Insurance status and pediatric mortality in nonaccidental trauma

Understanding Disparities in the Pediatric ICU: A Scoping Review

BACKGROUND AND OBJECTIVES

Health disparities are pervasive in pediatrics. We aimed to describe disparities among patients who are likely to be cared for in the PICU and delineate how sociodemographic data are collected and categorized.

METHODS

Using MEDLINE as a data source, we identified studies which included an objective to assess sociodemographic disparities among PICU patients in the United States. We created a review rubric, which included methods of sociodemographic data collection and analysis, outcome and exposure variables assessed, and study findings. Two authors reviewed every study. We used the National Institute on Minority Health and Health Disparities Research Framework to organize outcome and exposure variables.

RESULTS

The 136 studies included used variable methods of sociodemographic data collection and analysis. A total of 30 of 124 studies (24%) assessing racial disparities used self- or parent-identified race. More than half of the studies (52%) dichotomized race as white and "nonwhite" or "other" in some analyses. Socioeconomic status (SES) indicators also varied; only insurance status was used in a majority of studies (72%) evaluating SES. Consistent, although not uniform, disadvantages existed for racial minority populations and patients with indicators of lower SES. The authors of only 1 study evaluated an intervention intended to mitigate health disparities. Requiring a stated objective to evaluate disparities aimed to increase the methodologic rigor of included studies but excluded some available literature.

CONCLUSIONS

Variable, flawed methodologies diminish our understanding of disparities in the PICU. Meaningfully understanding and addressing health inequity requires refining how we collect, analyze, and interpret relevant data.

Using the Social Vulnerability Index to Examine Disparities in Surgical Pediatric Trauma Patients

INTRODUCTION

The Social Vulnerability Index (SVI) is a composite measure geocoded at the census tract level that has the potential to identify target populations at risk for postoperative surgical morbidity. We applied the SVI to examine demographics and disparities in surgical outcomes in pediatric trauma patients.

METHODS

Surgical pediatric trauma patients (≤18-year-old) at our institution from 2010 to 2020 were included. Patients were geocoded to identify their census tract of residence and estimated SVI and were stratified into high (≥70th percentile) and low (<70th percentile) SVI groups. Demographics, clinical data, and outcomes were compared using Kruskal-Wallis and Fisher's exact tests.

RESULTS

Of 355 patients included, 21.4% had high SVI percentiles while 78.6% had low SVI percentiles. Patients with high SVI were more likely to have government insurance (73.7% versus 37.2%, P < 0.001), be of minority race (49.8% versus 19.1%, P < 0.001), present with penetrating injuries (32.9% versus 19.7%, P = 0.007), and develop surgical site infections (3.9% versus 0.4%, P = 0.03) compared to the low SVI group.

CONCLUSIONS

The SVI has the potential to examine health care disparities in pediatric trauma patients and identify discrete at-risk target populations for preventative resources allocation and intervention. Future studies are necessary to determine the utility of this tool in additional pediatric cohorts.

Children from disadvantaged neighborhoods experience disproportionate injury from interpersonal violence

BACKGROUND

Disparities in pediatric injury have been widely documented and are driven, in part, by differential exposures to social determinants of health (SDH). Here, we hypothesized that neighborhood socioeconomic deprivation and specific sociodemographic characteristics would be associated with interpersonal violence-related injury admission.

METHODS

We conducted a retrospective cohort study of all patients ≤16 years, residing in Hamilton County, admitted to our level 1 pediatric trauma center. Residential addresses were geocoded to link admissions with a census tract-level socioeconomic deprivation index. Admissions were categorized as resulting from interpersonal violence or not - based on a mechanism of injury (MOI) of abuse or assault. The percentage of interpersonal violence-related injury admissions was compared across patient demographics and neighborhood deprivation index tertiles. These factors were then evaluated with multivariable regression analysis.

RESULTS

Interpersonal violence accounted for 6.2% (394 of 6324) of all injury-related admissions. Interpersonal violence-related injury admission was associated with older age, male sex, Black race, public insurance, and living in tertiles of census tracts with higher socioeconomic deprivation. Those living in the most deprived tertile experienced 62.2% of all interpersonal violence-related injury admissions but only 36.9% of non-violence related injury admissions (p < 0.001). After adjustment, insurance and neighborhood deprivation accounted for much of the increase in interpersonal violence-related admissions for Black compared to White children.

CONCLUSIONS

Children from higher deprivation neighborhoods, who are also disproportionately Black and publicly insured, experience a higher burden of interpersonal violence-related injury admissions. Level of evidence Level III.

Disparities in detection of suspected child abuse

BACKGROUND

Child abuse is a significant cause of injury and death among children, but accurate identification is often challenging. This study aims to assess whether racial disparities exist in the identification of child abuse.

METHODS

The 2010-2014 and 2016-2017 National Trauma Data Bank was queried for trauma patients ages 1-17. Using ICD-9CM and ICD-10CM codes, children with injuries consistent with child abuse were identified and analyzed by race.

RESULTS

Between 2010-2014 and 2016-2017, 798,353 patients were included in NTDB. Suspected child abuse victims (SCA) accounted for 7903 (1%) patients. Of these, 51% were White, 33% Black, 1% Asian, 0.3% Native Hawaiian/Other Pacific Islander, 2% American Indian, and 12% other race. Black patients were disproportionately overrepresented, composing 12% of the US population, but 33% of SCA patients (p < 0.001). Although White SCA patients were more severely injured (ISS 16-24: 20% vs 16%, p < 0.01) and had higher in-hospital mortality (9% vs. 6%, p = 0.01), Black SCA patients were hospitalized longer (7.2 ± 31.4 vs. 6.2 ± 9.9 days, p < 0.01) despite controlling for ISS (1-15: 4. 5.7 ± 35.7 vs. 4.2 ± 6.2 days, p < 0.01). In multivariate regression, Black children continued to have longer lengths of stay despite controlling for ISS and insurance type.

CONCLUSIONS

Utilizing a nationally representative dataset, Black children were disproportionately identified as potential victims of abuse. They were also subjected to longer hospitalizations, despite milder injuries. Further studies are needed to better understand the etiology of the observed trends and whether they reflect potential underlying unconscious or conscious biases of mandated reporters.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

III.

Socioeconomic Factors and Pediatric Injury

Purpose of Review

The goal of this review is to describe how socioeconomic status (SES) is evaluated in the pediatric trauma literature and further consider how differences in SES can lead to inequities in pediatric injury.

Recent Findings

Insurance status, area-level income, and indices of socioeconomic deprivation are the most common assessments of socioeconomic status. Children from socioeconomically disadvantaged backgrounds experience higher rates of firearm-related injuries, motor vehicle-related injuries, and violence-related injuries, contributing to inequities in morbidity and mortality after pediatric injury. Differences in SES may also lead to inequities in post-injury care and recovery, with higher rates of readmission, recidivism, and PTSD for children from socioeconomically disadvantaged backgrounds.

Summary

Additional research looking at family-level measures of SES and more granular measures of neighborhood deprivation are needed. SES can serve as an upstream target for interventions to reduce pediatric injury and narrow the equity gap.

Social determinants of health as drivers of inequities in pediatric injury

A child's social determinants of health (SDH), including their neighborhood environment, insurance status, race and ethnicity, English language proficiency and geographic location, all significantly impact their risk of injury and outcomes after injury. Children from socioeconomically disadvantaged neighborhoods experience overall higher rates of injury and different types of injuries, including higher rates of motor vehicle-, firearm-, and violence-related injuries. Similarly, children with public insurance or no insurance, as a proxy for lower socioeconomic status, experience higher rates of injuries including firearm-related injuries and non-accidental trauma, with overall worse outcomes. Race and associated racism also impact a child's risk of injury and care received after injury. Black children, Hispanic children, and those from other minority groups disproportionately experience socioeconomic disadvantage with sequelae of injury risk as described above. Even after controlling for socioeconomic status, there are still notable disparities with further evidence of racial inequities and bias in pediatric trauma care after injury. Finally, where a child lives geographically also significantly impacts their risk of injury and available care after injury, with differences based on whether a child lives in a rural or urban area and the degree of state laws regarding injury prevention. There are clear inequities based on a child's SDH, most predominantly in a child's risk of injury and the types of injuries they experience. These injuries are preventable and the SDH provide potential upstream targets in injury prevention efforts.

Medicaid Expansion Under the Affordable Care Act and Pediatric Trauma Patient Insurance Coverage

INTRODUCTION

Uninsured pediatric trauma patients are at increased risk of poor outcomes. The impact of the Patient Protection and Affordable Care Act (ACA) on pediatric trauma patients has not been studied. We hypothesized that the expansion of Medicaid coverage under the ACA was associated with increased insurance coverage and improved outcomes.

METHODS

Retrospective review of patients <18 y old presenting to a level 1 pediatric trauma center 2009-2019. An interrupted time series analysis was performed to assess the impact of Medicaid expansion under the ACA in January 2014. The primary outcome was rate of insurance coverage. Secondary outcomes included in-hospital mortality, disposition, 30-day readmission, length of stay (LOS), and intensive care unit (ICU) LOS.

RESULTS

A total of 5645 patients were evaluated, (pre-ACA n = 2,243, post-ACA n = 3402). Expansion of Medicaid was associated with minimal changes on insurance coverage. There a decrease in mortality (RR = 0.96, P = 0.0355) and a slight increase in disposition to a rehabilitation facility (RR = 1.02, P = 0.0341). There was no association with 30-day readmission (RR = 1.02, P = 0.3498). Similarly, expansion of Medicaid was not associated with change in LOS (estimate = -0.00, P = 0.8893). There was a slight decrease in ICU LOS (estimate = -0.03, P < 0.0001).

CONCLUSIONS

Medicaid expansion was associated with marginal changes in insurance coverage among pediatric trauma patients. We did not identify significant impacts on patient outcomes.

Association of health insurance coverage and probability of dying in an emergency department or hospital from a motor vehicle traffic injury

OBJECTIVE

Describe the association of health insurance coverage with the odds of mortality in an emergency department (ED) or hospital for adult victims of a motor vehicle crash.

METHODS

This cross-sectional study pooled and averaged 6 years of data, 2009-2014, from the Nationwide Emergency Department Sample (NEDS). Our analysis was restricted to patients 20-85 years old that were treated in an ED for an injury sustained from a motor vehicle traffic crash (N = 2,203,407 average annual hospital discharges). The outcome variables were whether the motor vehicle crash victim died in the ED or hospital. The predictor variable was health insurance status that was measured as uninsured, Medicare, Medicaid, private insurance, and other health insurance.

RESULTS

Most patients that died had some form of health insurance with less than a quarter classified as uninsured (23%). Nearly half of the patients that died had private insurance (48%) followed by Medicare (13%), Medicaid (9%), and other insurance (8%). Compared to the uninsured, the multivariate adjusted odds ratios (ORs) for death were significantly (P < 0.001) lower for Medicare (OR = 0.83, 95% confidence interval [CI] = 0.76-0.92), Medicaid (OR = 0.76, 95% CI = 0.69-0.84), private insurance (OR = 0.63, 95% CI = 0.58-0.68), and other insurance (OR = O.61, 95% CI = 0.54-0.70).

CONCLUSION

After accounting for hospital and patient characteristics, lack of health insurance was associated with a higher likelihood of death for patients admitted to an ED or hospital for injuries sustained from a motor vehicle crash.

Documentation of drug abuse in the family or household of children admitted to the hospital for non-accidental trauma

BACKGROUND

Drug abuse in the family is known to increase the risk of child abuse, but its impact on outcomes of hospitalizations for non-accidental trauma (NAT) has not been characterized.

OBJECTIVE

We aimed to identify how frequently drug abuse in the household was documented among children with known or suspected NAT, and to correlate drug abuse in the family with hospitalization outcomes.

PARTICIPANTS AND SETTING

At our tertiary care hospital, we retrospectively queried hospital admissions of children ages 0-17 who had a Child Abuse and Neglect consultation ordered during an inpatient stay.

METHODS

Case manager documentation and consult notes from the inpatient response team were used to determine suspected or confirmed presence of household substance abuse.

RESULTS

We identified 185 children meeting inclusion criteria (59 % <1 year; 34 % 1-5 years; 7% 6-14 years of age). Drug abuse in the family was documented in 44 cases (24 %). Among 178 children surviving to discharge, drug abuse was associated with lower likelihood of discharge home (50 % vs. 70 % among children with no documented drug abuse, p = 0.018). After discharge, we found no statistically significant differences in rehospitalizations or emergency department visits according to documentation of drug abuse in the family.

CONCLUSION

Our study addresses the role of family drug abuse in outcomes of hospitalizations for NAT. Significantly, half of cases with suspected or known drug abuse had no prior CPS involvement, and drug abuse was associated with discharge outcomes after controlling for prior CPS involvement.

What Variables Correlate With Different Clinical Outcomes of Abusive Head Injury?

BACKGROUND

The spectrum of injury severity for abusive head trauma (AHT) severity is broad, but outcomes are unequivocally worse than accidental trauma. There are few publications that analyze different outcomes of AHT.

OBJECTIVE

To determine variables associated with different outcomes of AHT.

METHODS

Patients were identified using our AHT database. Three different, but not mutually exclusive, outcomes of AHT were modeled: (1) death or hemispheric stroke (diffuse loss of grey-white differentiation); (2) stroke(s) of any size; and (3) need for a neurosurgical operation. Demographic and clinical variables were collected and correlations to the 3 outcomes of interest were identified using bivariate and multivariable analysis.

RESULTS

From January 2009 to December 2017, 305 children were identified through a prospectively maintained AHT database. These children were typically male (60%), African American (54%), and had public or no insurance (90%). A total of 29 children (9.5%) died or suffered a massive hemispheric stroke, 57 (18.7%) required a neurosurgical operation, and 91 (29.8%) sustained 1 or more stroke. Death or hemispheric stroke was statistically associated with the pupillary exam (odds ratio [OR] = 45.7) and admission international normalized ratio (INR) (OR = 17.3); stroke was associated with the pupillary exam (OR = 13.2), seizures (OR = 14.8), admission hematocrit (OR = 0.92), and INR (9.4), and need for surgery was associated with seizures (OR = 8.6).

CONCLUSION

We have identified several demographic and clinical variables that correlate with 3 clinically applicable outcomes of abusive head injury.

An investigation of social determinants of health and outcomes in pediatric nonaccidental trauma

OBJECTIVES

Nonaccidental trauma (NAT) is a leading cause of pediatric mortality and disability. We examined our institution's experience with NAT to determine if socioeconomic status is correlated with patient outcomes.

METHODS

NAT cases were reviewed retrospectively. Socioeconomic determinants included insurance status and race; outcomes included mortality, discharge disability and disposition. Correlations were identified using t test, Fisher's exact test, and logistic regression.

RESULTS

The cohort comprised of 337 patients, with an overall uninsured rate of 5.6%. This rate was achieved by insuring 64.7% of the cohort after admission. Non-survivors were more likely to have no insurance coverage (14.8% versus 4.8%, p = 0.041). Regression revealed that uninsured had 8 times (95% CI 1.7-38.7, p = 0.008) higher in-hospital mortality than those with insurance when controlling for injury severity. Additionally, injury severity score ≥ 15, transfer from outside hospital, need for ICU or operative treatment were predictive of mortality. Adjusted risk factors for severe disability at discharge did not include insurance status or race, while ISS ≥ 15 and ICU stay were predictive.

CONCLUSIONS

There are significant associations of insurance status with pediatric NAT outcomes, highlighting that determinants other than disease severity may influence mortality and morbidity. High-risk patients should be identified to develop strategies to improve outcomes.