Abstract
Objective: Technology-dependent children with medical complexity (CMC) are frequently admitted to the pediatric intensive care unit (PICU). The social risk factors for high PICU utilization in these children are not well described. The objective of this study was to describe the relationship between race, ethnicity, insurance status, estimated household income, and PICU admission following the placement of a tracheostomy and/or gastrostomy (GT) in CMC.Study Design: This was a retrospective multicenter study of children <19 years requiring tracheostomy and/or GT placement discharged from a hospital contributing to the Pediatric Health Information System (PHIS) database between January 2016 and March 2019. Primary predictors included estimated household income, insurance status, and race/ethnicity. Additional predictor variables collected included patient age, sex, number of chronic complex conditions (CCC), history of prematurity, and discharge disposition following index hospitalization. The primary outcome was need for PICU readmission within 30 days of hospital discharge. Secondary outcomes included repeated PICU admissions and total hospital costs within 1 year of tracheostomy and/or GT placement.Results: Patients requiring a PICU readmission within 30 days of index hospitalization for tracheostomy or GT placement accounted for 6% of the 20,085 included subjects. In multivariate analyses, public insurance [OR 1.28 (95% C.I. 1.12–1.47), p < 0.001] was associated with PICU readmission within 30 days of hospital discharge while living below the federal poverty threshold (FPT) was associated with a lower odds of 30-day PICU readmission [OR 0.7 (95% C.I. 0.51–0.95), p = 0.0267]. Over 20% (n = 4,197) of children required multiple (>1) PICU admissions within one year from index hospitalization. In multivariate analysis, Black children [OR 1.20 (95% C.I. 1.10–1.32), p < 0.001] and those with public insurance [OR 1.34 (95% C.I. 1.24–1.46), p < 0.001] had higher odds of multiple PICU admissions. Social risk factors were not associated with total hospital costs accrued within 1 year of tracheostomy and/or GT placement.Conclusions: In a multicenter cohort study, Black children and those with public insurance had higher PICU utilization following tracheostomy and/or GT placement. Future research should target improving healthcare outcomes in these high-risk populations.
Highlights
One-third of health care costs for children are attributed to the one percent of children with medical complexity (CMC), in part due to their need for frequent hospitalizations [1, 2]
There is some evidence to suggest that technology-dependent children of minority race and those living in poverty with inadequate environmental conditions are at risk for repeated emergency department visits, prolonged hospital stays, and hospital readmission, and have a higher mortality [6,7,8,9]
There were 20,085 children
Summary
One-third of health care costs for children are attributed to the one percent of children with medical complexity (CMC), in part due to their need for frequent hospitalizations [1, 2]. In the United States (US), a subset of technology-dependent CMC rely upon life-sustaining medical technologies, including gastrointestinal and respiratory devices [3]. Because of their medical fragility and the complication rate of medical devices, technology-dependent children are at risk for high hospital utilization, including frequent admissions and need for intensive care. An estimated 20% of admissions to a US pediatric intensive care unit (PICU) are children with a tracheostomy or gastrostomy tube (GT) [4]. The risk factors for PICU admission in technology-dependent children have not been well described but are likely similar to risk factors for general hospital admission including younger age and higher medical complexity [5].
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