Receipt, disparities, and impact of early primary care follow-up after pediatric critical illness

摘要 在美国，每年有近17万名儿童在危重疾病中幸存下来，但往往面临着身体上、情感上和 儿科重症监护病房(PICU)住院后的认知发病率。尽管人们的意识不断增强 纵向评估和支持可以改善PICU后的结果，既包括当前的做法，也包括最佳做法 对于PICU后的随访情况尚不清楚。早期院后初级保健跟进提供了一个关键机会 评估和解决新的和持续的健康问题，支持持续增长和发展，以及 协助完成返乡和返校工作。由于预防性护理是儿科医学的核心租户， 有些人可能会认为，所有儿童在住院后都会得到及时的随访，特别是在PICU住院之后。 然而，先前的研究表明，情况并非如此。因此，迫切需要更好的数据来指导 PICU出院后的随访时间。使用国家多付款人数据(商业保险 和Medicaid)，我们将衡量PICU住院后早期(7天内)初级保健跟进的情况 并评估患者年龄、合并症状况和社会经济状况之间的差异。其次，我们将 测试接受PICU后随访是否与减少90天的急性护理卫生保健利用率有关 (医院再入院和急诊科使用)使用“目标试验仿真”。目标试验仿真 结合了随机对照试验的特点，以提供可能的最佳因果推断 观测数据。我们的具体目标包括： 目的1：量化PICU住院出院后早期随访的收受情况，并测试 接受PICU后早期跨患者亚组的随访。 目的2：测量PICU术后早期随访与PICU中急性护理利用之间的关系 幸存者使用目标试验仿真框架。 这项提议在三个关键方面是创新的--我们将使用创新的技术回答一个新问题 和数据。据我们所知，没有研究描述PICU后随访的总体情况，也没有 评估了对随后的急性卫生保健利用的影响。我们将应用一种新的方法来 观察性因果推理，“靶向试验模拟”，它利用随机对照试验的特点来 从观测数据中做出因果推断。我们的发现将提供所需的数据，说明早期 PICU后的随访应该是护理的标准，并确定早期随访滞后的患者群体。这 这项工作将作为未来研究的基础，以优化PICU幸存者的医院后护理-a 易受伤害且不断增长的患者群体。

ABSTRACT Each year in the US, nearly 170,000 children survive critical illness but often face physical, emotional, and cognitive morbidity following Pediatric Intensive Care Unit (PICU) hospitalization. Despite a rising awareness that longitudinal evaluation and support may improve post-PICU outcomes, both current and optimal practice for follow-up after PICU are unclear. Early post-hospital primary care follow-up provides a key opportunity to evaluate for and address new and ongoing health problems, support continued growth and development, and assist in the transition back to home and school. As preventative care is a core tenant of pediatric medicine, some may assume that all children receive timely follow-up after hospitalization, especially after a PICU stay. However, prior studies show this is not the case. Thus, there is an urgent need for better data to guide the timing of follow-up after PICU hospitalization discharge. Using national multi-payer data (commercial insurance & Medicaid), we will measure receipt of early (within 7 days) primary care follow-up after PICU hospitalization and assess for disparities across patient age, comorbidity status, and socioeconomic status. Secondly, we will test whether receipt of post-PICU follow-up is associated with reduced 90-day acute care health care utilization (hospital readmission and emergency department use) using a “target trial emulation”. Target trial emulation incorporates features of a randomized control trial to provide the best possible causal inference from observational data. Our specific aims include: Aim 1: To quantify receipt of early follow-up after PICU hospitalization discharge, and test for variation in the receipt of early post-PICU follow-up across patient subgroups. Aim 2: To measure the association between early post-PICU follow-up and acute care utilization among PICU survivors using a target trial emulation framework. This proposal is innovative in three key ways—we will answer a novel question using an innovative technique and data. No studies, to our knowledge, have described the overarching landscape of post-PICU follow up, nor assessed the impact on subsequent acute health care utilization. We will apply a novel approach to observational causal inference, “target trial emulation”, which leverages features of randomized control trials to make causal inferences from observational data. Our findings will provide needed data about whether early post-PICU follow-up should be standard of care and identify patient groups for whom early follow-up lags. This work will serve as the foundation for future studies to optimize post-hospital care of PICU survivors—a vulnerable and growing population of patients.