While mortality from pediatric critical illness remains an important focus for outcomes research, morbidities related to stays in the pediatric ICU are being increasingly evaluated. Specifically, the questions of health-related quality of life (HRQL) after critical illness are being investigated more often. HRQL relates to the effect illness has on a person’s “physical, mental, emotional, and social functioning” (Killien et al. Pediatr Crit Care Med. 2019; Epub ahead of print). In pediatric survivors of sepsis, different outcomes have been reported related to HRQL, some reporting no difference from baseline and others reporting significant declines (Bronner et al. Pediatr Crit Care Med. 2009;10:636-642; Farris et al. Pediatr Crit Care Med. 2013;835-842). In this retrospective cohort study, the authors sought to evaluate the prevalence of HRQL decline in pediatric survivors of community-acquired sepsis, severe sepsis, and septic shock and to determine which factors are associated with a failure to return to baseline HRQL.
The authors examined records of children aged 1 month to 21 years who were admitted to the hospital with community-acquired sepsis (using the 2005 consensus sepsis criteria) between 2012 and the end of 2015 and who were enrolled in an outcome assessment program at Seattle Children’s Hospital. The staff approached parents of these children at the beginning of their hospital stay and after discharge to assess HRQL using the Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core and Infant Scales. The authors then queried the electronic health record and other databases to obtain demographics, medical histories, and illness severity measures. The primary outcome for this study was the number of patients who failed to recover to baseline HRQL. The secondary outcome was the absolute change in scores between baseline and follow-up assessments.
A total of 790 patients made up the final study cohort. Of these, 23.8% failed to recover to baseline HRQL, 34.9% recovered to baseline, and 41.5% improved to greater than baseline. Demographic risk factors associated with a failure to return to baseline included older age and use of private insurance (these patients also tended to be older). A history of immunocompromised state also was associated with a failure to return to baseline. The presence of septic shock (compared to sepsis or severe sepsis) and longer hospital length of stay were also associated with worse outcomes. While the offending organisms (bacterial vs. viral vs. fungemic) had no effect on outcomes, the site of the infection appeared to matter; nearly 50% and 60% of patients with central nervous systemic and bacteremic infections, respectively, failed to recover to baseline. Interestingly, the presence of chronic medical conditions (other than immunocompromised state) was not associated with worse HRQL scores.
There were a few limitations to this study. First, baseline assessments were based on familial recall, which is subject to bias. Another limitation is that follow-up assessments were made at different time points after discharge. Also, although younger children did not experience deterioration from baseline HRQL as older children did, the study did not examine whether this was because of the younger children’s resilience recovering from illness or because the HRQL deterioration may be manifest more in failure to develop appropriately as they grow older.
The authors highlight an important area other than mortality that needs to be explored in outcomes research—not just HRQL, but also a comparison to a patient’s own baseline. While few of the factors that worsened outcome are modifiable, they can help with prognostication and possibly help develop treatments (even for recovering patients after their hospital stay) for particularly vulnerable patients.
Author of this installment of Concise Critical Appraisal:
Daniel E. Sloniewsky, MD, FCCM, is an associate professor in the Division of Pediatric Critical Care Medicine in the Department of Pediatrics at Stony Brook Long Island Children’s Hospital. Dr. Sloniewsky is an editor of Concise Critical Appraisal.