SCCM Resource Library-36-Community Level Income and Hospital Resource Utilization in Pediatric Severe Sepsis

Video Transcription

Good afternoon, everyone. My name is Brian Combs. I am a Pediatric Critical Care Fellow at Rainbow Babies and Children's Hospital in Cleveland, Ohio.  Today, I will be speaking on community-level income and hospital resource utilization in pediatric severe sepsis.  Severe sepsis is a leading cause of pediatric mortality and morbidity worldwide. Its incidence in the United States is increasing, and it now accounts for 7% of PICU admissions.  For years, it has been well-known that social determinants of health can have a major impact on outcomes.  Some factors that contribute to this disparity, such as substandard living conditions, inadequate  nutrition, and limited access to preventative medicine, are often rooted in poverty. Wealth inequality is a significant problem in the United States, where more than one  in five children live in poverty. That is, a family of four is being supported on less than $25,000 per year.  American adults living in neighborhoods with lower median household income have higher rates of sepsis mortality.  Additionally, disparities in outcomes based on socioeconomic status with other common pediatric diseases, such as asthma and diabetes, have been described.  Disparities in outcomes for children with severe sepsis are influenced by things like race, ethnicity, and insurance status.  For instance, we know that black children have higher rates of mortality than white children. Black children and Hispanic children experience longer hospital lengths of stay.  But to our knowledge, there are no larger multicenter studies investigating the relationship between income inequality and outcomes for pediatric severe sepsis.  Our objective was to use a larger multicenter administrative database to describe associations between estimated median household income and hospital outcomes.  We hypothesized that there would be different outcomes for children with severe sepsis across income groups, increased mortality, longer hospital length of stay, and higher billed  charges. My hope is that by identifying children, families, and communities at risk, we can better equip  these families to help them through the challenges associated with having a hospitalized child.  This was a retrospective analysis using the PHIS database, Pediatric Health Information  System, which comprises 50 children's hospitals in the United States and accounts for approximately 20% of pediatric hospitalizations.  It has information on ICD diagnoses and procedures, as well as length of stay and billing information.  We included children under 19 years of age over a three-year study period from January 2016 through December 2019.  We used a primary diagnosis of severe sepsis, which we defined using ICD-10 diagnosis codes for fungal or bacterial infection, as well as the presence of acute organ dysfunction.  We collected demographic information, including age, gender, race, the presence of chronic comorbid conditions, and insurance status.  We also collected information on illness severity level, which is derived from APR-DRG codes,  the All Patient Refined Diagnostic Related Groups, which is a classification system that categorizes patients according to their reason for admission, their severity of illness,  and their risk of mortality. We collected data on income level. The PHIS database uses zip code as a de-identified surrogate for family household income.  We based our calculations off the 2015 federal poverty threshold, which for a family of four was $24,858.  We examined the following outcomes, PICU admission, mechanical ventilation, use of ECMO, mortality, hospital length of stay, and billed charges.  Subjects were categorized into four income groups based on the federal poverty threshold.  The group living in poverty were those living less than 100% of the federal poverty threshold, which again was $24,858.  The next group were those living 100% to 150% of the poverty threshold, and the next group was 150% to 200% of the poverty threshold, and the highest income group were those living  at 200% of the poverty threshold, or more than $49,716. Subjects and outcomes were analyzed using chi-square tests and Kruskal-Wallis.  Overall, around 7,000 children, or 6.5%, were living in poverty. Similar as to what's been reported in other literature, we saw disparities in the distribution  of race based on income level. For example, 37% of children living in poverty were Black, compared to only 14% of children from families at the highest income level.  And we found similar disparities based on insurance status, with 79% of children living in poverty using public insurance, compared to only 40% of children from families living  at over 200% of the poverty threshold. And we also found differences in the presence of chronic comorbid conditions between groups.  Looking at our illness severity for our patient population, it's quite clear that our patient population was fairly ill, and we found a modest increase in extreme illness severity  in the most impoverished neighborhoods. Looking at our outcomes, we did not find a difference in PICU admission between income groups.  There was, however, a difference in the requirement for mechanical ventilation across groups.  For instance, 47% of children living in poverty needed it, while only 42% of children in the highest income group required it.  The use of ECMO is fairly uncommon, but we did see a small and statistically significant difference in its use between income levels.  Contrary to our hypothesis, we actually did not find any difference in mortality between income groups.  Hospital length of stay was different between groups, with around eight or nine days in the lower income categories, and seven days with the highest income group.  Additionally, we found a difference between median billed charges between income groups,  with a median of around $109,000 for children living in poverty, and a median of only $95,000 in the highest income group.  Taking into account the 7,000 children living in poverty with these median billed charges, the differences could account for $95 million of additional charges over our three-year  study period. In conclusion, we did not find a difference in mortality. We found differences in length of stay, the need for mechanical ventilation, and billed  charges based on household income. Our study was limited by the fact that this was a retrospective analysis of a large database,  but it highlights some very important differences in outcomes of severe sepsis, and this is something that we really need to keep studying.  If we're able to get a better understanding of these disparities in outcomes, then we can change our practice in order to provide the highest quality and most equitable care  to all children. Thank you to Sindhusha Millay for all the help with statistical analysis, to Catherine  Slane for all the guidance and mentorship, but most importantly, thank you to everyone in the audience. I really appreciate your time and attention today.  This is something that really matters, so I appreciate you listening. Thank you.

Video Summary

Pediatric critical care fellow, Brian Combs, discusses the relationship between community-level income and hospital resource utilization in pediatric severe sepsis. Severe sepsis is a leading cause of pediatric mortality, and social determinants of health, such as poverty, can have a major impact on outcomes. Using a larger multicenter database, Combs and his team found that children from lower income groups had higher rates of mechanical ventilation, longer hospital stays, and higher billed charges compared to children from higher income groups. However, there was no difference in mortality between income groups. Understanding these disparities can help improve the quality and equity of care for all children.

Asset Subtitle

Pediatrics, Sepsis, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Bryan Combs

Introduction/Hypothesis: Severe sepsis is a leading cause of pediatric mortality and morbidity; in the US, it accounts for 7.7% of PICU admissions. Compared to other acute illnesses, disparities in health outcomes of low-income children with severe sepsis are not well known.

Methods: This was a retrospective cohort study using the de-identified Pediatric Health Information System (PHIS) database, which contains clinical and resource utilization data from 52 free-standing US children's hospitals. PHIS was queried for children <19 years old with severe sepsis, as defined by ICD-10 codes, from 1/1/16â€“9/30/19. Demographics, including estimated household income based on ZIP code were collected. Subjects were divided into 4 groups based on the federal poverty threshold (FPT), which in 2017 was $24,858 for a family of 4: <100%FPT, 100-150%FPT, 150-200%FPT, and >200%FPT. Illness severity and hospital outcomes including need for mechanical ventilation (MV), length of stay (LOS), estimated hospital costs, and mortality were compared between the groups. Statistical methods included chi square and Kruskal-Wallis.

Results: The median age of this cohort of 106,209 children was 6 years [IQR 1-13]. Most (57.2%) were white, most (58.2%) had public insurance, and 6.6% were living in poverty (<100%FPT). There were significant differences in patient demographics and illness severity based on income group (all p<0.001). Illness severity was classified as 'extreme' in 58.7% of children <100%FPT vs. 56.4% in children >200%FPT. MV was utilized in 47.6% of children <100%FPT vs. 42.4% of children >200%FPT, with significant differences found between the 4 income groups (p<0.001). There were significant differences between hospital LOS and estimated hospital costs between income groups (all p<0.001). Median LOS was 8 days [IQR 4-20] with estimated hospital costs $31,884 [IQR 12,513-88,895] for children <100%FPT, vs 7 days [IQR 3-17] and costs $28,906 [12,258-81,657] for children >200%FPT. Overall 4.0% (n=4,241) of children died, with no differences in mortality between income groups (p=0.096).

Conclusions: In this large multicenter cohort study of children with severe sepsis, differences in illness severity and hospital outcomes were found based on estimated median household income.

Meta Tag

Content Type Presentation

Knowledge Area Pediatrics

Knowledge Area Sepsis

Knowledge Level Advanced

Membership Level Select

Tag Multiple Organ Dysfunction

Tag Scoring Systems

Tag Monitoring

Year 2021

Keywords

Pediatric critical care fellow

Brian Combs

community-level income

hospital resource utilization

pediatric severe sepsis

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