Epidemiology of Pediatric Oncology and Bone Marrow Transplant in U.S. ICUs Over Time

Introduction: Although pediatric cancer survival has improved over the past decade, oncology, and bone marrow transplant (BMT) patients continue to frequently require ICU admission. We aimed to evaluate the epidemiology of ICU admissions for pediatric oncology and BMT patients in the US from 2001-2019, hypothesizing that the frequency of ICU care has increased with higher ICU mortality, organ dysfunction and support, and resource use over time.


Methods: We used the Healthcare Cost and Utilization Project’s State Inpatient Databases from a total of 21 U.S. states in 2001, 2004, 2010, 2016, and 2019 and included all admissions for children 0-17 years, excluding newborns. We used ICD-9 and 10 codes to identify diagnoses, comorbidities, and organ failure. We used generalized linear Poisson regression to evaluate changes from 2001-2019.


Results: Among 2,157,991 pediatric admissions, 82,988 (3.9%) had an oncologic diagnosis with 13.9% admitted to the ICU, and 7,381 (0.3%) underwent BMT with 19.5% admitted to the ICU. The percentage of patients hospitalized with acute lymphoblastic leukemia undergoing ICU admission rose from 2001-2019 (8.8% to 10.4%), as did those with lymphoma (8.5% to 10.2%), and brain tumors (28.9% to 35.3%). It decreased for patients with neuroblastoma (19.4% to 13.0%) and acute myeloid leukemia (19.0% to 17.3%). From 2001-2019, oncology patients in the ICU more commonly had chronic, non-oncologic comorbidities (41.4% to 80.5%; RR 1.94 [95% CI 1.61-2.34]), experienced multiple organ failure (9.5% to 33.3%; RR 3.52 [2.97-4.18]) and received dialysis (1.1% to 3.6%; RR 3.17 [1.86-5.40]). Hospital mortality decreased for ICU patients with hematologic malignancies (9.4% to 6.2%) and BMT patients (12.4% to 7.2%) but increased for patients with solid tumors (4.1% to 4.9%). Inflation-adjusted costs for an admission involving ICU care for oncology patients rose by $43,138 (95% CI 33,751-52,524) from 2001-2019 vs. $18,187 (95% CI 16,987-19,389) for non-oncology patients.


Conclusions: Critically ill pediatric oncology and BMT patients have become increasingly medically complex with greater prevalence of organ failure and resource use. Pediatric ICUs will require increased financial and staffing support to care for these patients in the future.