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Variation in Utilization of Intensive Care for Pediatric Diabetic Ketoacidosis
Arpita K Vyas1,2, Yiu Ming Chan3, Lavi Oud4
1Department of Pediatrics, 12344Texas Tech University Health Sciences Center at the Permian Basin, Odessa, TX, USA.
Insights
Hospital variation in pediatric intensive care unit (ICU) use for diabetic ketoacidosis (DKA) is significant. However, patient and hospital factors, not individual hospital differences, explain most of this variation in ICU admissions.
Area of Science:
- Pediatric critical care medicine
- Health services research
- Endocrinology
Background:
- Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes in children.
- Intensive care unit (ICU) utilization for DKA varies across hospitals.
- Understanding the drivers of this variation is crucial for optimizing care and resource allocation.
Purpose of the Study:
- To investigate hospital-level variations in ICU admission rates for pediatric DKA hospitalizations.
- To determine the proportion of this variation attributable to patient characteristics versus individual hospital factors.
Main Methods:
- Analysis of the Texas Inpatient Public Use Data File (2005-2014) for pediatric DKA hospitalizations.
- Multilevel, mixed-effects logistic regression to model ICU admission predictors.
- Risk and reliability adjustment to assess hospital-level variation in ICU utilization.
Main Results:
- Over 23,000 pediatric DKA hospitalizations were analyzed; 62.1% were admitted to the ICU.
- Higher hospital DKA volume was associated with decreased odds of ICU admission.
- After adjustment, the variation in ICU admission rates attributable to individual hospitals was negligible.
Conclusions:
- Significant hospital-level variation exists in ICU utilization for pediatric DKA.
- Patient mix and hospital characteristics, rather than unique hospital factors, largely explain this variation.
- Further research should focus on standardizing care protocols for pediatric DKA.
Objective:
To examine the hospital-level variation in intensive care unit (ICU) utilization and quantify the relative contribution of patient and hospital characteristics versus individual hospital factors to the variation in ICU admission rates among pediatric hospitalizations with diabetic ketoacidosis (DKA).
Methods:
The Texas Inpatient Public Use Data File was used to identify hospitalizations of state residents aged 1 month to 19 years with a primary diagnosis of DKA between 2005 and 2014. Multilevel, mixed-effects logistic regression modeling was performed to examine the association of patient- and hospital-level factors with ICU admission. Risk and reliability adjustment was then performed to assess hospital-level variation in ICU utilization. Intraclass correlation coefficient was used to quantify variation in use of ICU attributable to individual hospitals. The association between adjusted rates of ICU admission and total hospital charges and length of stay was examined using linear regression.
Results:
Of the 23 585 DKA hospitalizations, 14 638 (62.1%) were admitted to ICU. On multilevel analysis, the odds of ICU admission progressively decreased with rising volume of DKA hospitalizations (adjusted odds ratio: 0.08 [highest vs lowest quartile]; 95% confidence interval [CI]: 0.03-0.24). The crude median (interquartile range [IQR]; range) of ICU admissions across hospitals was 82.6% (73%-90%; 11.1%-100%). The median (IQR) risk- and reliability-adjusted ICU admission rate was 81.0% (73.0%-86.9%), ranging from 11.2% to 94%. Following risk and reliability adjustment, the intraclass correlation coefficient was 0.005 (95% CI: 0.004-0.006). For each 10% increase in adjusted ICU admission rate, total hospital charges rose by 7% (95% CI: 3%-11%). There was no association between ICU admission rates and hospital length of stay.
Conclusion:
Although high variation in ICU utilization was noted across hospitals among pediatric DKA hospitalizations, the proportion of variation attributable to individual hospitals was negligible, once adjusted for patient mix and hospital characteristics.
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