(299) Regionalization of Pediatric Critical Care in the United States

Introduction: Only 1/3 of US children live within an hour’s drive of pediatric intensive care unit (PICU) services, with longer distances for children in poverty . International data suggest PICU patients living farther from critical care services have higher resource use and mortality, but it is unknown how this translates to the US.

Methods: We conducted a retrospective cohort study of children < 18 years admitted to a non-neonatal US ICU using 7 State Inpatient Databases from the 2019 Healthcare Cost and Utilization Project. We included patients with geographic data to calculate the distance from the centroid of the child’s home zip code to the admitting hospital and nearest children’s hospital using geographic information systems, and used ICD-10-CM codes to identify diagnoses, organ failures, and procedures.

Results: Of 170,579 pediatric admissions, 15.0% (n=25,663) included ICU care, 86.2% of which were in children’s hospitals. Children admitted to a non-children’s hospital ICU (n=3,418) were older (7.9 ±6.5 years vs. 6.1 ±6.0 years, p< 0.01), more commonly admitted with injury or poisoning (25.2% vs. 13.6%, p< 0.01), and had less multiple organ dysfunction (MODS; 12.5% vs. 21.0%, p< 0.01). Children admitted to a non-children’s hospital ICU traveled a median (IQR) distance of 11 (4, 25) miles for admission, while children admitted to a children’s hospital ICU traveled 22 (9, 52) miles (p < 0.01). For children admitted to a non-children’s hospital ICU, the median difference in distance from their admitting hospital to the closest children’s hospital was 28 (8, 76) miles. Of children admitted to children’s hospital ICUs, 21.6% traveled >50 miles from home (median 96 miles [69, 151] miles). Compared to patients admitted to children’s hospital ICUs < 50 miles away, patients traveling >50 miles had a longer median hospital stay (5 [3, 10] vs. 4 [2, 8] days, p< 0.01), higher prevalence of MODS (24.5% vs. 19.8%, p< 0.01) and mechanical ventilation (19.9% vs. 16.7%, p< 0.01), and higher mortality (2.4% vs. 2.0%, p=0.05).

Conclusions: The distance that U.S. children travel for ICU care varies significantly and is associated with illness severity and mortality. The U.S. healthcare system must ensure that increasing regionalization of specialty care is accompanied by adequate access to care for rural children.