High-Value Care in Pediatric Critical Care: Intravenous to Enteral Gastrointestinal Medications

Abstract

Advancing pediatric critical care medicine includes identifying and reducing health care costs while maintaining—and even enhancing—the delivery of high-value care. Gastrointestinal (GI) prophylaxis (PPX) is commonly prescribed for children in the pediatric intensive care unit (PICU). Histamine type-2 receptor antagonists, such as ranitidine, and proton pump inhibitors demonstrate equivalent efficacy across routes of administration,1–4 but intravenous (IV) formulations are considerably more expensive. Our study aimed to characterize enteral medication coadministration and conversion opportunities among PICU patients receiving IV GI PPX, describe national variation in practice patterns, and identify patient subgroups with high opportunity days for targeted quality improvement efforts.We conducted an institutional review board–approved (CHLA-22-00081, Children’s Hospital Los Angeles) retrospective cohort study using the Pediatric Health Information System (PHIS) database (Children’s Hospital Association, Lenexa, KS). PHIS contains administrative and billing data from 47 tertiary, pediatric hospitals in the United States.We included all children aged 18 years or younger admitted to a PICU from January 1, 2021, to December 31, 2023. We excluded hospitals with incomplete data over the study period. Patients were excluded who received extracorporeal membrane oxygenation, had upper or lower GI bleeding, or required congenital heart surgery using the Risk Adjustment for Congenital Heart Surgery-2 categories.5PICU bed size was categorized into groups: 0 to 25, 26 to 36, 37 to 47, and more than 48 PICU beds, defined by quartiles. Patient characteristics included age, sex, payer status, and pediatric complex chronic conditions (CCCs), as defined by Feudtner et al.6Our primary outcome was opportunity days—defined by days when the patient received IV GI PPX while receiving other medications enterally while in the PICU. The routes of admission included were enteral, parenteral, and other parenteral. The percentage of opportunity days, defined as total opportunity days in grouptotal of ICU a days in groupx100, was calculated to track the percentage of PICU days that were opportunities to transition a GI PPX drug from an IV to enteral route.The following days were not included as opportunity days: day of intensive care unit (ICU) admission, days with vasoactive infusions, days with concurrent doses of sucralfate or rocuronium, and transition days, defined as days patients received both IV and enteral GI PPX. Intravenous GI PPX included pantoprazole and famotidine. Enteral GI PPX included ranitidine, famotidine, pantoprazole, omeprazole, esomeprazole, and lansoprazole.Descriptive analysis was performed to summarize patient and hospital characteristics by PICU bed size. Kruskal-Wallis tests were performed to evaluate the association between PICU LOS and opportunity days per patient. At the hospital level, we compared percent opportunity days over the study period across hospitals. To determine target populations for interventions, we evaluated number of opportunity days per encounter by length of stay and number of CCCs.6There were 146 928 PICU encounters from 43 PHIS hospitals (4 hospitals excluded for incomplete data). For patients receiving IV GI PPX, 20% of ICU days were opportunity days. When comparing the PHIS hospitals over a 2-year period, percent opportunity days ranged across hospitals from 2.5% to 46% per quarter per year. There was a wide variation in percent opportunity days regardless of PICU bed size (Supplemental Figure 1). Mean opportunity days per encounter (1.4 days, P < .001) and percent opportunity days (22%) were highest among PICUs with a bed size of 25 to 36.Twelve percent of patients with a PICU LOS of more than 12 days accounted for more than 50% of opportunity days (Figure 1). Twenty-nine percent of patients with at least 3 CCCs also accounted for 50% of opportunity days (Figure 2).This study systematically quantified opportunities for converting GI prophylaxis from IV to enteral administration in the pediatric critical care populations. In this multicenter study, 3 key findings emerge. First, this study identified a substantial opportunity for IV-to-enteral conversion among patients receiving IV GI PPX, with potentially avoidable ICU days accounting for approximately 20% of total ICU utilization. Second, there was significant variation in opportunity across institutions (2.5% to 46%) underscoring the role of practice patterns and local prescribing culture. Third, certain patient groups—particularly those with prolonged ICU admissions (>12 days) and 3 or more CCCs—accounted for the greatest proportion of opportunity days, making them high-value targets for quality improvement intervention.