Research in Autism Spectrum Disorders 5 (2011) 1138–1142

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Research in Autism Spectrum Disorders

Journal homepage: http://ees.elsevier.com/RASD/default.asp

Utilization and expenditure of hospital admission in patients

with autism spectrum disorder: National Health Insurance
claims database analysis
Jin-Ding Lin a,*, Wen-Jiu Hung a, Lan-Ping Lin b, Chia-Im Lai c
a
School of Public Health, National Defense Medical Center, Taipei, Taiwan
b
Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan
c
Office of Medical Service, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan

A R T I C L E I N F O A B S T R A C T

Article history: There were not many studies to provide information on health access and health
Received 15 December 2010 utilization of people with autism spectrum disorders (ASD). The present study describes a
Accepted 31 December 2010 general profile of hospital admission and the medical cost among people with ASD, and to
Available online 26 January 2011 analyze the determinants of medical cost. A retrospective study was employed to analyze
medical fee of 397 individuals with ASD based on population-based National Health
Keywords: Insurance (NHI) claims data in Taiwan. The average frequency of hospital admission in the
Autism spectrum disorder respondents was 3.5 annually, mean of hospital stay was 111.9 days, and the mean
Hospital admission
medical expenditure was 94,293 NTD in the year of 2005. Those autistic individuals with
Medical expenditure
characteristics of younger age (OR = 31.085, 95% CI = 12.772–75.659), hold a serious illness
card (OR = 4.980, 95% CI = 1.690–14.673), more frequent in inpatient care (OR = 7.636, 95%
CI = 2.643–22.066), longer days in acute ward (OR = 3.840, 95% CI = 1.989–7.416), and days
in acute + chronic wards (OR = 3.804, 95% CI = 1.334–10.846) were more likely to consume
more medical expenditure than their counterparts. The present study provides valuable
medical care utilization information to health care decision makers to initiate a supportive
healing environment for people with ASD.
ß 2011 Elsevier Ltd. All rights reserved.

1. Introduction

In recent years, surveillance results indicate an increased prevalence of identified autism spectrum disorder (ASD) among
U.S. children and underscore the need to regard ASD as an urgent public health concern (Centers for Disease Control and
Prevention, 2009). Sun and Allison (2010) reviewed recent studies found that the overall reported prevalence of ASD was
higher than the previously reported in Asia. In Taiwan, the registered number of people with autism drastically increased
from 2062 to 7207 (increase rate = 249.5%), and the reported prevalence of each age group, aged 0–5 years was 2.4–7.8/
10,000, aged 6–11 was 5.0–17.3/10,000, and aged 12–17 years was 2.1–10.4/10,000 from year 2000 to 2007 (Lin, Lin, & Wu,
2009). However, the trend test revealed that child dependency ratio in autism decrease significantly as the identified
younger aged number increase during the past decade (Lin, Lin, Sung, & Wu, 2011). An increase in prevalence would suggest
the need for more attention and funding of services for this group of people.

* Corresponding author at: School of Public Health, National Defense Medical Center, No. 161, Min-Chun East Road, Section 6, Nei-Hu, Taipei, Taiwan.
Tel.: +886 2 87923100x18447; fax: +886 2 87923147.
E-mail address: a530706@ndmctsgh.edu.tw (J.-D. Lin).

1750-9467/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.rasd.2010.12.010
 J.-D. Lin et al. / Research in Autism Spectrum Disorders 5 (2011) 1138–1142 1139

Children with ASD have a social communication disorder with rigid or repetitive behaviors and poor imagination (Brooks,
Marshallsay, & Fraser, 2004). Brown, Ouellette-Kuntz, Hunter, and Kelley (2010) found that the autistic child’s adaptive skills
and challenging behaviors were important in predicting the extent of the parent’s perceived unmet need. There is a need to
tailor care to children with ASD who may find interfaces with healthcare services for any reason extremely stressful,
particularly in admission to hospital care (Brooks et al., 2004). Researchers have found that individuals with ASD who use
psychiatric hospitals have high clinical needs that are not always well met. Medical staff needs to be trained in the
assessment, diagnosis and treatment to provide more appropriate services for them (Lunsky, Gracey, & Bradley, 2009).
Studies revealed that many autistic individual often experience a number comorbid medical conditions, but the nature
and prevalence of which remain as yet, poorly defined (Bauman, 2010; Lauritsen, Mors, Mortensen, & Ewald, 2002). They also
incur elevated medical utilization and costs (Croen, Najjar, Ray, Lotspeich, & Bernal, 2006; Shimabukuro, Grosse, & Rice,
2008), which continually increase the burden in the health care system (Leslie & Martin, 2007). Understanding how to
improve the health care access, quality, and outcomes for individual with ASD is extremely complex (Young, Ruble, &
McGrew, 2009). For a child with an ASD, hospitalization can be an overwhelming sensory and cognitive experience
(Scarpinato et al., 2010). However, little information is known about hospitalization profile and their medical cost in health
services of individuals with ASD. Such information is important and provides valuable information in health care decision for
this group of people. Therefore, this study aimed to describe the use of hospitalization and medical fee of people with ASD
based on population-based National Health Insurance (NHI) claims data in Taiwan.

2. Methods

A retrospective analysis was conducted by using an merged database of hospital medical care discharge claims by Taiwan
Bureau of National Health Insurances (NHI), and Disability Registration System which administered by Ministry of the
Interior in Taiwan. The database was derived from the demographic data of people with ASD and their hospital inpatient care
utilization in 2005. The ASD case was ASD entified according to the International Classification of Diseases, 9th revision,
Clinical Modified (ICD-9-CM) coding system which has been used in Taiwan NHI diagnosis system. Those ASD cases are ICD
code 299, 299.0, 299.00, and 299.01. Data were analyzed by SPSS 18.0 software which the main methods included number,
percentage, mean, and Chi-square test to describe research subject admitted to hospital characteristics and inpatient care fee
of people with ASD. Logistic regression analyses were used to test the relation of ASD case’s demographic characteristics,
inpatient care use and medical fee in people with ASD.

Table 1
Demographic characteristics of people with ASD.

Variable n (%) Mean  SD

Gender (n = 397)
Female 70 (17.6)
Male 327 (82.4)
Age (years) (n = 297) 11.3  10.860
10 253 (63.7)
11–20 78 (19.6)
21–30 44 (11.1)
31–40 12 (3.0)
41 10 (2.5)
Severe illness card holder (n = 397)
No 102 (25.7)
Yes 295 (74.3)
Low income family (n = 397)
No 383 (96.5)
Yes 14 (3.5)
Frequency of inpatient care (n = 397) 3.5  2.804
2 188 (47.4)
3–4 90 (22.7)
5 119 (30.0)
Days in acute ward (n = 222) 40.4  67.038
4 76 (34.2)
5–21 72 (32.4)
22 74 (33.3)
Days in chronic ward (n = 223) 159.1  117.4
82 77 (34.5)
83–188 72 (32.3)
189 74 (33.2)
Days in acute + chronic ward (n = 397) 111.91  117.442
21 134 (33.8)
22–128 131 (33.0)
129 129 (33.2)
1140 J.-D. Lin et al. / Research in Autism Spectrum Disorders 5 (2011) 1138–1142

Table 2
Annual inpatient fee among people with ASD.

Items n Mean (NTD)

Total fee 397 94293.36

Consultation fee 207 8038.43
Ward fee 396 59965.67
Exam/lab test fee 205 4564.71
Medicine and pharmacy service fee 259 9438.44
Psychiatric treatment fee 69 70591.32

3. Results

Table 1 presents the demographic characteristics and hospital admission profile of people with ASD in Taiwan. There
were 397 persons with ASD admitted to hospital care within the year of 2005 Taiwan NHI claims. There were 327 (82.4%)
male and 70 (17.6%) female patients. The majority of the children were age under 10 years (63.7%) and the mean age of the
patients was 11.3 years old. With regard to the household income, 3.5% patients come from low income family in the study
respondents. Among those inpatient care users, there were 74.3% cases hold severe illness cards which their medical
copayment can partially waive from NHI scheme if medical necessary. Average hospital admission in the respondents was
3.5 annually, there was 47.4% cases used less than twice inpatient cares, 22.7% used 3–4 times, and 30.0% were hospitalized
more than five times in the year of 2005. The results also show that the mean of hospital stay was 111.9 days, which staying
in acute ward was 40.4 days and in chronic ward was 159.1 days.
The annual inpatient fee among people with ASD shown in Table 2, the results revealed that the mean expenditure was
94,293 NTD (1 USD = 30 NTD) in the year of 2005. The medical fee mainly includes ward fee (mean = 59,965 NTD), medicine
and pharmacy service fee (mean = 9438 NTD), exam/lab test fee (mean = 4564 NTD) physician consultant fee (mean = 8038
NTD). There were 69 cases used psychiatric service, and the mean of their treatment fee was 70,591 NTD.
Table 3 describes the relations of ASD case’s characteristics, inpatient care and medical fees in Chi-square tests. We found
that variables of patient’s age, a severe illness card holder, low income family, frequency of inpatient care, hospital stay either
in acute ward or chronic ward were significant differences between low (109,900 NTD) and high (>109,900 NTD) groups of
inpatient care expenditure. Finally, we use logistic regression model to identify the possible factors which affected the level
(low vs. high) of annual inpatient fee in people with ASD. Table 4 shows that factors – age (reference: 12 years; OR = 31.085,
95% CI = 12.772–75.659), hold a serious illness card (reference: no; OR = 4.980, 95% CI = 1.690–14.673), frequency of
inpatient care (reference: 3; OR = 7.636, 95% CI = 2.643–22.066), days in acute ward (reference: 9; OR = 3.840, 95%

Table 3
Relation of demographic characteristics, inpatient care and annual inpatient fee in Chi-square tests.

Variable Annual inpatient fee x2 p value

Low, n (%) High, n (%)

Gender (n = 397) 0.027 0.868

Female 52 (17.4) 18 (18.2)
Male 246 (82.6) 81 (81.8)
Age (n = 397) 95.732 <0.001
12 240 (80.5) 27 (27.3)
>12 58 (19.5) 72 (72.7)
Severe illness care holder (n = 397) 23.956 <0.001
No 95 (31.9) 7 (7.1)
Yes 203 (68.1) 92 (92.9)
Low income family (n = 397) 12.004 0.001
No 293 (98.3) 90 (90.9)
Yes 5 (1.7) 9 (9.1)
Frequency of inpatient care (n = 397) 77.640 <0.001
3 218 (73.2) 23 (23.2)
4 80 (26.8) 76 (76.8)
Days in acute ward (n = 222) 49.918 <0.001
9 108 (66.7) 8 (13.3)
10 54 (33.3) 52 (86.7)
Days in chronic ward (n = 223) 34.139 <0.001
126 100 (62.5) 12 (19.0)
127 60 (37.5) 51 (81.0)
Days in acute + chronic ward (n = 397) 50.483 <0.001
74 180 (60.4) 19 (19.2)
75 118 (39.6) 80 (80.8)

Low and high annual inpatient fee groups were categorized by 75% percentile: low: 109,900 NTD and high: >109,900 NTD.
 J.-D. Lin et al. / Research in Autism Spectrum Disorders 5 (2011) 1138–1142 1141

Table 4
Logistic regression of annual inpatient fee (low vs. high) in people with ASD.

Variables (reference) b Wald O.R. (95% C.I.) p-value

Constant 14.680 81.879 <0.001 <0.001

Age (12 years) 3.437 57.344 31.085 (12.772–75.659) <0.001
Severe illness card holder (No) 1.605 8.479 4.980 (1.690–14.673) 0.004
Frequency of inpatient care (3) 2.033 14.100 7.636 (2.643–22.066) <0.001
Days in acute ward (9) 1.346 16.056 3.840 (1.989–7.416) <0.001
Days in chronic ward (126) 0.782 3.559 2.185 (0.970–4.922) 0.059
Days in acute + chronic ward (74) 1.336 6.246 3.804 (1.334–10.846) 0.012

CI = 1.989–7.416), and days in acute + chronic wards (reference: 74; OR = 3.804, 95% CI = 1.334–10.846) were more likely to
consume more medical care fees than their counterparts.

4. Discussions

Our previous study revealed that the reported prevalence of autistic cases significantly increased from 0.93 to 3.96 per
10,000 and the group of mild disability grade was the most increased group of four disability levels in the year of 2000 and
2009 in Taiwan (Lin, Sung, et al., 2011). Although the number of studies published on ASD continues to increase and the most
frequently studied topics include genetics, perception and cognition, neurobiology, physiology and nosology (Matson &
LoVullo, 2009). There have not been many studies providing information on health access and health utilization of this group
of people. The present study describes a general profile of medical care use and medical cost among people with ASD. These
results will provide valuable information for health care decision makers to initiate appropriate health policy for this group
of people.
Our results revealed that people with ASD used more hospital admission (mean = 3.5 annually) than the general
population. Those cases who were of a younger age, held a serious illness card. More frequent hospital admissions and longer
stays in the hospital resulted in the consumption of more medical cost than their counterparts. Comparing to other studies in
the US, individuals with an ASD had average medical expenditures that exceeded those without an ASD by $4110–$6200 per
year. On average, medical expenditures for individuals with an ASD were 4.1–6.2 times greater than for those without an ASD
(Shimabukuro et al., 2008). Wang and Leslie (2010) found that the mean total health care expenditures per child with ASD
were $22,079 in 2000 (in 2003 US dollars), and rose by 3.1% to $22,772 in 2003 in Medicaid beneficiaries. Leslie and Martin
(2007) analyzed average health care expenditures for individuals with an ASD increased 20.4% from $4965 per patient in
2000 to $5979 per patient in 2004, even after adjustment for inflation.
Autistic children are participating in a wide range of therapies with most individuals using multiple treatments
simultaneously (Goin-Kochel, Myers, & Mackintosh, 2007). Over 70% had tried at least one complementary and alternative
medicine (CAM) treatment with their child, and about half were currently using one or more CAMs (Christon, Mackintosh, &
Myers, 2010). The present study also found that psychiatric treatment was the leading medical cost in hospital admission
among people with ASD. Matson and Hess (2011) assessed current prescription practices and concluded that the use of
psychotropic medication in general and antipsychotic drugs in particular is at an all time high among children and adults
diagnosed with autism. Croen et al. (2006) found that children with ASD experienced nearly 9 times more likely to use
psychotherapeutic medications as children without ASD. Fujiwara, Okuyama, and Funahashi (2011) suggested that a
national health policy to facilitate a referral system that coordinates hospitals that offer psychiatric services with other
settings is needed, to promote the timely provision of child psychiatric services.
The present paper provides the evidence-based information of medical care utilization data for decision making to initiate
quality of care for people with ASD. As researcher Inglese (2009) suggested, knowing the core medical care features of ASD
and realizing a particular individual’s sensitivities will allow health providers to create a supportive healing environment.

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