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Pediatric intensive care is the most expensive component of Emergency Medical Services for Children (EMSC). A report by the Institute of Medicine notes that PICUs can incur substantial unreimbursed costs by caring for large numbers of uninsured children. Reimbursement problems may become severe as managed care insurance contracts rapidly increase in both private and public sectors. Services provided to children in pediatric intensive care settings may be vulnerable to cost containment initiatives resulting from unreimbursed costs. Cost containment initiatives may deteriorate the quality of patient care by limiting the amount or type of resources used in patient care or the duration of the PICU stay. Research in adult ICU settings found significantly lower resource use for patients with managed care insurance compared to patients with fee-for-service insurance. Decreased resource use did not produce worse outcomes for adult ICU patients. This finding may not generalize, and could be misleading for pediatric intensive care. The effects of hospital reimbursement systems on resource use and quality of care have not been studied in pediatric intensive care.

This study investigates the relationship between cost containment and the quality of care in pediatric intensive care settings. The study will collect data prospectively for two years from three PICUs with managed care insurance rates that vary between 6% and 39%. Hospital reimbursement systems are expected to change rapidly during the study. Quality of care is assessed using both mortality and morbidity outcome measures. Mortality outcome measures may not have sufficient sensitivity for pediatric emergency medical systems analyses and may provide misleading results. We use morbidity measures derived from the newly validated Pediatric Overall Performance Category scale developed by one of the principal investigators in prior EMSC research. Use of the scale is limited, however, by lack of a severity measurement system designed specifically to predict morbidity. We will: i develop a pediatric morbidity prediction system; ii. document variations in pediatric intensive care mortality rates, morbidity rates, severity of illness/injury, and resource use based on the race and the insurance status of the patient; iii. explain variations in mortality, morbidity, and resource use with age, race, gender, and illness/injury severity; and iv. estimate relationships between insurance status, resource use, mortality, and morbidity. The study findings will aid EMSC response to changing fiscal environments. In addition, the morbidity prediction model will be an important tool for case-mix adjustment for future EMSC applied quality assessment work as well as future EMSC clinical research.

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