Introduction: The Centers for Medicare and Medicaid Services hospital-acquired conditions (HACs) and the Agency for Healthcare Research and Quality patient safety indicators (PSIs) are quality metrics linked to reimbursement. An assessment of these events in the pediatric stroke population has not previously been reported.
Methods: The Nationwide Inpatient Sample (2002-2011) was queried using primary ICD-9-CM codes to identify hospitalizations for pediatric ischemic stroke (IS), subarachnoid hemorrhage (SAH), or intracerebral hemorrhage (ICH). We evaluated the effect of patient and hospital factors on occurrence of PSIs and HACs and the impact of these occurrences on length of stay (LOS), total costs, and in-hospital mortality.
Results: Of a total of 6,265 IS, 3,096 SAH, and 3,103 ICH admissions, the percentage of patients with 1 or more PSI or HAC, respectively, was 15.6% and 2.0% in IS, 44.7% and 2.7% in SAH, and 38.2% and 2.0% in ICH. The most frequently reported PSIs (incidence 56,000/100,000) were respiratory failure (50.7%), deep vein thrombosis (1.65%), and sepsis (1.32%), whereas falls/trauma (1.78%) and poor glycemic control (0.22%) were the most frequently reported HACs (incidence, 2,351/100,000). Multivariate adjusted risk factors for PSI included SAH (OR: 5.02), ICH (OR: 3.79), black and Hispanic race (OR: 1.35, 1.37), urban hospital (OR: 7.00), and 3+ comorbidities (OR: 7.06) (all p<0.0001). In adjusted analyses, Hispanic race (OR: 2.04), Medicaid insurance (OR: 1.51), 3+ comorbidities (OR: 2.18), weekend admission (OR: 1.78), rural hospitals (OR: 3.03), and nonteaching hospitals (OR: 1.64) increased odds of HAC occurrence (all p<0.01). PSI occurrence increased LOS by 11 days and total costs by $47,573 per admission, while HAC occurrence increased LOS by 12 days and total costs by $12,373 per admission (all p<0.0001). In adjusted analyses, children enduring a PSI were 5 times more likely to acquire disability and 21 times more likely to suffer mortality (all p<0.0001).
Conclusion: We established benchmark rates for PSIs and HACs in pediatric stroke. Race, insurance status, hospital characteristics, and pre-existing comorbidity significantly impact PSI and HAC occurrence, which further impacts LOS, costs, disability, and mortality.