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Maholtz D, Page-Goertz CK, Forbes ML, Nofziger RA, Bigham M, McKee B, Ramgopal S, Pelletier JH. Association Between the COI and Excess Health Care Utilization and Costs for ACSC. Hosp Pediatr 2024; 14:592-601. [PMID: 38919989 DOI: 10.1542/hpeds.2023-007526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 02/09/2024] [Indexed: 06/27/2024]
Abstract
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.
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Affiliation(s)
- Danielle Maholtz
- Division of Critical Care Medicine, Department of Pediatrics
- Department of Pediatrics, Northeast Ohio Medical University College of Medicine, Rootstown, Ohio
| | - Christopher K Page-Goertz
- Division of Critical Care Medicine, Department of Pediatrics
- Department of Pediatrics, Northeast Ohio Medical University College of Medicine, Rootstown, Ohio
| | - Michael L Forbes
- Division of Critical Care Medicine, Department of Pediatrics
- Rebecca D. Considine Research Institute, Akron Children's Hospital, Akron, Ohio
- Department of Pediatrics, Northeast Ohio Medical University College of Medicine, Rootstown, Ohio
| | - Ryan A Nofziger
- Division of Critical Care Medicine, Department of Pediatrics
- Department of Pediatrics, Northeast Ohio Medical University College of Medicine, Rootstown, Ohio
| | - Michael Bigham
- Division of Critical Care Medicine, Department of Pediatrics
- Department of Pediatrics, Northeast Ohio Medical University College of Medicine, Rootstown, Ohio
| | - Bryan McKee
- Division of Critical Care Medicine, Department of Pediatrics
- Department of Pediatrics, Northeast Ohio Medical University College of Medicine, Rootstown, Ohio
| | - Sriram Ramgopal
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jonathan H Pelletier
- Division of Critical Care Medicine, Department of Pediatrics
- Department of Pediatrics, Northeast Ohio Medical University College of Medicine, Rootstown, Ohio
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Alizadeh F, Gauvreau K, Barreto JA, Hall M, Bucholz E, Nathan M, Newburger JW, Vitali S, Thiagarajan RR, Chan T, Moynihan KM. Child Opportunity Index and Pediatric Extracorporeal Membrane Oxygenation Outcomes; the Role of Diagnostic Category. Crit Care Med 2024:00003246-990000000-00351. [PMID: 38920540 DOI: 10.1097/ccm.0000000000006358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
OBJECTIVES To study the impact of social determinants of health (SDoH) on pediatric extracorporeal membrane oxygenation (ECMO) outcomes. DESIGN, SETTING, AND PATIENTS Retrospective study of children (< 18 yr) supported on ECMO (October 1, 2015 to March 1, 2021) using Pediatric Health Information System (44 U.S. children's hospitals). Patients were divided into five diagnostic categories: neonatal cardiac, pediatric cardiac, neonatal respiratory, pediatric respiratory, and sepsis. SDoH included the Child Opportunity Index (COI; higher indicates social advantage), race, ethnicity, payer, and U.S. region. Children without COI were excluded. Diagnostic category-specific clinical variables related to baseline health and illness severity were collected. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Children supported on ECMO experienced a 33% in-hospital mortality (2863/8710). Overall, children with lower COI, "other" race, Hispanic ethnicity, public insurance and from South or West regions had greater mortality. Associations between SDoH and ECMO outcomes differed between diagnostic cohorts. Bivariate analyses found that only pediatric cardiac patients had an association between COI or race and mortality. Multivariable logistic regression analyses examined relationships between SDoH, clinical variables and mortality within diagnostic categories. Pediatric cardiac patients had 5% increased odds of death (95% CI, 1.01-1.09) for every 10-point decrement in COI, while Hispanic ethnicity was associated with higher survival (adjusted odds ratio [aOR] 0.72 [0.57-0.89]). Children with heart disease from the highest COI quintile had less cardiac-surgical complexity and earlier cannulation. Independent associations with mortality were observed in sepsis for Black race (aOR 1.62 [1.06-2.47]) and other payer in pediatric respiratory patients (aOR 1.94 [1.23-3.06]). CONCLUSIONS SDoH are statistically associated with pediatric ECMO outcomes; however, associations differ between diagnostic categories. Influence of COI was observed only in cardiac patients while payer, race, and ethnicity results varied. Further research should investigate differences between diagnostic cohorts and age groups to understand drivers of inequitable outcomes.
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Affiliation(s)
- Faraz Alizadeh
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Jessica A Barreto
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Matt Hall
- Children's Hospital Association, Lenexa, KS
| | - Emily Bucholz
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Sally Vitali
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Anesthesia, Harvard Medical School, Boston, MA
| | - Ravi R Thiagarajan
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Titus Chan
- The Heart Center, Seattle Children's Hospital, Seattle, WA
- Department of Pediatrics, University of Washington, Seattle, WA
| | - Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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3
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Lenz KB, McDade J, Petrozzi M, Dervan LA, Beckstead R, Banks RK, Reeder RW, Meert KL, Zimmerman J, Killien EY. Social Determinants of Health and Health-Related Quality of Life following Pediatric Septic Shock: Secondary Analysis of the Life After Pediatric Sepsis Evaluation Dataset, 2014-2017. Pediatr Crit Care Med 2024:00130478-990000000-00353. [PMID: 38836691 DOI: 10.1097/pcc.0000000000003550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
OBJECTIVES Social determinants of health (SDOH) are associated with disparities in disease severity and in-hospital outcomes among critically ill children. It is unknown whether SDOH are associated with later outcomes. We evaluated associations between SDOH measures and mortality, new functional morbidity, and health-related quality of life (HRQL) decline among children surviving septic shock. DESIGN Secondary analysis of the Life After Pediatric Sepsis Evaluation (LAPSE) prospective cohort study was conducted between 2014 and 2017. SETTING Twelve academic U.S. PICUs were involved in the study. PATIENTS Children younger than 18 years with community-acquired septic shock were involved in the study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We assessed associations between race, ethnicity, income, education, marital status, insurance, language, and home U.S. postal code with day 28 mortality, new functional morbidity at discharge per day 28, and HRQL decline using logistic regression. Of 389 patients, 32% (n = 98) of families had household income less than $50,000 per year. Median Pediatric Risk of Mortality (PRISM) score was 11 (interquartile range 6, 17). We found that English language and Area Deprivation Index less than 50th percentile were associated with higher PRISM scores. Mortality was 6.7% (n = 26), new functional morbidity occurred in 21.8% (n = 78) of patients, and HRQL decline by greater than 10% occurred in 31.0% of patients (n = 63). We failed to identify any association between SDOH measures and mortality, new functional morbidity, or HRQL decline. We are unable to exclude the possibility that annual household income greater than or equal to $50,000 was associated with up to 81% lesser odds of mortality and, in survivors, more than three-fold greater odds of HRQL decline by greater than 10%. CONCLUSIONS In this secondary analysis of the 2014-2017 LAPSE dataset, we failed to identify any association between SDOH measures and in-hospital or postdischarge outcomes following pediatric septic shock. This finding may be reflective of the high illness severity and single disease (sepsis) of the cohort, with contribution of clinical factors to functional and HRQL outcomes predominating over prehospital and posthospital SDOH factors.
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Affiliation(s)
- Kyle B Lenz
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
| | - Jessica McDade
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
| | - Mariagrazia Petrozzi
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
| | - Leslie A Dervan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
| | - Rylee Beckstead
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Russell K Banks
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Ron W Reeder
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Kathleen L Meert
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Jerry Zimmerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
| | - Elizabeth Y Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
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Tasker RC. Editor's Choice Articles for June. Pediatr Crit Care Med 2024; 25:489-492. [PMID: 38836708 DOI: 10.1097/pcc.0000000000003530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Affiliation(s)
- Robert C Tasker
- orcid.org/0000-0003-3647-8113
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Selwyn College, Cambridge University, Cambridge, United Kingdom
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5
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Grunwell JR, Mutic AD, Ezhuthachan ID, Mason C, Tidwell M, Caldwell C, Norwood J, Zack S, Jordan N, Fitzpatrick AM. Environmental Injustice Is Associated With Poorer Asthma Outcomes in School-Age Children With Asthma in Metropolitan Atlanta, Georgia. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1263-1272.e1. [PMID: 38378096 PMCID: PMC11081836 DOI: 10.1016/j.jaip.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 02/10/2024] [Accepted: 02/12/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Environmental justice mandates that no person suffers disproportionately from environmental exposures. The Environmental Justice Index (EJI) provides an estimate of the environmental burden for each census tract but has not yet been used in asthma populations. OBJECTIVE We hypothesized that children from census tracts with high environmental injustice determined by the EJI would have a greater burden of asthma exacerbations, poorer asthma control, and poorer lung function over 12 months. METHODS Children aged 6 to 18 years with asthma (N = 575) from metropolitan Atlanta, Georgia, completed a baseline research visit. Participant addresses were geocoded to obtain the EJI Social-Environmental Ranking for each participant's census tract, which was divided into tertiles. Medical records were reviewed for 12 months for asthma exacerbations. A subset of participants completed a second research visit involving spirometry and questionnaires. RESULTS Census tracts with the greatest environmental injustice had more racial and ethnic minorities, lower socioeconomic status, more hazardous exposures (particularly to airborne pollutants), and greater proximity to railroads and heavily trafficked roadways. Children with asthma residing in high injustice census tracts had a longer duration of asthma, greater historical asthma-related health care utilization, poorer asthma symptom control and quality of life, and more impaired lung function. By 12 months, children from high injustice census tracts also had more asthma exacerbations with a shorter time to exacerbation and persistently more symptoms, poorer asthma control, and reduced lung function. CONCLUSIONS Disparities in environmental justice are present in metropolitan Atlanta that may contribute to asthma outcomes in children. These findings require an additional study and action to improve health equity.
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Affiliation(s)
- Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Abby D Mutic
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Ga
| | - Idil D Ezhuthachan
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Allergy and Immunology, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Carrie Mason
- Division of Pulmonary Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Mallory Tidwell
- Division of Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Cherish Caldwell
- Division of Pulmonary Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jalicae Norwood
- Division of Pulmonary Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Sydney Zack
- Division of Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Natalie Jordan
- Division of Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Pulmonary Medicine, Children's Healthcare of Atlanta, Atlanta, Ga.
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6
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Andrist E, Clarke RG, Phelps KB, Dews AL, Rodenbough A, Rose JA, Zurca AD, Lawal N, Maratta C, Slain KN. Understanding Disparities in the Pediatric ICU: A Scoping Review. Pediatrics 2024; 153:e2023063415. [PMID: 38639640 DOI: 10.1542/peds.2023-063415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2024] [Indexed: 04/20/2024] Open
Abstract
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.
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Affiliation(s)
- Erica Andrist
- Division of Pediatric Critical Care Medicine
- Departments of Pediatrics
| | - Rachel G Clarke
- Division of Pediatric Critical Care Medicine, Upstate University Hospital, Syracuse, New York
- Center for Bioethics and Humanities, SUNY Upstate Medical University, Syracuse, New York
| | - Kayla B Phelps
- Division of Pediatric Critical Care Medicine, Louisiana State University Health Sciences Center, Children's Hospital of New Orleans, New Orleans, Louisiana
| | - Alyssa L Dews
- Human Genetics, University of Michigan Medical School, Ann Arbor, Michigan
- Susan B. Meister Child Health and Adolescent Research Center, University of Michigan, Ann Arbor, Michigan
| | - Anna Rodenbough
- Division of Pediatric Critical Care Medicine, Children's Hospital of Atlanta, Atlanta, Georgia
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Jerri A Rose
- Pediatric Emergency Medicine
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Adrian D Zurca
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Nurah Lawal
- Stepping Stones Pediatric Palliative Care Program, C.S. Mott Children's Hospital, Ann Arbor, Michigan
- Departments of Pediatrics
| | - Christina Maratta
- Department of Critical Care, The Hospital for Sick Children, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Katherine N Slain
- Pediatric Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Bush A, Byrnes CA, Chan KC, Chang AB, Ferreira JC, Holden KA, Lovinsky-Desir S, Redding G, Singh V, Sinha IP, Zar HJ. Social determinants of respiratory health from birth: still of concern in the 21st century? Eur Respir Rev 2024; 33:230222. [PMID: 38599675 PMCID: PMC11004769 DOI: 10.1183/16000617.0222-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 01/20/2024] [Indexed: 04/12/2024] Open
Abstract
Respiratory symptoms are ubiquitous in children and, even though they may be the harbinger of poor long-term outcomes, are often trivialised. Adverse exposures pre-conception, antenatally and in early childhood have lifetime impacts on respiratory health. For the most part, lung function tracks from the pre-school years at least into late middle age, and airflow obstruction is associated not merely with poor respiratory outcomes but also early all-cause morbidity and mortality. Much would be preventable if social determinants of adverse outcomes were to be addressed. This review presents the perspectives of paediatricians from many different contexts, both high and low income, including Europe, the Americas, Australasia, India, Africa and China. It should be noted that there are islands of poverty within even the highest income settings and, conversely, opulent areas in even the most deprived countries. The heaviest burden of any adverse effects falls on those of the lowest socioeconomic status. Themes include passive exposure to tobacco smoke and indoor and outdoor pollution, across the entire developmental course, and lack of access even to simple affordable medications, let alone the new biologicals. Commonly, disease outcomes are worse in resource-poor areas. Both within and between countries there are avoidable gross disparities in outcomes. Climate change is also bearing down hardest on the poorest children. This review highlights the need for vigorous advocacy for children to improve lifelong health. It also highlights that there are ongoing culturally sensitive interventions to address social determinants of disease which are already benefiting children.
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Affiliation(s)
- Andrew Bush
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, London, UK
| | - Catherine A Byrnes
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Starship Children's Health and Kidz First Hospital, Auckland, New Zealand
| | - Kate C Chan
- Department of Paediatrics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Anne B Chang
- School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane and Menzies School of Health Research, Darwin, Australia
| | - Juliana C Ferreira
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Karl A Holden
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Stephanie Lovinsky-Desir
- Department of Pediatrics and Environmental Health Sciences, Columbia University Medical Center, New York, NY, USA
| | - Gregory Redding
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Varinder Singh
- Department of Pediatrics, Lady Hardinge Medical College and Kalawati Saran Children's Hospital, New Delhi, India
| | - Ian P Sinha
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Heather J Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital and SA-MRC Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
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8
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McCrory MC, Akande M, Slain KN, Kennedy CE, Winter MC, Stottlemyre MG, Wakeham MK, Barnack KA, Huang JX, Sharma M, Zurca AD, Pinto NP, Dziorny AC, Maddux AB, Garg A, Woodruff AG, Hartman ME, Timmons OD, Heidersbach RS, Cisco MJ, Sochet AA, Wells BJ, Halvorson EE, Saha AK. Child Opportunity Index and Pediatric Intensive Care Outcomes: A Multicenter Retrospective Study in the United States. Pediatr Crit Care Med 2024; 25:323-334. [PMID: 38088770 DOI: 10.1097/pcc.0000000000003427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
OBJECTIVES To evaluate for associations between a child's neighborhood, as categorized by Child Opportunity Index (COI 2.0), and 1) PICU mortality, 2) severity of illness at PICU admission, and 3) PICU length of stay (LOS). DESIGN Retrospective cohort study. SETTING Fifteen PICUs in the United States. PATIENTS Children younger than 18 years admitted from 2019 to 2020, excluding those after cardiac procedures. Nationally-normed COI category (very low, low, moderate, high, very high) was determined for each admission by census tract, and clinical features were obtained from the Virtual Pediatric Systems LLC (Los Angeles, CA) data from each site. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among 33,901 index PICU admissions during the time period, median patient age was 4.9 years and PICU mortality was 2.1%. There was a higher percentage of admissions from the very low COI category (27.3%) than other COI categories (17.2-19.5%, p < 0.0001). Patient admissions from the high and very high COI categories had a lower median Pediatric Index of Mortality 3 risk of mortality (0.70) than those from the very low, low, and moderate COI groups (0.71) ( p < 0.001). PICU mortality was lowest in the very high (1.7%) and high (1.9%) COI groups and highest in the moderate group (2.5%), followed by very low (2.3%) and low (2.2%) ( p = 0.001 across categories). Median PICU LOS was between 1.37 and 1.50 days in all COI categories. Multivariable regression revealed adjusted odds of PICU mortality of 1.30 (95% CI, 0.94-1.79; p = 0.11) for children from a very low versus very high COI neighborhood, with an odds ratio [OR] of 0.996 (95% CI, 0.993-1.00; p = 0.05) for mortality for COI as an ordinal value from 0 to 100. Children without insurance coverage had an OR for mortality of 3.58 (95% CI, 2.46-5.20; p < 0.0001) as compared with those with commercial insurance. CONCLUSIONS Children admitted to a cohort of U.S. PICUs were often from very low COI neighborhoods. Children from very high COI neighborhoods had the lowest risk of mortality and observed mortality; however, odds of mortality were not statistically different by COI category in a multivariable model. Children without insurance coverage had significantly higher odds of PICU mortality regardless of neighborhood.
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Affiliation(s)
- Michael C McCrory
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Manzilat Akande
- Pediatrics, Oklahoma University Health Sciences Center, Oklahoma City, OK
| | - Katherine N Slain
- Pediatrics, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH
| | | | - Meredith C Winter
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | | | - Kyle A Barnack
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Jia Xin Huang
- Pediatrics, University of California San Francisco, UCSF Benioff Children's Hospital Oakland, Oakland, CA
- Pediatrics, University of California San Francisco, UCSF Benioff Children's Hospital San Francisco, San Francisco, CA
| | - Meesha Sharma
- Pediatrics, University of California San Francisco, UCSF Benioff Children's Hospital Oakland, Oakland, CA
- Pediatrics, University of California San Francisco, UCSF Benioff Children's Hospital San Francisco, San Francisco, CA
| | - Adrian D Zurca
- Pediatrics, Northwestern University Feinberg School of Medicine and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Neethi P Pinto
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Adam C Dziorny
- Pediatrics, University of Rochester School of Medicine, Rochester, NY
| | - Aline B Maddux
- Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Anjali Garg
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Johns Hopkins Charlotte Bloomberg Children's Center, Baltimore, MD
| | - Alan G Woodruff
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Mary E Hartman
- Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Otwell D Timmons
- Pediatrics, Atrium Health Levine Children's Hospital, Charlotte, NC
| | - R Scott Heidersbach
- Pediatrics, University of California San Francisco, UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | - Michael J Cisco
- Pediatrics, University of California San Francisco, UCSF Benioff Children's Hospital San Francisco, San Francisco, CA
| | - Anthony A Sochet
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Brian J Wells
- Department of Biostatistics and Data Science; Wake Forest University School of Medicine, Winston-Salem, NC
| | - Elizabeth E Halvorson
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Amit K Saha
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC
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9
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Webb LV, Evans J, Smith V, Pettibone E, Tofil J, Hicks JF, Green S, Nassel A, Loberger JM. Sociodemographic Factors are Associated with Care Delivery and Outcomes in Pediatric Severe Sepsis. Crit Care Explor 2024; 6:e1056. [PMID: 38415020 PMCID: PMC10896474 DOI: 10.1097/cce.0000000000001056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024] Open
Abstract
IMPORTANCE Sepsis is a leading cause of morbidity and mortality in the United States and disparate outcomes exist between racial/ethnic groups despite improvements in sepsis management. These observed differences are often related to social determinants of health (SDoH). Little is known about the role of SDoH on outcomes in pediatric sepsis. OBJECTIVE This study examined the differences in care delivery and outcomes in children with severe sepsis based on race/ethnicity and neighborhood context (as measured by the social vulnerability index). DESIGN SETTING AND PARTICIPANTS This retrospective, cross-sectional study was completed in a quaternary care children's hospital. Patients 18 years old or younger who were admitted between May 1, 2018, and February 28, 2022, met the improving pediatric sepsis outcomes (IPSO) collaborative definition for severe sepsis. Composite measures of social vulnerability, care delivery, and clinical outcomes were stratified by race/ethnicity. MAIN OUTCOMES AND MEASURES The primary outcome of interest was admission to the PICU. Secondary outcomes were sepsis recognition and early goal-directed therapy (EGDT). RESULTS A total of 967 children met the criteria for IPSO-defined severe sepsis, of whom 53.4% were White/non-Hispanic. Nearly half of the cohort (48.7%) required PICU admission. There was no difference in illness severity at PICU admission by race (1.01 vs. 1.1, p = 0.18). Non-White race/Hispanic ethnicity was independently associated with PICU admission (odds ratio [OR] 1.35 [1.01-1.8], p = 0.04). Although social vulnerability was not independently associated with PICU admission (OR 0.95 [0.59-1.53], p = 0.83), non-White children were significantly more likely to reside in vulnerable neighborhoods (0.66 vs. 0.38, p < 0.001). Non-White race was associated with lower sepsis recognition (87.8% vs. 93.6%, p = 0.002) and less EGDT compliance (35.7% vs. 42.8%, p = 0.024). CONCLUSIONS AND RELEVANCE Non-White race/ethnicity was independently associated with PICU admission. Differences in care delivery were also identified. Prospective studies are needed to further investigate these findings.
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Affiliation(s)
- Lece V Webb
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Jakob Evans
- Department of Pediatrics, Pediatrics Residency Program, University of Alabama at Birmingham, Birmingham, AL
| | - Veronica Smith
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Elisabeth Pettibone
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | | | - Jessica Floyd Hicks
- Performance Improvement and Accreditation Department, Children's of Alabama, Birmingham, AL
| | - Sherry Green
- Performance Improvement and Accreditation Department, Children's of Alabama, Birmingham, AL
| | - Ariann Nassel
- Lister Hill Center for Health Policy, School of Public Health, University of Alabama at Birmingham, AL
| | - Jeremy M Loberger
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
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10
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Garg A, Sochet AA, Hernandez R, Stockwell DC. Association of the Child Opportunity Index and Inpatient Illness Severity in the United States, 2018-2019. Acad Pediatr 2023:S1876-2859(23)00473-4. [PMID: 38159600 PMCID: PMC11211241 DOI: 10.1016/j.acap.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE Children residing in impoverished neighborhoods have reduced access to health care resources. Our objective was to identify potential associations between Child Opportunity Index (COI), a composite score of neighborhood characteristics, and inpatient severity of illness and clinical trajectory among United States (US) children. METHODS This retrospective cohort study assessed data using the Pediatric Health Information System Registry from 2018 to 2019. Primary exposure variable was COI level (range: very low [CO1 1], low [COI 2], moderate [COI 3], high [COI 4], and very high [COI 5]). Markers of inpatient clinical severity included index mortality, Pediatric Intensive Care Unit (PICU) admission, invasive mechanical ventilation (IMV), and hospital length of stay (LOS). Subgroup analysis of COI and clinical outcome variation by United States Census Geographic Regions was conducted. Adjusted regression analysis was utilized to understand associations between COI and inpatient clinical severity outcomes. RESULTS Of the 132,130 encounters, 44% resided in very low or low COI neighborhoods. In adjusted models, very low COI was associated with increased mortality (aOR: 1.35, 95% CI: 1.05-1.74, P = .018), PICU admission (aOR: 1.06, 95% CI: 1.02-1.11, P = 0.014), IMV (aOR: 1.12, 95% CI: 1.04-1.21, P = .002), and higher hospital LOS (P = .045). Regional variation by COI depicted the East North Central region having the highest rate of mortality (20.5%), P < .001, and PICU admissions (23%), P = .014. CONCLUSIONS Our multicenter, retrospective study highlights the interaction between neighborhood-level deprivation and worsened health disparities, indicating a need for prospective study.
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Affiliation(s)
- Anjali Garg
- Department of Anesthesia and Critical Care Medicine (A Garg, AA Sochet, and DC Stockwell), Johns Hopkins School of Medicine, Baltimore, Md.
| | - Anthony A Sochet
- Department of Anesthesia and Critical Care Medicine (A Garg, AA Sochet, and DC Stockwell), Johns Hopkins School of Medicine, Baltimore, Md; Department of Medicine (AA Sochet), Divisions of Pediatrics, Johns Hopkins All Children's Hospital Institute for Clinical and Translational Research, St. Petersburg, Fla
| | - Raquel Hernandez
- Pediatric Critical Care Medicine and Pediatrics (R Hernandez), Johns Hopkins All Children's Hospital Institute for Clinical and Translational Research, St. Petersburg, Fla; Department of Pediatrics (R Hernandez), Johns Hopkins University School of Medicine, Baltimore, Md
| | - David C Stockwell
- Department of Anesthesia and Critical Care Medicine (A Garg, AA Sochet, and DC Stockwell), Johns Hopkins School of Medicine, Baltimore, Md
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11
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Myers CN, Chandran A, Psoter KJ, Bergmann JP, Galiatsatos P. Indicators of Neighborhood-Level Socioeconomic Position and Pediatric Critical Illness. Chest 2023; 164:1434-1443. [PMID: 37487988 PMCID: PMC10925544 DOI: 10.1016/j.chest.2023.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 06/21/2023] [Accepted: 07/06/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND With recent prioritization of equity in pediatric health outcomes, a shift to examine neighborhood-level health care disparities within pediatric populations has occurred, specifically in the context of critical illness. RESEARCH QUESTION Does an association exist between individual indicators of neighborhood-level disadvantage and incidence of PICU admission? STUDY DESIGN AND METHODS Pediatric patients younger than 18 years admitted to a PICU in a large urban tertiary pediatric hospital from January 1, 2016, through December 31, 2019, with a residential address in the city of Baltimore or Baltimore County on the day of admission were included in this ecological study. Demographic and clinical characteristics of children admitted to the PICU were summarized, with the primary outcome being PICU admission. Unadjusted negative binomial regression was used to examine the association between census tract-level PICU admissions and the previously described census tract-level indicators of neighborhood socioeconomic position. Regression models included an offset term for the population younger than 18 years for each census tract; results of models are reported as incidence rate ratios (IRRs) with corresponding 95% CIs. RESULTS We identified 2,476 PICU admissions: 1,351 patients from the city of Baltimore (10.25 per 1,000 children) and 1,125 patients from Baltimore County (6.31 per 1,000 children). Most PICU admissions (n = 906 [68%]) for the city of Baltimore represented an area deprivation index (ADI) of > 60, whereas most Baltimore County PICU admissions (n = 919 [82.3%]) represented an ADI of < 60. At the neighborhood level, the percentage of families living below the poverty line was associated with greater incidence of PICU admission in the city of Baltimore (IRR, 1.09; 95% CI, 1.00-1.18) and Baltimore County (IRR, 1.19; 95% CI, 1.05-1.36). For every $10,000 increase in median household income, PICU admission rates dropped by 9% for the city of Baltimore (IRR, 0.91; 95% CI, 0.86-0.95) and Baltimore County (IRR, 0.91; 95% CI, 0.88-0.94). Neighborhoods with vacant housing units also were associated with a higher incidence of PICU admission in the city of Baltimore (IRR, 1.10; 95% CI, 1.01-1.21) and Baltimore County (IRR, 1.46; 95% CI, 1.21-1.77), as was a 10% increase in occupied homes without vehicles (city of Baltimore: IRR, 1.14; 95% CI, 1.07-1.21; Baltimore County: IRR, 1.23; 95% CI, 1.11-1.37). INTERPRETATION Health outcomes of pediatric critical illness should be examined in the context of structural determinants of health, including neighborhood-level and environmental characteristics.
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Affiliation(s)
- Carlie N Myers
- Division of Critical Care Medicine, Cincinnati Children's Hospital, Cincinnati, OH; University of Cincinnati School of Medicine, Cincinnati, OH.
| | - Aruna Chandran
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins School of Medicine, Baltimore, MD
| | - Kevin J Psoter
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Jules P Bergmann
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins School of Medicine, Baltimore, MD
| | - Panagis Galiatsatos
- Department of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
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12
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Shanahan KH, James P, Rifas-Shiman SL, Gold DR, Oken E, Aris IM. Neighborhood Conditions and Resources in Mid-Childhood and Dampness and Pests at Home in Adolescence. J Pediatr 2023; 262:113625. [PMID: 37463640 PMCID: PMC10789911 DOI: 10.1016/j.jpeds.2023.113625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 06/05/2023] [Accepted: 07/11/2023] [Indexed: 07/20/2023]
Abstract
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.
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Affiliation(s)
- Kristen H Shanahan
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA.
| | - Peter James
- Division of Chronic Disease Research Across the Lifecourse, Department of Population Medicine, Harvard Medical School, Harvard University and Harvard Pilgrim Health Care Institute, Boston, MA; Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Sheryl L Rifas-Shiman
- Division of Chronic Disease Research Across the Lifecourse, Department of Population Medicine, Harvard Medical School, Harvard University and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Diane R Gold
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA; Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA; Department of Medicine, Harvard Medical School, Boston, MA
| | - Emily Oken
- Division of Chronic Disease Research Across the Lifecourse, Department of Population Medicine, Harvard Medical School, Harvard University and Harvard Pilgrim Health Care Institute, Boston, MA; Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Izzuddin M Aris
- Division of Chronic Disease Research Across the Lifecourse, Department of Population Medicine, Harvard Medical School, Harvard University and Harvard Pilgrim Health Care Institute, Boston, MA
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13
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Fitzpatrick AM, Lee T, Vickery BP, Corace EA, Mason C, Norwood J, Caldwell C, Grunwell JR. Social determinants of health influence preschool and caregiver experiences during symptoms and exacerbations of wheezing. Ann Allergy Asthma Immunol 2023; 131:75-81.e3. [PMID: 37100275 PMCID: PMC10330199 DOI: 10.1016/j.anai.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/28/2023] [Accepted: 04/14/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Social determinants of health have been inadequately studied in preschool children with wheezing and their caregivers but may influence the care received. OBJECTIVE To evaluate the symptom and exacerbation experiences of wheezing preschool children and their caregivers, stratified by risk of social vulnerability, over 1 year of longitudinal follow-up. METHODS A total of 79 caregivers and their preschool children with recurrent wheezing and at least 1 exacerbation in the previous year were stratified by a composite measure of social vulnerability into "low" (N = 19), "intermediate" (N = 27), and "high" (N = 33) risk groups. Outcome measures at the follow-up visits included child respiratory symptom scores, asthma control, caregiver-reported outcome measures of mental and social health, exacerbations, and health care utilization. The severity of exacerbations reflected by symptom scores and albuterol use and exacerbation-related caregiver quality of life were also assessed. RESULTS Preschool children at high risk of social vulnerability had greater day-to-day symptom severity and more severe symptoms during acute exacerbations. High-risk caregivers were also distinguished by lower general life satisfaction at all visits and lower global and emotional quality of life during acute exacerbations which did not improve with exacerbation resolution. Rates of exacerbation or emergency department visits did not differ, but intermediate- and high-risk families were significantly less likely to seek unscheduled outpatient care. CONCLUSION Social determinants of health influence wheezing outcomes in preschool children and their caregivers. These findings argue for routine assessment of social determinants of health during medical encounters and tailored interventions in high-risk families to promote health equity and improve respiratory outcomes.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia.
| | - Tricia Lee
- Department of Pediatrics, Emory University, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Brian P Vickery
- Department of Pediatrics, Emory University, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | - Carrie Mason
- Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | | | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia
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14
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Fitzpatrick AM, Diani B, Kavalieratos D, Corace EA, Mason C, Van Dresser M, Grunwell JR. Poorer Caregiver Mental and Social Health Is Associated With Worse Respiratory Outcomes in Preschool Children With Recurrent Wheezing. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1814-1822. [PMID: 36868472 PMCID: PMC10258161 DOI: 10.1016/j.jaip.2023.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/17/2023] [Accepted: 02/21/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND Mental and social health in caregivers of preschool children has been inadequately studied, but it may influence respiratory symptom recognition and management. OBJECTIVE To identify preschool caregivers at highest risk for poor mental and social health outcomes on the basis of patient-reported outcome measures. METHODS Female caregivers 18 to 50 years old (N = 129) with a preschool child aged 12 to 59 months with recurrent wheezing and at least 1 exacerbation in the previous year completed 8 validated patient-reported outcome measures of mental and social health. k-means cluster analysis was performed using the T score for each instrument. Caregiver/child dyads were followed for 6 months. Primary outcomes included caregiver quality of life and wheezing episodes in their preschool children. RESULTS Three clusters of caregivers were identified: low risk (n = 38), moderate risk (n = 56), and high risk (n = 35). The high-risk cluster had the lowest life satisfaction, meaning and purpose, and emotional support and the highest social isolation, depression, anger, perceived stress, and anxiety that persisted for more than 6 months. This cluster had the poorest quality of life and marked disparities in social determinants of health. Preschool children from caregivers in the high-risk cluster had more frequent respiratory symptoms and a higher occurrence of any wheezing episode, but a lower outpatient physician utilization for wheezing management. CONCLUSIONS Caregiver mental and social health is associated with respiratory outcomes in preschool children. Routine assessment of mental and social health in caregivers is warranted to promote health equity and improve wheezing outcomes in preschool children.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga.
| | - Badiallo Diani
- Department of Biomedical Engineering, Emory University, Atlanta, Ga; Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Ga
| | - Dio Kavalieratos
- Department of Family and Preventative Medicine, Emory University, Atlanta, Ga
| | | | | | | | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga
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15
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Salazar EG, Montoya-Williams D, Passarella M, McGann C, Paul K, Murosko D, Peña MM, Ortiz R, Burris HH, Lorch SA, Handley SC. County-Level Maternal Vulnerability and Preterm Birth in the US. JAMA Netw Open 2023; 6:e2315306. [PMID: 37227724 PMCID: PMC10214038 DOI: 10.1001/jamanetworkopen.2023.15306] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/11/2023] [Indexed: 05/26/2023] Open
Abstract
Importance Appreciation for the effects of neighborhood conditions and community factors on perinatal health is increasing. However, community-level indices specific to maternal health and associations with preterm birth (PTB) have not been assessed. Objective To examine the association of the Maternal Vulnerability Index (MVI), a novel county-level index designed to quantify maternal vulnerability to adverse health outcomes, with PTB. Design, Setting, and Participants This retrospective cohort study used US Vital Statistics data from January 1 to December 31, 2018. Participants included 3 659 099 singleton births at 22 plus 0/7 to 44 plus 6/7 weeks of gestation born in the US. Analyses were conducted from December 1, 2021, through March 31, 2023. Exposure The MVI, a composite measure of 43 area-level indicators, categorized into 6 themes reflecting physical, social, and health care landscapes. Overall MVI and theme were stratified by quintile (very low to very high) by maternal county of residence. Main Outcomes and Measures The primary outcome was PTB (gestational age <37 weeks). Secondary outcomes were PTB categories: extreme (gestational age ≤28 weeks), very (gestational age 29-31 weeks), moderate (gestational age 32-33 weeks), and late (gestational age 34-36 weeks). Multivariable logistic regression quantified associations of MVI, overall and by theme, with PTB, overall and by PTB category. Results Among 3 659 099 births, 298 847 (8.2%) were preterm (male, 51.1%; female, 48.9%). Maternal race and ethnicity included 0.8% American Indian or Alaska Native, 6.8% Asian or Pacific Islander, 23.6% Hispanic, 14.5% non-Hispanic Black, 52.1% non-Hispanic White, and 2.2% with more than 1 race. Compared with full-term births, MVI was higher for PTBs across all themes. Very high MVI was associated with increased PTB in unadjusted (odds ratio [OR], 1.50 [95% CI, 1.45-1.56]) and adjusted (OR, 1.07 [95% CI, 1.01-1.13]) analyses. In adjusted analyses of PTB categories, MVI had the largest association with extreme PTB (adjusted OR, 1.18 [95% CI, 1.07-1.29]). Higher MVI in the themes of physical health, mental health and substance abuse, and general health care remained associated with PTB overall in adjusted models. While the physical health and socioeconomic determinant themes were associated with extreme PTB, physical health, mental health and substance abuse, and general health care themes were associated with late PTB. Conclusions and Relevance The findings of this cohort study suggest that MVI was associated with PTB even after adjustment for individual-level confounders. The MVI is a useful measure for county-level PTB risk that may have policy implications for counties working to lower preterm rates and improve perinatal outcomes.
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Affiliation(s)
- Elizabeth G. Salazar
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Diana Montoya-Williams
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Molly Passarella
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Carolyn McGann
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kathryn Paul
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Daria Murosko
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michelle-Marie Peña
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
- Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Robin Ortiz
- Department of Pediatrics, Institute for Excellence in Health Equity, NYU Grossman School of Medicine, New York, New York
- Department of Population Health, Institute for Excellence in Health Equity, NYU Grossman School of Medicine, New York, New York
| | - Heather H. Burris
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott A. Lorch
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sara C. Handley
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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16
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Menon K, Sorce LR, Argent A, Bennett TD, Carrol ED, Kissoon N, Sanchez-Pinto LN, Schlapbach LJ, de Souza DC, Watson RS, Wynn JL, Zimmerman JJ, Ranjit S. Reporting of Social Determinants of Health in Pediatric Sepsis Studies. Pediatr Crit Care Med 2023; 24:301-310. [PMID: 36696549 PMCID: PMC10332854 DOI: 10.1097/pcc.0000000000003184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Standardized, consistent reporting of social determinants of health (SDOH) in studies on children with sepsis would allow for: 1) understanding the association of SDOH with illness severity and outcomes, 2) comparing populations and extrapolating study results, and 3) identification of potentially modifiable socioeconomic factors for policy makers. We, therefore, sought to determine how frequently data on SDOH were reported, which factors were collected and how these factors were defined in studies of sepsis in children. DATA SOURCES AND SELECTION We reviewed 106 articles (published between 2005 and 2020) utilized in a recent systematic review on physiologic criteria for pediatric sepsis. DATA EXTRACTION Data were extracted by two reviewers on variables that fell within the World Health Organization's SDOH categories. DATA SYNTHESIS SDOH were not the primary outcome in any of the included studies. Seventeen percent of articles (18/106) did not report on any SDOH, and a further 36.8% (39/106) only reported on gender/sex. Of the remaining 46.2% of articles, the most reported SDOH categories were preadmission nutritional status (35.8%, 38/106) and race/ethnicity (18.9%, 20/106). However, no two studies used the same definition of the variables reported within each of these categories. Six studies reported on socioeconomic status (3.8%, 6/106), including two from upper-middle-income and four from lower middle-income countries. Only three studies reported on parental education levels (2.8%, 3/106). No study reported on parental job security or structural conflict. CONCLUSIONS We found overall low reporting of SDOH and marked variability in categorizations and definitions of SDOH variables. Consistent and standardized reporting of SDOH in pediatric sepsis studies is needed to understand the role these factors play in the development and severity of sepsis, to compare and extrapolate study results between settings and to implement policies aimed at improving socioeconomic conditions related to sepsis.
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Affiliation(s)
- Kusum Menon
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Lauren R Sorce
- Ann & Robert H. Lurie Children's Hospital AND Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Andrew Argent
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Tellen D Bennett
- Sections of Informatics and Data Science and Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Enitan D Carrol
- Department of Clinical Infection Microbiology and Immunology, University of Liverpool Institute of Infection, Veterinary and Ecological Sciences, Liverpool, United Kingdom
| | - Niranjan Kissoon
- British Columbia Children's Hospital and The University of British Columbia, Vancouver, BC, Canada
| | - L Nelson Sanchez-Pinto
- Division of Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Luregn J Schlapbach
- Department of Intensive Care and Neonatology, Children`s Research Center University Children's Hospital Zurich, Zurich, Switzerland
| | - Daniela C de Souza
- Child Health Research Centre, The University of Queensland, St Lucia, QLD, Australia
| | - R Scott Watson
- Departments of Pediatrics, Hospital Sírio-Libanês and Hospital Universitário da Universidade de São Paulo, São Paolo, Brazil
| | - James L Wynn
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Jerry J Zimmerman
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Florida, Gainesville, FL
| | - Suchitra Ranjit
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
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17
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Maholtz DE, Riley CL. Screening for Social Needs in Critically Ill Patients: Addressing More Than Health Conditions. Pediatr Crit Care Med 2022; 23:e541-e542. [PMID: 36326466 DOI: 10.1097/pcc.0000000000003067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Danielle E Maholtz
- Division of Critical Care, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Carley L Riley
- Division of Critical Care, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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18
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Affiliation(s)
- Robert C Tasker
- orcid.org/0000-0003-3647-8113.,Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA.,Selwyn College, Cambridge University, Cambridge, United Kingdom
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Paquette ET. Reckoning With Redlining and Other Structural Barriers to Health of Critically Ill Children: Addressing Systemic Racism Will Require Shifting the Focus From Micro- to Macrolevel Analysis of Social Risks. Pediatr Crit Care Med 2022; 23:662-665. [PMID: 36165942 PMCID: PMC9523488 DOI: 10.1097/pcc.0000000000003016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Erin Talati Paquette
- Division of Critical Care Medicine, Ann & Robert H.
Lurie Children’s Hospital of Chicago
- Department of Pedatrics, Northwestern University Feinberg
School of Medicine
- Northwestern University Pritzker School of Law
(courtesy)
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