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Hospital Variation in Intensive Care Resource Utilization and Mortality in Newly Diagnosed Pediatric Leukemia
Julie C Fitzgerald1,2, Yimei Li2,3,4, Brian T Fisher2,5,6,7
1Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA.
Insights
Hospital mortality for children with leukemia requiring ICU care varies widely. Payer mix, or the proportion of publicly insured patients, significantly impacts these outcomes, suggesting a need for standardized care guidelines.
Area of Science:
- Pediatric Critical Care Medicine
- Hematology-Oncology
- Health Services Research
Background:
- Children with leukemia requiring intensive care unit (ICU) support face variable outcomes.
- Understanding hospital-level differences in resource utilization and mortality is crucial for improving care.
Purpose of the Study:
- To assess variability in ICU resource use and mortality among children with newly diagnosed leukemia.
- To identify patient and hospital factors associated with these variations.
Main Methods:
- Retrospective cohort study of 1,754 pediatric patients with new leukemia requiring ICU support (1999-2011).
- Data sourced from the Pediatric Health Information Systems database.
- Mixed-effects modeling used to analyze hospital-level mortality variation and associated factors.
Main Results:
- Significant hospital-level variability in mortality (0% to 42.9%) and ICU resource use was observed.
- Younger age, acute myeloid leukemia, earlier diagnosis year, and higher proportion of publicly insured patients were associated with mortality.
- Hospital-level factors, specifically payer mix and proportion of leukemia patients receiving ICU care, explained significant mortality variation.
Conclusions:
- Substantial hospital-level disparities exist in the care and outcomes of pediatric leukemia patients needing ICU support.
- Hospital payer mix is a significant factor influencing mortality variability.
- Further research is needed to standardize ICU care through clinical guidelines and understand the impact of payer mix on resource allocation and patient outcomes.
Objectives:
To evaluate hospital-level variability in resource utilization and mortality in children with new leukemia who require ICU support, and identify factors associated with variation.
Design:
Retrospective cohort study.
Setting:
Children's hospitals contributing to the Pediatric Health Information Systems administrative database from 1999 to 2011.
Patients:
Inpatients less than 25 years old with newly diagnosed acute lymphocytic leukemia or acute myeloid leukemia requiring ICU support (n = 1,754).
Interventions, Measurements, And Main Results:
Evaluated exposures included leukemia type, year of diagnosis, and hospital-wide proportion of patients with public insurance. The main outcome was hospital mortality. Wide variability existed in the ICU resources used across hospitals. Combined acute lymphocytic leukemia and acute myeloid leukemia mortality varied by hospital from 0% (95% CI, 0-14.8%) to 42.9% (95% CI, 17.7-71.1%). A mixed-effects model with a hospital-level random effect suggests significant variation across hospitals in mortality (p = 0.007). When including patient and hospital factors as fixed effects into the model, younger age, acute myeloid leukemia versus acute lymphocytic leukemia diagnosis, leukemia diagnosis prior to 2005, hospital-wide proportion of public insurance patients, and hospital-level proportion of leukemia patients receiving ICU care are significantly associated with mortality. The variation across hospitals remains significant with all patient factors included (p = 0.021) but is no longer significant after adjusting for the hospital-level factors proportion of public insurance and proportion receiving ICU care (p = 0.48).
Conclusions:
Wide hospital-level variability in ICU resource utilization and mortality exists in the care of children with leukemia requiring ICU support. Hospital payer mix is associated with some mortality variability. Additional study into how ICU support could be standardized through clinical practice guidelines, impact of payer mix on hospital resources allocation to the ICU, and subsequent impact on patient outcomes is warranted.
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