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Association Between Centralization and Outcome for Children Admitted to Intensive Care in Australia and New Zealand:
Anthony Slater1,2,3, John Beca4, Elizabeth Croston5
1Department of Paediatric Intensive Care Medicine, Children's Health Queensland Hospital and Health Service, South Brisbane, QLD, Australia.
Insights
Pediatric intensive care centralization in Australia and New Zealand shows regional differences. Specialist pediatric intensive care units (PICUs) improved outcomes, while general intensive care units (GICUs) showed increased mortality for high-risk children.
Area of Science:
- Pediatric Critical Care Medicine
- Health Services Research
- Epidemiology
Background:
- Centralization of pediatric intensive care services aims to improve outcomes for critically ill children.
- Understanding regional variations and temporal trends in pediatric intensive care unit (PICU) utilization is crucial for resource allocation and quality improvement.
- Comparing outcomes between specialist PICUs and general ICUs (GICUs) provides insights into the effectiveness of different care models.
Purpose of the Study:
- To examine regional differences and changes over time in the centralization of pediatric intensive care in Australia and New Zealand (ANZ).
- To compare the characteristics and intensive care unit (ICU) mortality of children admitted to specialist PICUs versus general ICUs (GICUs).
Main Methods:
- Retrospective cohort study utilizing registry data from two distinct epochs: 2003-2005 and 2016-2018.
- Inclusion of 43,256 pediatric ICU admissions (aged <16 years) across ANZ, excluding neonates without cardiac conditions.
- Logistic regression analysis to assess the association between ICU type, epoch, and risk-adjusted ICU mortality.
Main Results:
- Specialist PICUs admitted younger children (median 25 vs. 47 months) who had longer ICU stays (1.6 vs. 1.0 days) compared to GICUs.
- Significant regional variation observed: 93% of Australian admissions were to PICUs, compared to 63% in New Zealand.
- Overall risk-adjusted ICU mortality decreased between epochs (AOR 0.50). However, GICU admissions in the later epoch showed increased mortality risk (AOR 1.63), particularly for high-risk children.
Conclusions:
- Risk-adjusted mortality for children in specialist PICUs significantly decreased over 14 years.
- High-risk children admitted to GICUs did not experience similar improvements in outcomes, with increased mortality observed in the later epoch.
- Findings support the continued utilization of a centralized model for delivering intensive care to critically ill children in ANZ.
Objectives:
To describe regional differences and change over time in the degree of centralization of pediatric intensive care in Australia and New Zealand (ANZ) and to compare the characteristics and ICU mortality of children admitted to specialist PICUs and general ICUs (GICUs).
Design:
A retrospective cohort study using registry data for two epochs of ICU admissions, 2003-2005 and 2016-2018.
Setting:
Population-based study in ANZ.
Patients:
A total of 43,256 admissions of children aged younger than 16 years admitted to an ICU in ANZ were included. Infants aged younger than 28 days without cardiac conditions were excluded.
Interventions:
None.
Measurements And Main Results:
The primary outcome was risk-adjusted ICU mortality. Logistic regression was used to investigate the association of mortality with the exposure to ICU type, epoch, and their interaction. Compared with children admitted to GICUs, children admitted to PICUs were younger (median 25 vs 47 mo; p < 0.01) and stayed longer in ICU (median 1.6 vs 1.0 d; p < 0.01). For the study overall, 93% of admissions in Australia were to PICUs whereas in New Zealand only 63% of admissions were to PICUs. The adjusted odds of death in epoch 2 relative to epoch 1 decreased (adjusted odds ratio [AOR], 0.50; 95% CI, 0.42-0.59). There was an interaction between unit type and epoch with increased odds of death associated with care in a GICU in epoch 2 (AOR, 1.63; 95% CI, 1.05-2.53 for all admissions; 1.73, CI, 1.002-3.00 for high-risk admissions).
Conclusions:
Risk-adjusted mortality of children admitted to specialist PICUs decreased over a study period of 14 years; however, a similar association between time and outcome was not observed in high-risk children admitted to GICUs. The results support the continued use of a centralized model of delivering intensive care for critically ill children.
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