• Murray M Pollack, Richard Holubkov, Tomohiko Funai, John T Berger, Amy E Clark, Kathleen Meert, Robert A Berg, Joseph Carcillo, David L Wessel, Frank Moler, Heidi Dalton, Christopher J L Newth, Thomas Shanley, Rick E Harrison, Allan Doctor, Tammara L Jenkins, Robert Tamburro, J Michael Dean, and Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network.
• 1Department of Pediatrics, Children's National Medical Center and the George Washington University School of Medicine and Health Sciences, Washington, DC. 2Department of Child Health, Phoenix Children's Hospital and the University of Arizona School of Medicine, Phoenix, AZ. 3Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT. 4Department of Pediatrics, Children's National Medical Center, Washington, DC. 5Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI. 6Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA. 7Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA. 8Department of Pediatrics, Children's National Medical Center, Washington, DC. 9Department of Pediatrics, University of Michigan, Ann Arbor, MI. 10Department of Child Health, Phoenix Children's Hospital and University of Arizona College of Medicine-Phoenix, Phoenix, AZ. 11Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA. 12Department of Pediatrics, University of California at Los Angeles, Los Angeles, CA. 13Department of Pediatrics, Washington University School of Medicine, St. Louis, MO. 14Department of Biochemistry, Washington University School of Medicine, St. Louis, MO. 15Pediatric Trauma and Critical Illness Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institutes of Health, Bethesda, MD.
• Crit. Care Med. 2015 Aug 1; 43 (8): 1699-709.

ObjectivesAssessments of care including quality assessments adjusted for physiological status should include the development of new morbidities as well as mortalities. We hypothesized that morbidity, like mortality, is associated with physiological dysfunction and could be predicted simultaneously with mortality.DesignProspective cohort study from December 4, 2011, to April 7, 2013.SettingGeneral and cardiac/cardiovascular PICUs at seven sites.PatientsRandomly selected PICU patients from their first PICU admission.InterventionsNone.Measurements And Main ResultsAmong 10,078 admissions, the unadjusted morbidity rates (measured with the Functional Status Scale and defined as an increase of ≥ 3 from preillness to hospital discharge) were 4.6% (site range, 2.6-7.7%) and unadjusted mortality rates were 2.7% (site range, 1.3-5.0%). Morbidity and mortality were significantly (p < 0.001) associated with physiological instability (measured with the Pediatric Risk of Mortality III score) in dichotomous (survival and death) and trichotomous (survival without new morbidity, survival with new morbidity, and death) models without covariate adjustments. Morbidity risk increased with increasing Pediatric Risk of Mortality III scores and then decreased at the highest Pediatric Risk of Mortality III values as potential morbidities became mortalities. The trichotomous model with covariate adjustments included age, admission source, diagnostic factors, baseline Functional Status Scale, and the Pediatric Risk of Mortality III score. The three-level goodness-of-fit test indicated satisfactory performance for the derivation and validation sets (p > 0.20). Predictive ability assessed with the volume under the surface was 0.50 ± 0.019 (derivation) and 0.50 ± 0.034 (validation) (vs chance performance = 0.17). Site-level standardized morbidity ratios were more variable than standardized mortality ratios.ConclusionsNew morbidities were associated with physiological status and can be modeled simultaneously with mortality. Trichotomous outcome models including both morbidity and mortality based on physiological status are suitable for research studies and quality and other outcome assessments. This approach may be applicable to other assessments presently based only on mortality.

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