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Variable Identification of Children With Medical Complexity in United States PICUs
Julia A Heneghan1, Denise M Goodman2, Sriram Ramgopal3
1Division of Pediatric Critical Care, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, University of Minnesota, Minneapolis, MN.
Insights
Definitions for pediatric medical complexity in the PICU show fair agreement, identifying distinct patient groups. This highlights the need for a consensus definition to improve research and care for critically ill children.
Area of Science:
- Pediatric Critical Care Medicine
- Health Services Research
- Complex Chronic Conditions
Background:
- Children with medical complexity face higher risks of critical illness and adverse outcomes.
- A standardized definition of medical complexity in pediatric critical care research is lacking.
Purpose of the Study:
- To evaluate the agreement between two common definitions of multisystem medical complexity in critically ill children.
- To identify distinct patient populations based on these definitions.
Main Methods:
- Retrospective, cross-sectional cohort study of 291,583 pediatric intensive care unit (PICU) admissions from 2017-2019.
- Utilized two definitions: Pediatric Complex Chronic Conditions (CCC) (≥2 diagnoses) and Pediatric Medical Complexity Algorithm (PMCA).
- Assessed agreement using Cohen kappa statistic.
Main Results:
- Over 77% of admissions met at least one complexity definition, with 63.3% identified by both.
- Cohen kappa was 0.39, indicating only fair agreement between CCC and PMCA definitions.
- CCC patients were younger, had longer ICU stays, and higher in-hospital mortality compared to PMCA patients.
Conclusions:
- Commonly used definitions of pediatric medical complexity identify distinct patient groups in the PICU.
- The fair agreement between definitions underscores the need for a consensus definition in research and clinical practice.
Objectives:
Children with medical complexity are at increased risk for critical illness and adverse outcomes. However, there is currently no consensus definition of medical complexity in pediatric critical care research.
Design:
Retrospective, cross-sectional cohort study.
Setting:
One hundred thirty-one U.S. PICUs participating in the Virtual Pediatric Systems Database.
Subjects:
Children less than 21 years old admitted from 2017 to 2019. Multisystem complexity was identified on the basis of two common definitions of medical complexity, Pediatric Complex Chronic Conditions (CCC), greater than or equal to 2 qualifying diagnoses, and Pediatric Medical Complexity Algorithm (PMCA), complex chronic disease.
Interventions:
None.
Measurements And Main Results:
Of 291,583 index PICU admissions, 226,430 (77.7%) met at least one definition of multisystem complexity, including 168,332 patients identified by CCC and 201,537 by PMCA. Of these, 143,439 (63.3%) were identified by both definitions. Cohen kappa was 0.39, indicating only fair agreement between definitions. Children identified by CCC were younger and were less frequently scheduled admissions and discharged home from the ICU than PMCA. The most common reason for admission was respiratory in both groups, although this represented a larger proportion of CCC patients. ICU and hospital length of stay were longer for patients identified by CCC. No difference in median severity of illness scoring was identified between definitions, but CCC patients had higher inhospital mortality. Readmission to the ICU in the subsequent year was seen in approximately one-fifth of patients in either group.
Conclusions:
Commonly used definitions of medical complexity identified distinct populations of children with multisystem complexity in the PICU with only fair agreement.
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