFI. Mean annual charges per patient from food-secure households were $5,735, compared to $6,707 per patient in food-insecure households. Adjusted for inflation, these annual charges reflect $11,442 and $13,382 in 2017 dollars, respectively.[viii] Adjusted average charges per day did not differ for the two groups, however, average annual number of hospital days was significantly higher for infants exposed to HFI, compared to those not exposed. Infants exposed to HFI had an average of 4.79 hospital days per year, compared to 4.03 days for infants from food-secure households.

The higher annual hospitalization charges for infants from food insecure households appear to be due to either more hospital admissions or increased length of stay per admission, or both, but not to higher charges per day. Thus, these results suggest that HFI may be associated with higher hospital charges as a result of more hospital days when infants < 12 months of age in food-insecure households have any hospital stays for reasons other than birth. Additional research is needed using larger nationally-representative samples, with data subsequent to the implementation of the Affordable Care Act, and for children beyond infancy.

Implementation of the Affordable Care Act and its strong emphasis on decreasing overall medical expenditures through preventive programs has created possibilities for innovative approaches to improving population health in the U.S.[ix] Reducing HFI-related hospitalizations among young infants, however, will require that health professionals, hospital administrators, and policymakers develop strategies for identifying, addressing, and alleviating food insecurity in families with young children, ideally before hospitalization becomes necessary. Recognizing the impact of food insecurity on the health of patients, several health care systems across the nation have incorporated brief, validated, clinical screeners for food insecurity into routine medical histories, a protocol now recognized as a best practice by the American Academy of Pediatrics.[x],[xi],[xii] Treating food insecurity as a vital sign (the “Hunger Vital Sign™”), and recording results of the screener in patients’ Electronic Health Records (EHRs), facilitates appropriate referrals for immediate assistance from the private food assistance system, and applications for public food assistance.[xiii]

[i] Tarasuk V, Cheng J, de Oliveira C, Dachner N, Gundersen C, Kurdyak P. Association between household food insecurity and annual health care costs. Can Med Assoc J. 2015;187(14):E429-36.

[ii] Berkowitz SA, Basu S, Meigs JB, Seligman HK. Food Insecurity and Health Care Expenditures in the United States, 2011-2013. Health Serv Res. 2018;53(3):1600-1620. https://www.ncbi.nlm.nih.gov/pubmed/28608473

[iii] Cook JT, Frank DA, Berkowitz C, et al. Food insecurity is associated with adverse health outcomes among human infants and toddlers. JNutr. 2004;134(6):1432-1438.

[iv] Cook JT, Frank D a, Levenson SM, et al. Child food insecurity increased risks posed by household food insecurity to young children’s health. J Nutr. 2006;136(4):1073-1076. Doi: Retrieved from http://jn.nutrition.org/content/136/4/1073.short.

[v] Cook JT, Frank DA. Food security, poverty, and human development in the United States. Ann N Y Acad Sci. 2008; 1136: 193-209.

[vi] HCUPnet, Healthcare Cost and Utilization Project. Agency for Healthcare Research and Quality. http://hcupnet.ahrq.gov. Published 2011. Accessed June 13, 2014.

[vii] Ibid.

[viii] Consumer Price Index. Bureau of Labor Statistics. http://www.bls.gov/cpi/data.htm. Published 2014. Accessed April 19, 2014.

[ix] Patient Protection and Affordable Care Act. United States; 2010. https://www.healthcare.gov/where-can-i-read-the-affordable-careact/.

[x] Hager ER, Quigg AM, Black MM, et al. Development and Validity of a 2-Item Screen to Identify Families at Risk for Food Insecurity. Pediatrics. 2010;126(1):e26-e32. doi:10.1542/peds.2009-3146.

[xi] Kleinman R, Murphy J, Wieneke D, Desmond M, Schiff A, Gapinski J. Use of a single-question screening tool to detect hunger in families attending a neighborhood health center. Amublatory Pediatr. 2007;7(4):278284.

[xii] Schwarzenberg S, Kuo A, Linten J, Flanagan P. Promoting food security for all children. Pediatrics. = 2015;136(5):e1431-1438.

[xiii] Cantor MN, Thorpe L. Integrating Data On Social Determinants Of Health Into Electronic Health Records. Health Aff. 2018;37(4):585-590. doi:10.1377/hlthaff.2017.1252.