Risk Factors Associated With Escalation of Therapy in Hospitalized Children With Asthma

OBJECTIVE: Children hospitalized for asthma exacerbations may require escalation of therapy (EOT), but risk factors remain poorly defined. We aimed to identify risk factors for EOT to inform interventions and improve care. PATIENTS AND METHODS: We conducted a retrospective cohort study using the Pediatric Health Information System of hospitalized children aged 4 to 18 years with a diagnosis of an asthma exacerbation from January 1, 2018, to December 31, 2023, across 45 children’s hospitals. EOT was defined as intensive care unit transfer, advanced respiratory support, or adjunctive asthma therapy (ie, magnesium sulfate, methylprednisolone) after the first hospital day. Mixed-effects regression estimated the association between EOT and risk factors: age, sex, race and ethnicity, insurance, Child Opportunity Index (COI), complex chronic conditions (CCC), and season. RESULTS: Among 92 224 encounters, 15 989 (17.34%) required EOT. Adjusted analysis showed lower odds of EOT in male patients (adjusted odds ratio [aOR], 0.91 [CI, 0.88, 0.94]) and spring compared with summer admissions (aOR, 0.93 [0.88, 0.99]). Compared with early childhood (<5 years), the odds of EOT were higher in late childhood (5–12 years) (aOR, 1.19 [1.13, 1.26]), adolescence (13–17 years) (aOR, 1.48 [1.38, 1.59]), and adults (≥18 years) (aOR, 1.43 [1.17, 1.73]). Higher odds were observed in Hispanic (aOR, 1.07 [1.00, 1.14]) and multiracial (aOR, 1.17 [1.02, 1.34]) patients and those with CCC (aOR, 2.07 [1.95, 2.19]). COI and insurance were not significantly associated with EOT. CONCLUSION: We identified key risk factors for EOT in children hospitalized for asthma exacerbations. Such findings can help with early risk stratification or serve as proxies for modifiable features of inpatient care. Further research is warranted to explore these associations to improve care.