Association Between Neighborhood-Level Social Determinants of Health and Access to Pediatric Appendicitis Care

Association Between the COI and Excess Health Care Utilization and Costs for ACSC

BACKGROUND AND OBJECTIVES

The authors of previous work have associated the Childhood Opportunity Index (COI) with increased hospitalizations for ambulatory care sensitive conditions (ACSC). The burden of this inequity on the health care system is unknown. We sought to understand health care resource expenditure in terms of excess hospitalizations, hospital days, and cost.

METHODS

We performed a retrospective cross-sectional study of the Pediatric Health Information Systems database, including inpatient hospitalizations between January 1, 2016 and December 31, 2022 for children <18 years of age. We compared ACSC hospitalizations, mortality, and cost across COI strata.

RESULTS

We identified 2 870 121 hospitalizations among 1 969 934 children, of which 44.5% (1 277 568/2 870 121) were for ACSCs. A total of 49.1% (331 083/674 548) of hospitalizations in the very low stratum were potentially preventable, compared with 39.7% (222 037/559 003) in the very high stratum (P < .001). After adjustment, lower COI was associated with higher odds of potentially preventable hospitalization (odds ratio 1.18, 95% confidence interval [CI] 1.17-1.19). Compared with the very high COI stratum, there were a total of 137 550 (95% CI 134 582-140 517) excess hospitalizations across all other strata, resulting in an excess cost of $1.3 billion (95% CI $1.28-1.35 billion). Compared with the very high COI stratum, there were 813 (95% CI 758-871) excess deaths, with >95% from the very low and low COI strata.

CONCLUSIONS

Children with lower neighborhood opportunity have increased risk of ACSC hospitalizations. The COI may identify communities in which targeted intervention could reduce health care utilization and costs.

Improving Accuracy of Administrative Data for Perforated Appendicitis Classification

INTRODUCTION

Reliance on International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes may misclassify perforated appendicitis with resultant research, fiscal, and public health implications. We aimed to improve the accuracy of administrative data for perforated appendicitis classification relying on ICD-10-CM codes from 2015 to 2018.

METHODS

We conducted a retrospective study of randomly sampled patients aged ≤18 years diagnosed with acute appendicitis from eight children's hospitals. Patients were identified using the Pediatric Health Information System, and true perforation status was determined by medical record review. We developed two algorithms by leveraging Pediatric Health Information System data elements and data mining (DM) approaches. The two developed algorithm performance was compared against algorithms that exclusively relied on ICD-10-CM codes using area under the curve and other measures.

RESULTS

Of 1051 clinically validated encounters that were included, 383 (36.4%) patients were identified to have perforated appendicitis. The two algorithms developed using DM approaches primarily leveraged ICD-10-CM codes and length of stay. DM-developed algorithms had a significantly higher accuracy than algorithms relying exclusively on ICD-10-CM (P value < 0.01): sensitivity and specificity for DM-developed algorithms were 0.86-0.88 and 0.95-0.97, respectively, which were overall higher than algorithms that relied on only ICD-10-CM.

CONCLUSIONS

This study provides an algorithm that can improve the accuracy of perforated appendicitis classification using commonly available elements in administrative data. We recommend that this algorithm is used in future appendicitis classification to ensure valid reporting, hospital-level benchmarking, and fiscal or public health assessments.

Socioeconomic differences in access to scoliosis care in the pediatric population

PURPOSE

Adolescent idiopathic scoliosis (AIS) is a common spinal deformity affecting pediatric patients, with up to 10% requiring surgical intervention. Studies have shown disparities in these patients associated with race, ethnicity, and insurance type, but there is limited information on disparities that exist based on geographical parameters. In this study, we aim to explore the disparities in the care for AIS by looking at differences in the rates of readmission, infection, and revision between patients residing in rural and urban environments.

METHODS

This is a retrospective cohort study utilizing the Pediatric Health Information System. Pediatric patients that underwent posterior spinal fusion (PSF) for AIS from October 2015 to July 2022 were included. Diagnoses and procedures were identified based on ICD-10 codes and internal tools built into the database. Descriptive statistics were used to summarize the data, including demographics, infection rates, readmission rates, and revision rates. T tests, Chi-squared tests, and logistic regression were used to assess differences between the rural and urban populations. We utilized STATA/SE 15.1 for all data analysis.

RESULTS

15,318 patients were included in the final cohort. Demographics and baseline characteristics were similar between the rural and urban patients, although more rural patients used Medicaid over commercial insurance (41.5% vs. 32.7%, p < 0.01), median household income was lower in rural patients (p < 0.01), and there was a higher proportion of Hispanic patients in the urban patient cohort (13.9% vs. 6.4%, p < 0.01). Complication rates were not significantly different between the urban and rural patient cohorts, although rural patients did have a significantly higher 90-day readmission rate (7.3% vs. 6.1%, p = 0.03) and higher rates of instrumentation removal (7.7% vs. 4.9%, p = 0.01).

CONCLUSIONS

The surgical outcomes between rural and urban pediatric AIS patients undergoing PSF are comparable, although 90-day readmission rates and rates of instrumentation removal were higher in rural patients. Insurance status is likely a significant driver for the differences observed in this study. Future research is needed to better understand the reasons for these differences and to develop strategies to improve outcomes.

LEVEL OF EVIDENCE

Retrospective cohort study, Level III.

Disparities in Healthcare Utilization: An Analysis of Disease Specific and Patient Level Factors in a Congenital Diaphragmatic Hernia Clinic

OBJECTIVES

Our study examines if the disease severity profile of our Congenital Diaphragmatic Hernia (CDH) patient cohort adherent to long-term follow-up differs from patients lost to follow-up after discharge and examines factors associated with health care utilization.

METHODS

Retrospective review identified CDH survivors born 2005-2019 with index repair at our institution. Primary outcome was long-term follow-up status: "active" or "inactive" according to clinic guidelines. Markers of CDH disease severity including CDH defect classification, oxygen use, tube feeds at discharge, and sociodemographic factors were examined as exposures.

RESULTS

Of the 222 included patients, median age [IQR] was 10.2 years [6.7-14.3], 61% male, and 57 (26%) were insured by Medicaid. Sixty-three percent (139/222) of patients were adherent to follow-up. Seventy-six percent of patients discharged on tube feeds had active follow-up compared to 55% of patients who were not, with similar findings for oxygen at discharge (76% vs. 55%). Kaplan-Meier analysis showed patients with smaller defect size had earlier attrition compared to patients with larger defect size. Other race (Hispanic, Asian, Middle Eastern) patients had 2.87 higher odds of attrition compared to white patients (95% CI 1.18-7.0). Medicaid patients had 2.64 higher odds of attrition compared to private insurance (95% CI 1.23-5.66).

CONCLUSION

Loss to follow-up was associated with race and insurance type. Disease severity was similar between the active and inactive clinic cohorts. Long-term CDH clinic publications should examine attrition to ensure reported outcomes reflect the discharged population. This study identified important factors to inform targeted interventions for follow-up adherence.

LEVEL OF EVIDENCE

Level III.

Delayed diagnosis of serious paediatric conditions in 13 regional emergency departments

OBJECTIVE

To evaluate rates, risk factors and outcomes of delayed diagnosis of seven serious paediatric conditions.

METHODS

This was a retrospective, cross-sectional study of children under 21 years old visiting 13 community and tertiary emergency departments (EDs) with appendicitis, bacterial meningitis, intussusception, mastoiditis, ovarian torsion, sepsis or testicular torsion. Delayed diagnosis was defined as having a previous ED encounter within 1 week in which the condition was present per case review. Patients with delayed diagnosis were each matched to four control patients without delay by condition, facility and age. Conditional logistic regression models evaluated risk factors of delay. Complications were compared between by delayed diagnosis status.

RESULTS

Among 14 972 children, delayed diagnosis occurred in 1.1% (range 0.3% for sepsis to 2.6% for ovarian torsion). Hispanic (matched OR 2.71, 95% CI 1.69 to 4.35) and non-Hispanic black (OR 2.40, 95% CI 1.21 to 4.79) race/ethnicity were associated with delayed diagnosis, whereas Asian and other race/ethnicity were not. Public (OR 2.21, 95% CI 1.42 to 3.44) and other (OR 2.43, 95% CI 1.50 to 3.93) insurance were also associated with delay. Non-English language was associated with delay (OR 1.65, 95% CI 1.02 to 2.69). Abnormal vital signs were associated with a lower likelihood of delay (OR 0.15, 95% CI 0.09 to 0.25). In an adjusted model, Hispanic race/ethnicity, other insurance, abnormal vital signs and complex chronic conditions (CCCs) were associated with delay. The odds of a complication were 2.5-fold (95% CI 1.6 to 3.8) higher among patients with a delay.

CONCLUSION

Delayed diagnosis was uncommon across 13 regional EDs but was more likely among children with Hispanic ethnicity, CCCs or normal vital signs. Delays were associated with a higher risk of complications.

Childhood opportunity and appropriate use of child safety restraints in motor vehicle collisions

Objectives

Safety restraints reduce injuries from motor vehicle collisions (MVCs) but are often improperly applied or not used. The Childhood Opportunity Index (COI) reflects social determinants of health and its study in pediatric trauma is limited. We hypothesized that MVC patients from low-opportunity neighborhoods are less likely to be appropriately restrained.

Methods

A retrospective cross-sectional study was performed on children/adolescents ≤18 years old in MVCs between January 1, 2011 and December 31, 2021. Patients were identified from the Children's Hospital Los Angeles trauma registry. The outcome was safety restraint use (appropriately restrained, not appropriately restrained). COI levels by home zip codes were stratified as very low, low, moderate, high, and very high. Multivariable regression controlling for age identified factors associated with safety restraint use.

Results

Of 337 patients, 73.9% were appropriately restrained and 26.1% were not appropriately restrained. Compared with appropriately restrained patients, more not appropriately restrained patients were from low-COI (26.1% vs 20.9%), high-COI (14.8% vs 10.8%) and very high-COI (10.2% vs 3.6%) neighborhoods. Multivariable analysis demonstrated no significant associations in appropriate restraint use and COI. There was a non-significant trend that children/adolescents from moderate-COI neighborhoods were more likely than those from very low-COI neighborhoods to be appropriately restrained (OR=1.82, 95% CI 0.78, 4.28).

Conclusion

Injury prevention initiatives focused on safety restraints should target families of children from all neighborhood types.

Level of evidence

III.

Social Care Education and Training Among US Pediatric Emergency Medicine Fellowship Programs

OBJECTIVE

The aim of the study is to assess the association of social determinants of health (SDOH) education and social needs training on pediatric emergency medicine (PEM) physician perception and practices of social care.

METHODS

Data were derived from the 2021 National Social Care Practices Survey of PEM program directors (PDs) and fellows. Ordinal and binary logistic regression modeling were completed for educational/training factors and social care perspective and practice outcomes.

RESULTS

A national sample of 44 PDs (49% response rate) and 109 fellows (28%) participated. A minority of fellows received SDOH education and social needs training during fellowship. Fellows and PDs with SDOH education had a 3.1 odds (95% confidence interval CI, 1.4-6.9) of screening for social needs, with 4.4 odds among fellows (95% CI, 1.2-20.7). Those with social needs training were more comfortable assessing social risk, with 2.4 odds overall (95% CI, 1.2-4.7) and 3.1 odds among fellows (95% CI, 1.4-6.7). They also had 2.4 odds overall (95% CI, 1.1-4.9) of screening for social needs, with a 2.9 odds among fellows (95% CI, 1.3-6.8).

CONCLUSIONS

Social care education and training appear to be associated with comfort assessing social risk and social needs screening tendency among both PEM PDs and fellows. Key areas for educational interventions are identified among PEM fellows, who are uniquely positioned as clinical leaders and patient advocates.

The impact of COVID-19 on racial and ethnic disparities in presentation with perforated appendicitis in children: A retrospective cohort study

Background

Children from racial and ethnic minority groups have higher prevalence of perforated appendicitis, and the COVID-19 pandemic worsened racial and ethnic health-related disparities. We hypothesized that the incidence of perforated appendicitis worsened for children from racial and ethnic minorities during the COVID-19 pandemic.

Methods

We performed a retrospective cohort study of the Pediatric Health Information System for children ages 2-18y undergoing appendectomy pre-pandemic (3/19/2019-3/18/2020) and intra-pandemic (3/19/2020-3/30/2021). The primary outcome was presentation with perforated appendicitis. Multivariable logistic regression with mixed effects estimated the likelihood of presentation with perforated appendicitis. Covariates included race, ethnicity, pandemic status, Child Opportunity Index, gender, insurance, age, and hospital region.

Results

Overall, 33,727 children underwent appendectomy: 16,048 (47.6 %) were Non-Hispanic White, 12,709 (37.7 %) were Hispanic, 2261 (6.7 %) were Non-Hispanic Black, 960 (2.8 %) were Asian, and 1749 (5.2 %) Other. Overall perforated appendicitis rates were unchanged during the pandemic (37.4 % intra-pandemic, 36.4 % pre-pandemic, p = 0.06). Hispanic children were more likely to present with perforated appendicitis intra-pandemic versus pre-pandemic (OR 1.18, 95%CI: 1.07, 1.13). Hispanic children had higher odds of perforated appendicitis versus Non-Hispanic White children pre-pandemic (OR 1.10, 95%CI: 1.00, 1.20) which increased intra-pandemic (OR 1.19, 95%CI: 1.09, 1.30). Publicly-insured children had increased odds of perforated appendicitis intra-pandemic versus pre-pandemic (OR 1.14, 95%CI: 1.03, 1.25), and had increased odds of perforated appendicitis versus privately-insured children (intra-pandemic OR 1.26, 95%CI: 1.16, 1.36; pre-pandemic OR 1.12, 95%CI: 1.04, 1.22).

Conclusions

During the COVID-19 pandemic, Hispanic and publicly-insured children were more likely to present with perforated appendicitis, suggesting that the pandemic exacerbated existing disparities in healthcare for children with appendicitis.

Key message

We found that Hispanic children and children with public insurance were more likely to present with perforated appendicitis during the COVID-19 pandemic. Public health efforts aimed at ameliorating racial and ethnic disparities created during the COVID-19 pandemic should consider increasing healthcare access for Hispanic children to address bias, racism, and systemic barriers that may prevent families from seeking care.

Variation in follow-up for children born very preterm in Europe

BACKGROUND

Children born very preterm (<32 weeks of gestation) face high risks of neurodevelopmental and health difficulties compared with children born at term. Follow-up after discharge from the neonatal intensive care unit is essential to ensure early detection and intervention, but data on policy approaches are sparse.

METHODS

We investigated the characteristics of follow-up policy and programmes in 11 European countries from 2011 to 2022 using healthcare informant questionnaires and the published/grey literature. We further explored how one aspect of follow-up, its recommended duration, may be reflected in the percent of parents reporting that their children are receiving follow-up services at 5 years of age in these countries using data from an area-based cohort of very preterm births in 2011/12 (N = 3635).

RESULTS

Between 2011/12 and 22, the number of countries with follow-up policies or programmes increased from 6 to 11. The policies and programmes were heterogeneous in eligibility criteria, duration and content. In countries that recommended longer follow-up, parent-reported follow-up rates at 5 years of age were higher, especially among the highest risk children, born <28 weeks' gestation or with birthweight <1000 g: between 42.1% and 70.1%, vs. <20% in most countries without recommendations.

CONCLUSIONS

Large variations exist in follow-up policies and programmes for children born very preterm in Europe; differences in recommended duration translate into cross-country disparities in reported follow-up at 5 years of age.

Associations Between Social Vulnerability Indicators and Pediatric Tonsillectomy Outcomes

OBJECTIVE

To investigate the impact of neighborhood-level social vulnerability on pediatric tonsillectomy outcomes.

METHODS

This single-center retrospective cohort study included tonsillectomies performed on children aged 1 to 18 between August 2019 and August 2020. Geographic information systems were used to geocode addresses, and spatial overlays were used to assign census-tract level social vulnerability index (SVI) scores to each patient. For categorical variables, two-sided Pearson chi-square tests were used, whereas for continuous variables, paired t-tests, means, and standard deviations were calculated. SVI and its four subthemes were investigated using binomial logistic regressions to determine their impact on post-T&A complications and readmissions.

RESULTS

The study included 397 patients, with 52 having complications (13.1%) and 33 (8.3%) requiring readmissions due to their complications. Controlling for age, gender, race, insurance status, surgical indication, comorbidities, obesity, and obstructive sleep apnea, postoperative complications were associated with high overall SVI (odds ratio [OR] 5.086, 95% confidence interval [CI] 1.128-22.938), high socioeconomic vulnerability (SVI theme 1, OR 6.003, 95% CI 1.270-28.385), and high house composition vulnerability (SVI theme 2, OR 6.340, 95% CI 1.275-31.525). Readmissions were also associated with high overall SVI (10.149, 95% CI 1.293-79.647) and high housing/transportation vulnerability (SVI theme 4, OR 5.657, 95% CI 1.089-29.396).

CONCLUSION

Social vulnerability at the neighborhood level is linked to poorer surgical outcomes in otherwise healthy children, suggesting a target for community-based interventions. Because of the increased risk, it may have implications for preoperative decision-making, treatment plans, and clinic follow-ups.

LEVEL OF EVIDENCE: 3

Laryngoscope, 134:954-962, 2024.

Neighborhood Conditions and Resources in Mid-Childhood and Dampness and Pests at Home in Adolescence

OBJECTIVE

To examine prospectively associations of neighborhood opportunity with the presence of dampness or pests in the home environment during early adolescence.

STUDY DESIGN

We geocoded residential addresses from 831 children (mean age 7.9 years, 2007-2011) in the Project Viva cohort. We linked each address with census tract-level Child Opportunity Index scores, which capture neighborhood conditions and resources influencing child heath including educational, health, environmental, and socioeconomic factors. Our primary outcome was presence of dampness or pests in the home in early adolescence (mean age 13.2 years, 2013-2016). Secondary outcomes included current asthma and lung function testing results. Mixed-effects regression models estimated longitudinal associations of Child Opportunity Index scores with outcomes, adjusting for individual and family sociodemographics.

RESULTS

Children residing in neighborhoods with greater overall opportunity were less likely to live in homes with dampness or pests approximately 5 years later (aOR 0.85 per 20-unit increase in Child Opportunity Index percentile rank, 95% CI 0.73-0.998). We observed no significant associations in adjusted models of overall neighborhood opportunity with current asthma or lung function. Lower school poverty or single-parent households and greater access to healthy food or economic resource index were associated with lower odds of a home environment with dampness or pests.

CONCLUSIONS

More favorable neighborhood conditions in mid-childhood were associated with lower likelihood of living in a home with dampness or pests in the early adolescence.

Neighborhood context and children's health care utilization and health outcomes: a comprehensive descriptive analysis of national survey data

While child health and health care disparities arising from unequal distribution of resources are well documented, a nationally representative inventory of health and well-being for children across the spectrum of opportunity is lacking. Using the nationally representative sample of children from pooled 2013-2017 Medical Expenditure Panel Survey data linked to the census-tract-level Child Opportunity Index 2.0, a composite measure of neighborhood health, education, and socioeconomic conditions, we describe US children's socioeconomic characteristics, health care utilization and expenditures across the spectrum of child neighborhood opportunity levels. We found that neighborhood level of child opportunity was associated with almost all of children's health status, health care utilization, expenditures, access to care, and satisfaction with care outcomes. Children living in lower-opportunity neighborhoods had the highest rates of poor physical and mental health status and fewest ambulatory care visits but accounted for the highest share of emergency department visits. Their parents were also least likely to report having positive experiences with health care, good communication with providers, and easy access to care. Our findings underscore the myriad harms to children of gaps in health, education, and financial resources at the community level and provide targets for public investments to improve child-focused outcomes.

Pediatric instant noodle burns: A ten-year single center retrospective study

INTRODUCTION

Children are particularly vulnerable to scald injuries, and hot beverages/foods are often implicated in this subset of pediatric burns. Burns from instant noodles are common and thus an attractive target for burn prevention. The purpose of this study is to characterize the frequency, demographics, outcomes, and circumstances of pediatric instant noodle burns to guide future educational and prevention efforts.

METHODS

This is a retrospective review of all pediatric patients (<18 years) admitted to the University of Chicago Burn Center with a diagnosis of scald injury between 2010 and 2020. Burns caused by instant noodles were identified and compared to all other scald burns over this period.

RESULTS

Among 790 pediatric scald burns, 245 (31.0 %) were attributed to instant noodles. Compared to other scalds, patients with instant noodle burns were older (5.4 vs. 3.8 years, p < 0.001), equally likely to be male (51 % vs. 54 %, p = 0.488), and more likely to be Black/African American (90.6 % vs. 75.2 %, p < 0.001). Patients with instant noodle burns lived in zip codes with a lower average childhood opportunity index score (9.9 vs. 14.6, p < 0.001). In terms of circumstances, children with instant noodle burns were more likely to be unsupervised at the time of injury (37 % vs 21 %, p < 0.001). Instant noodle burns were smaller (3.6 % total body surface area (TBSA) vs. 5.8 % TBSA, p < 0.001) and less likely to require operative intervention (29 % vs. 41 %, p < 0.001). Instant noodle burns had a shorter length of stay (4.2 days vs. 6.4 days, p < 0.001), but similar adjusted length of stay (1.7 days/%TBSA vs. 1.5 days/%TBSA, p = 0.18) and experienced similar complication rates (10 % vs. 15 %, p = 0.06).

CONCLUSION

Instant noodle burns comprised nearly one-third of all pediatric scald burn admissions at our institution, a higher proportion than previously reported. While less severe than other scald burns in this series, instant noodles injuries still demonstrated a need for hospitalization and operative intervention. Instant noodle burns disproportionately affected Black/African American patients, as well as from neighborhoods with lower socioeconomic status. These findings suggest that focused burn prevention efforts may be successful at reducing the incidence of these common, but serious injuries.

Neighborhood Childhood Opportunity, Race/Ethnicity, and Surgical Outcomes in Children With Congenital Heart Disease

BACKGROUND

Racial and ethnic disparities in outcomes for children with congenital heart disease (CHD) coexist with disparities in educational, environmental, and economic opportunity.

OBJECTIVES

We sought to determine the associations between childhood opportunity, race/ethnicity, and pediatric CHD surgery outcomes.

METHODS

Pediatric Health Information System encounters aged <18 years from 2016 to 2022 with International Classification of Diseases-10th edition codes for CHD and cardiac surgery were linked to ZIP code-level Childhood Opportunity Index (COI), a score of neighborhood educational, environmental, and socioeconomic conditions. The associations of race/ethnicity and COI with in-hospital surgical death were modeled with generalized estimating equations and formal mediation analysis. Neonatal survival after discharge was modeled by Cox proportional hazards.

RESULTS

Of 54,666 encounters at 47 centers, non-Hispanic Black (Black) (OR: 1.20; P = 0.01), Asian (OR: 1.75; P < 0.001), and Other (OR: 1.50; P < 0.001) groups had increased adjusted mortality vs non-Hispanic Whites. The lowest COI quintile had increased in-hospital mortality in unadjusted and partially adjusted models (OR: 1.29; P = 0.004), but not fully adjusted models (OR: 1.14; P = 0.13). COI partially mediated the effect of race/ethnicity on in-hospital mortality between 2.6% (P = 0.64) and 16.8% (P = 0.029), depending on model specification. In neonatal multivariable survival analysis (n = 13,987; median follow-up: 0.70 years), the lowest COI quintile had poorer survival (HR: 1.21; P = 0.04).

CONCLUSIONS

Children in the lowest COI quintile are at risk for poor outcomes after CHD surgery. Disproportionally increased mortality in Black, Asian, and Other populations may be partially mediated by COI. Targeted investment in low COI neighborhoods may improve outcomes after hospital discharge. Identification of unmeasured factors to explain persistent risk attributed to race/ethnicity is an important area of future exploration.

The association between childhood opportunity index and pediatric hospitalization for firearm injury or motor vehicle crash

BACKGROUND

Community-level factors can profoundly impact children's health, including the risk of violent injury. This study's objective was to understand the relationship between the Childhood Opportunity Index and pediatric firearm injury owing to interpersonal violence compared with a motor vehicle crash.

METHODS

All pediatric patients (<18 years) who presented with an initial encounter with a firearm injury or motor vehicle crash between 2016 to 2021 were identified from 35 children's hospitals included in the Pediatric Health Information System database. The child-specific community-level vulnerability was determined by the Childhood Opportunity Index, a composite score of neighborhood opportunity level data specific to pediatric populations.

RESULTS

We identified 67,407 patients treated for injuries related to motor vehicle crashes (n = 61,527) or firearms (n = 5,880). The overall cohort had a mean age of 9.3 (standard deviation 5.4) years; 50.0% were male patients, 44.0% non-Hispanic Black, and were 60.8% publicly insured. Compared with motor vehicle crash injuries, patients with firearm-related injuries were older (12.2 vs 9.0 years), more likely to be male patients (77.7% vs 47.4%), non-Hispanic Black (63.5% vs 42.1%), and had public insurance (76.4 vs 59.3%; all P < .001). In multivariable analysis, children living in communities with lower Childhood Opportunity Index levels were more likely to present with firearm injury than those living in communities with a very high Childhood Opportunity Index. The odds increased as the Childhood Opportunity Index level decreased (odds ratio 1.33, 1.60, 1.73, 2.00 for high, moderate, low, and very low Childhood Opportunity Index, respectively; all P ≤ .001).

CONCLUSION

Children from lower-Childhood Opportunity Index communities are disproportionately impacted by firearm violence, and these findings have important implications for both clinical care and public health policy.

Pre-appendectomy hyponatremia is associated with increased rates of complicated appendicitis

Background

Acute appendicitis is one of the most common surgical emergencies worldwide. Preoperative assessment of the risk of complicated appendicitis may aid in treatment planning. We sought to investigate the association between pre-appendectomy hyponatremia and diagnosis of complicated appendicitis.

Methods

The TriNetX platform, a federated health research network that aggregates de-identified electronic health record data of over 90 million patients across the United States, was queried for patients who underwent appendectomy starting January 2019 and who had at least one sodium value from the preoperative period. The study population was stratified into three age groups: pediatric (age < 18), adult (age 18-64), and older adult (age ≥ 65). These groups were subdivided into patients with preoperative hyponatremia (<135 mmol/L) and normonatremia (135-145 mmol/L).

Results

Among the 61,245 patients who met inclusion criteria, 17,546 were included for analysis following propensity score matching. The odds of complicated appendicitis were highest in pediatric patients (age < 18) with pre-appendectomy hyponatremia (odds ratio [OR] = 2.91, 95 % CI [2.53, 3.35]). Patients age 18-64 and aged ≥ 65 with preoperative hyponatremia also demonstrated increased odds of a complicated appendicitis diagnosis, but to a lesser extent (OR = 2.11, 95 % CI [1.92, 2.32] (OR = 1.49, 95 % CI [1.25, 1.77], respectively).

Conclusions

In a large analysis of matched patients with acute appendicitis, we found an association between immediate preoperative hyponatremia and complicated appendicitis. Future studies are indicated to further evaluate the role of hyponatremia as a potential diagnostic marker for complicated appendicitis in all age groups.

Key message

This study suggests a role of hyponatremia as one of multiple variables to incorporate into future clinical decision tools for complicated acute appendicitis.

Racialized economic segregation and potentially preventable hospitalizations among Medicaid/CHIP-enrolled children

OBJECTIVE

To examine geographic variation in preventable hospitalizations among Medicaid/CHIP-enrolled children and to test the association between preventable hospitalizations and a novel measure of racialized economic segregation, which captures residential segregation within ZIP codes based on race and income simultaneously.

DATA SOURCES

We supplement claims and enrollment data from the Transformed Medicaid Statistical Information System (T-MSIS) representing over 12 million Medicaid/CHIP enrollees in 24 states with data from the Public Health Disparities Geocoding Project measuring racialized economic segregation.

STUDY DESIGN

We measure preventable hospitalizations by ZIP code among children. We use logistic regression to estimate the association between ZIP code-level measures of racialized economic segregation and preventable hospitalizations, controlling for sex, age, rurality, eligibility group, managed care plan type, and state.

DATA EXTRACTION METHODS

We include children ages 0-17 continuously enrolled in Medicaid/CHIP throughout 2018. We use validated algorithms to identify preventable hospitalizations, which account for characteristics of the pediatric population and exclude children with certain underlying conditions.

PRINCIPAL FINDINGS

Preventable hospitalizations vary substantially across ZIP codes, and a quarter of ZIP codes have rates exceeding 150 hospitalizations per 100,000 Medicaid-enrolled children per year. Preventable hospitalization rates vary significantly by level of racialized economic segregation: children living in the ZIP codes that have the highest concentration of low-income, non-Hispanic Black residents have adjusted rates of 181 per 100,000 children, compared to 110 per 100,000 for children in ZIP codes that have the highest concentration of high-income, non-Hispanic white residents (p < 0.01). This pattern is driven by asthma-related preventable hospitalizations.

CONCLUSIONS

Medicaid-enrolled children's risk of preventable hospitalizations depends on where they live, and children in economically and racially segregated neighborhoods-specifically those with higher concentrations of low-income, non-Hispanic Black residents-are at particularly high risk. It will be important to identify and implement Medicaid/CHIP and other policies that increase access to high-quality preventive care and that address structural drivers of children's health inequities.

Addressing pediatric surgical health inequities through quality improvement efforts

Concepts of healthcare quality and health equity should be inextricably linked but are often pursued separately. Quality improvement (QI) can serve as a powerful means to eliminate health inequities by adopting an equity-focused lens to diagnose and address baseline disparities among pediatric populations using targeted interventions. QI and pediatric surgery practitioners should integrate concepts of equity at every stage of formulating a QI project including conceptualization, planning, and execution. Early adaptation of an equity conscious perspective using QI methodology can prevent exacerbation of preexisting disparities while improving overall outcomes.

Discordance between Subjective and Objective Assessments of Activity after Pediatric Appendectomy

BACKGROUND

Physical activity recovery after pediatric surgery can be assessed using objective measures such as step counts, but practice currently relies on subjective assessment by proxy. It is unclear how subjective and objective assessments of activity relate. We compared caregiver assessment of return to normal physical activity after pediatric appendectomy to step count recovery measured by a Fitbit.

METHODS

Pediatric patients who underwent appendectomy were recruited between 2020 and 2022 to be monitored for 21 d with a Fitbit. Patients were grouped by the postoperative day (POD) (7, 14, or 21) their caregiver first reported their activity was "back to normal." Objective return to normal step count was estimated for each group by modeling the inflection point from increasing steps to a plateau. These measures were determined discordant if the subjective report remained outside the modeled 95% confidence interval (CI) for the day the group plateaued.

RESULTS

Thirty-nine simple appendicitis and 40 complicated appendicitis patients were recruited. Among simple appendicitis patients, daily steps plateaued on POD 10.8 (95% CI 7.4-14.3), POD 14.0 (95% CI 11.0-17.1), and POD 11.1 (95% CI 6.9-15.3) for the day 7, day 14, and day 21 groups, respectively. Complicated appendicitis groups plateaued on POD 12.8 (95% CI 8.7-16.9), POD 15.2 (95% CI 11.1-19.3), and POD 16.7 (95% CI 12.3-21.0), respectively. Significant discordance was observed between subjective and objective assessments for the day 7 and day 14 simple groups and for the day 7 complicated group.

CONCLUSIONS

There was significant discordance between caregiver and accelerometer-assessed activity recovery after pediatric surgery. Development of objective measures of recovery could help standardize assessment of children's recovery after surgery.

Hospitalizations at United States Children's Hospitals and Severity of Illness by Neighborhood Child Opportunity Index

OBJECTIVE

To describe the association between neighborhood opportunity measured by the Child Opportunity Index 2.0 (COI) and patterns of hospital admissions and disease severity among children admitted to US pediatric hospitals.

STUDY DESIGN

Retrospective, cross-sectional study of 773 743 encounters for children <18 years of age admitted to US children's hospitals participating in the Pediatric Health Information System database 7/2020-12/2021.

RESULTS

The proportion of children from each COI quintile was inversely related to the degree of neighborhood opportunity. The difference between the proportion of patients from Very Low COI and Very High COI ranged from +32.0% (type 2 diabetes mellitus with complications) to -14.1% (mood disorders). The most common principal diagnoses were acute bronchiolitis, respiratory failure/insufficiency, chemotherapy, and asthma. Of the 45 diagnoses which occurred in ≥0.5% of the cohort, 22, including type 2 diabetes mellitus, asthma, and sleep apnea had higher odds of occurring in lower COI tiers in multivariable analysis. Ten diagnoses, including mood disorders, neutropenia, and suicide and intentional self-inflicted injury had lower odds of occurring in the lower COI tiers. The proportion of patients needing critical care and who died increased, as neighborhood opportunity decreased.

CONCLUSIONS

Pediatric hospital admission diagnoses and severity of illness are disproportionately distributed across the range of neighborhood opportunity, and these differences persist after adjustment for factors including race/ethnicity and payor status, suggesting that these patterns in admissions reflect disparities in neighborhood resources and differential access to care.

Child Opportunity Index and Hospital Utilization in Children With Traumatic Brain Injury Admitted to the PICU

The need to understand how Community-based disparities impact morbidity and mortality in pediatric critical illness, such as traumatic brain injury. Test the hypothesis that ZIP code-based disparities in hospital utilization, including length of stay (LOS) and hospital costs, exist in a cohort of children with traumatic brain injury (TBI) admitted to a PICU using the Child Opportunity Index (COI).

DESIGN

Multicenter retrospective cohort study.

SETTING

Pediatric Health Information System (PHIS) database.

PATIENTS

Children 0-18 years old admitted to a PHIS hospital with a diagnosis of TBI from January 2016 to December 2020 requiring PICU care. To identify the most severely injured children, a study-specific definition of "Complicated TBI" was created based on radiology, pharmacy, and procedure codes.

INTERVENTIONS

None.

Main Outcomes and Measures

Using nationally normed ZIP code-level COI data, patients were categorized into COI quintiles. A low COI ZIP code has low childhood opportunity based on weighted indicators within educational, health and environmental, and social and economic domains. Population-averaged generalized estimating equation (GEE) models, adjusted for patient and clinical characteristics examined the association between COI and study outcomes, including hospital LOS and accrued hospital costs. The median age of this cohort of 8,055 children was 58 months (interquartile range [IQR], 8-145 mo). There were differences in patient demographics and rates of Complicated TBI between COI levels. The median hospital LOS was 3.0 days (IQR, 2.0-6.0 d) and in population-averaged GEE models, children living in very low COI ZIP codes were expected to have a hospital LOS 10.2% (95% CI, 4.1-16.8%; p = 0.0142) longer than children living in very high COI ZIP codes. For the 11% of children with a Complicated TBI, the relationship between COI and LOS was lost in multivariable models. COI level was not predictive of accrued hospital costs in this study.

CONCLUSIONS

Children with TBI requiring PICU care living in low-opportunity ZIP codes have higher injury severity and longer hospital LOS compared with children living in higher-opportunity ZIP codes. Additional studies are needed to understand why these differences exist.

Fecal continence disparities in patients with idiopathic constipation treated at referral institutions for pediatric colorectal surgery

PURPOSE

Fecal continence is a concern for many patients with idiopathic constipation and can significantly impact quality of life. It is unknown whether racial, ethnic, and socioeconomic disparities are seen in fecal continence within the idiopathic constipation population. We aimed to evaluate fecal continence and associated demographic characteristics in children with idiopathic constipation referred for surgical evaluation.

METHODS

A multicenter retrospective study of children with idiopathic constipation was performed at sites participating in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC). All patients >3y of age with idiopathic constipation diagnosis were included. The primary outcome was fecal continence, categorized as complete (no accidents ever), daytime (no accidents during the day), partial (occasional incontinence day/night), and none (incontinent). We evaluated for associations between fecal continence and race, sex, age, insurance status, and other patient-level factors, employing Kruskal-Wallis and trend tests.

RESULTS

458 patients with idiopathic constipation from 12 sites were included. The median age of diagnosis was 4.1 years. Only 25% of patients referred for surgical evaluation were completely continent. Age at the visit was significantly associated with fecal continence level (p = 0.002). In addition, patients with public and mixed public and private insurance had lower levels of continence (p<0.001). Patients with developmental delay were also more likely to have lower continence levels (p = 0.009) while diagnoses such as anxiety, ADD/ADHD, autism, depression, obsessive-compulsive disorder were not associated. Approximately 30% of patients had an ACE operation (antegrade continence enema) at a median age of 9.2 years at operation. Black patients were significantly less likely to undergo ACE operation (p = 0.016) when compared to white patients.

CONCLUSION

We observed data that suggest differences in fecal incontinence rates based on payor status. Further investigation is needed to characterize these potential areas of disparate care.

LEVEL OF EVIDENCE

Level III.

Distribution of Emergency Department Encounters and Subsequent Hospital Admissions for Children by Child Opportunity Index

OBJECTIVE

To evaluate differences in emergency department (ED) utilization and subsequent admission among children by Child Opportunity Index (COI).

METHODS

We performed a cross-sectional study of pediatric (<18 years) encounters to 194 EDs in Illinois from 2016 to 2020. Each encounter was assigned to quntiles of COI 2.0 by postal code. We described the difference in the percent of encounters between lower (Very Low and Low) and higher (Very High and High) COI overall and among diagnoses with overrepresentation from lower COI groups. We evaluated the association of diagnosis with COI in ordinal models adjusted for demographics.

RESULTS

There were 4,653,026 eligible ED encounters classified by COI as Very Low (28.6%), Low (24.8%), Moderate (20.3%), High (15.6%), and Very High (10.8%) (difference between low and high COI encounters 27.0%). Diagnoses with the greatest difference between low and high COI were eye infection, upper respiratory tract infections, and cough. The COI distribution for children admitted from the ED (n = 140,298) was 29.1% Very Low, 19.3% Low, 18.2% Moderate, 17.7% High, and 15.7% Very High (percent difference 15.1%). Diagnoses with the greatest differences between low and high COI among admitted patients were sickle cell crisis, asthma, and influenza. All ED diagnoses and 7/12 admission diagnoses were associated with lower COI in multivariable ordinal models.

CONCLUSIONS

Children from lower COI areas are overrepresented in ED and inpatient encounters overall and within certain diagnosis groups. Further research is required to examine how health outcomes may be influenced by the structural and contextual characteristics of a child's neighborhood.

Social Determinants of Health are Associated With Postoperative Outcomes in Children With Complicated Appendicitis

INTRODUCTION

Socioeconomic disadvantage has been associated with increased complicated appendicitis rates. Our purpose was to analyze the complex interactions between social determinants of health (SDOH) and postoperative outcomes in pediatric appendicitis.

MATERIALS AND METHODS

Children who underwent appendectomy at our institution (1/2015-12/2020) were retrospectively reviewed. We used home addresses to determine composite measures of neighborhood/area-level socioeconomic advantage (Area Deprivation Index [ADI] and Social Deprivation Index [SDI]), and other area-level indicators. We created a novel, composite outcome score computed as a weighted average of eight outcome measures. Feature selection and exploratory factor analysis were used to create a multivariate model predictive of outcomes.

RESULTS

Of 1117 children with appendicitis, 20.59% had complicated (perforated) appendicitis. Factor analysis identified two multivariate latent factors; Factor 1 contained SDI, ADI, and % unemployed in the population, and Factor 2 contained % Hispanic and % foreign-born in the population. Low Factor 2 scores (communities with more Hispanic/foreign-born residents) were associated with increased length of stay, more frequent postoperative percutaneous drainage, and increased postoperative imaging.

CONCLUSIONS

Interactions between SDOH and pediatric surgical care go beyond the individual patient and suggest that vulnerable populations are exposed to contextual conditions that may impact outcomes. Specifically, neighborhood-level factors, including the prevalence of Hispanic ethnicity and foreign-born individuals, are associated with outcomes in pediatric patients with complicated appendicitis. Reducing disparities in complicated appendicitis outcomes may involve addressing neighborhood-level SDOH through strategic reallocation of healthcare resources and developing targeted interventions to improve access to pediatric surgical care in underserved communities.