Resources and Costs Associated With Repeated Admissions to PICUs

Abstract

Objective: To determine the costs and hospital resource use from all PICU patients readmitted with a PICU stay within 12 months of hospital index discharge. Design: Cross-sectional, retrospective cohort study using Pediatric Health Information System. Setting: Fifty-two tertiary children’s hospitals. Subjects: Pediatric patients under 18 years old admitted to the PICU from January 1, 2016, to December 31, 2017. Interventions: None. Measurements and Main Results: Patient characteristics and costs of care were compared between those with readmission requiring PICU care and those with only a single PICU admission per annum. In this 2-year cohort, there were 239,157 index PICU patients of which 36,970 (15.5%) were readmitted and required PICU care during the 12 months following index admission. The total hospital cost for all index admissions and readmissions was $17.3 billion, of which 21.5% ($3.71 billion) were incurred during a readmission stay involving care in the PICU; of the 3,459,079 hospital days, 20.3% (702,200) were readmission days including those where PICU care was required. Of the readmitted patients, 11,703 (30.0%) received only PICU care, accounting for $662 million in costs and 110,215 PICU days. Although 43.6% of all costs were associated with patients who required readmission, these patients only accounted for 15.5% of the index patients and 28% of index hospitalization expenditures. More patients in the readmitted group had chronic complex conditions at index discharge compared with those not readmitted (83.9% vs 54.9%; p < 0.001). Compared with those discharged directly to home without home healthcare, patients discharged to a skilled nursing facility had 18% lower odds of readmission (odds ratio 0.82 [95% CI, 0.75–0.89]; p < 0.001) and those discharged home with home healthcare had 43% higher odds of readmission (odds ratio, 1.43 [95% CI, 1.36–1.51]; p < 0.001). Conclusions: Repeated admissions with PICU care resulted in significant direct medical costs and resource use for U.S. children’s hospitals.

Social Factors Predictive of Intensive Care Utilization in Technology-Dependent Children, a Retrospective Multicenter Cohort Study

“…Third, like Black race, public insurance was also associated with high PICU utilization including 30-day PICU readmission and multiple PICU admissions within a year of index hospitalization. Public insurance has repeatedly been associated with high hospital utilization in pediatric patients ( 24 , 36 , 37 ). Upon hospital discharge, parents of publicly insured children are more likely to make errors in discharge plans, perhaps related to the prevalence of low literacy in this population ( 38 ).…”

“…Differential quality of healthcare based on patient race is a well described pervasive flaw in our healthcare system (21). However, there are few studies investigating differences in the risk of pediatric critical illness or in PICU utilization based on race (22)(23)(24). There are numerous studies describing racial/ethnic disparities in neonatal intensive care.…”

Outcome Measures Following Critical Illness in Children With Disabilities: A Scoping Review

“…The Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) network POST-PICU Investigators and the Eunice Kennedy Shriver National Institute for Child Health and Human Development Collaborative Pediatric Critical Care Research Network (CPCCRN) conducted a scoping review of all nonmortality outcomes measured following pediatric critical illness to inform the development of a core outcome set for use in pediatric critical care outcomes research. Details of the scoping review (9) and the core outcome set (10) have been previously published. In brief, PubMed, EMBASE, PsycINFO, Cumulative Index of Nursing and Allied Health Literature, and the Cochrane Central Register of Controlled Trials Registry were queried to identify studies published between 1970 and 2017 evaluating the outcomes of survivors or families after pediatric critical illness.…”

“…However, many children hospitalized with critical illness have baseline developmental delays and disabilities (2)(3)(4)(5). These patients have been shown to be at increased risk for critical illness, as well as for death, prolonged intensive care unit length of stay, and higher medical resource utilization during episodes of critical illness (5)(6)(7)(8)(9). In addition, many children with complex medical conditions may be at higher risk for impaired outcomes due to their underlying diseases, susceptibility to adverse effects of therapeutic interventions, or missed educational and therapy experiences while hospitalized, making them among the most vulnerable of pediatric intensive care unit (PICU) patients.…”

“…Recent work has resulted in a scoping review as well as a core set of outcome measures used to assess children after episodes of critical illness with a focus on these PICS-p domains (10,11). However, it is not known whether these measures are appropriate for use in children with pre-existing disabilities or complex medical needs, who make up a substantial portion of admissions to the modern PICU (5,8,9). Definitions and categorization of medical complexity [e.g., Children with Special Healthcare Needs (12,13), Complex Chronic Conditions (14), Pediatric Medical Complexity Algorithm (15), Pediatric Chronic Critical Illness (16)] differ, may inconsistently overlap (17,18), and variably incorporate assessments of functional status.…”