Hospital Variation in Intensive Care Resource Utilization and Mortality in Newly Diagnosed Pediatric Leukemia

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. The study sponsors did not have a role in the study design; the collection, analysis, and interpretation of data; the writing of the report; or the decision to submit the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://ift.tt/2gIrZ5Y). Supported, in part, by the National Institutes of Health (1R01CA165277 [to Dr. Aplenc]) and the Alex’s Lemonade Stand Foundation. Drs. Fitzgerald and Aplenc received support for article research from the National Institutes of Health (NIH). Dr. Fitzgerald’s institution received funding from the NIH and the Alex’s Lemonade Stand Foundation. Dr. Fisher’s institution received funding from Pfizer, Merck, and Ansun Biopharma. Dr. Seif’s institution received research grant funding from the American Cancer Society, the Hyundai Hope on Wheels Foundation, and the Alex’s Lemonade Stand Foundation (all unrelated to this project). Dr. Thomas’s institution received funding from GeneFluidics, and he received funding from Therabron and CareFusion. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: fitzgeraldj@email.chop.edu ©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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