In this cohort of commercially insured caregivers of children hospitalized for critical illness, financial measures were worse among post-PICU caregivers compared to caregivers whose financial outcomes were measured prior to their child’s hospitalization. Post-PICU caregivers had a higher odds of having any delinquent debt or having a low credit score. However, there was no difference in the amount of debt among individuals with nonzero debt outcomes between cohorts.

Measures of debt or poor credit were common and present in over one-third of caregivers both before and after PICU hospitalization. Socioeconomic status, which includes family financial status, has been associated with higher rates of PICU hospitalization and worse outcomes [10, 11]. However, our study is among the first to directly examine objective measures of caregiver financial status before and after a child’s critical illness. Given the high rates of debt and poor credit in the comparison group, consideration should be given to screening for financial hardship or stress during hospitalization and offering financial counseling, as many parents want to discuss cost during their child’s hospitalization [12, 13].

Our results suggest that caregivers’ financial status was worse after PICU hospitalization compared with before, as the odds of having delinquent debt or a low credit score were higher in the post-PICU cohort. Furthermore, the magnitude of debt owed was substantial following PICU hospitalization, as mean debt for those with any debt was nearly $3500. Given that prior research has shown that 1 in 4 families has less than $400 in liquid assets [14], this is an amount nearly nine times than what many families can afford. Additionally, 1 in 3 caregivers had a low credit score following their child’s PICU hospitalization. Low credit scores can lead to difficulty in not only obtaining loans or applying for a mortgage, but also renting an apartment, applying for a car loan, and paying utilities [6]. Thus, a decline in credit score may be far-reaching and could potentially impact a child’s subsequent health outcomes.

While our findings indicate caregivers may face poor financial status following their child’s critical illness, the drivers of this increased odds of debt or poor credit are unknown. It is possible that the direct costs of health care related to the hospitalization are at play. Indeed, a recent study of commercially insured children found out-of-pocket spending averaged $1300 for pediatric hospitalizations, with 1 in 7 totaling over $3000 [15]. Additionally, there are often ongoing health care costs following PICU discharge [16]. Non-medical costs (e.g., direct costs of meals or travel and indirect costs of lost work) may also be a key driver of debt and poor credit following PICU hospitalization [2, 13, 16]. Prior work suggests that the indirect financial costs of critical illness may be large, as 4 in 5 caregivers miss a median of 2 weeks of work during their child’s PICU hospitalization [17]. Thus, one potential mechanism of financial hardship may include missed work by caregivers which causes decreased income. This loss of income may cause families to acquire increased non-medical debt and ultimately worsened credit scores, as observed in our study. Further evaluation is needed to identify and ultimately intervene on these drivers of poor financial health.

This study has several limitations. Credit outcomes were available only for a single time-point, so pre- and post-hospitalization credit outcomes were measured in separate cohorts. Thus, there may be unmeasured differences in between the cohort including patient characteristics, hospitalization characteristics, and patient-level socioeconomic factors. However, the observed characteristics were similar. Second, we cannot rule out the presence of reverse-causality (i.e., worsening financial status could increase risk of critical illness) [10]. Third, the data come from a single-state, employer-based, commercially insured population and our cohort is older than other previously reported PICU cohorts [18], limiting generalizability. Fourth, financial status may have been improved across the board by pandemic-related payments [19]. Finally, as unemployment increased during the early pandemic [20], the generalizability may be further limited as the cohort had at least one employed caregiver (Additional file 1).

In this cross-sectional study, caregivers of critically ill children were found to have delinquent debt or poor credit both at the time of their child’s hospitalization and post-discharge. Our results suggest that caregiver financial status may be worse following their child’s hospitalization for critical illness. Further research with longitudinal assessment of families before and after critical illness is needed to better assess the financial impact of pediatric critical illness.