Socioeconomic differences in childhood hospital inpatient service utilisation and costs: prospective cohort study

Children with severe sepsis: relationship between community level income and morbidity and mortality

BACKGROUND

Health disparities surrounding pediatric severe sepsis outcomes remains unclear. We aimed to measure the relationship between indicators of socioeconomic status and mortality, hospital length of stay (LOS), and readmission rates among children hospitalized with severe sepsis.

METHODS

Children 0-18 years old, hospitalized with severe sepsis in the Nationwide Readmissions Database (2016-2018) were included. The primary exposure was median household income by ZIP Code of residence, divided into quartiles.

RESULTS

We identified 15,214 index pediatric severe sepsis hospitalizations. There was no difference in hospital mortality rate or readmission rate across income quartiles. Among survivors, patients in Q1 (lowest income) had a 2 day longer LOS compared to those in Q4 (Median 10 days [IQR 4-21] vs 8 days [IQR 4-18]; p < 0.0001). However, there was no difference after adjusting for multiple covariates.

CONCLUSIONS

Children living in Q1 had a 2 day longer LOS versus their peers in Q4. This was not significant on multivariable analysis, suggesting income quartile is not driving this difference. As pediatric severe sepsis remains an important source of morbidity and mortality in critically ill children, more sensitive metrics of socioeconomic status may better elucidate any disparities.

IMPACT

Children with severe sepsis living in the lowest income ZIP Codes may have longer hospital stays compared to peers in higher income communities. More precise metrics of socioeconomic status are needed to better understand health disparities in pediatric severe sepsis.

Impact of parents' education on variation in hospital admissions for children: a population-based cohort study

OBJECTIVES

To assess the impact of parental educational level on hospital admissions for children, and to evaluate whether differences in parents' educational level can explain geographic variation in admission rates.

DESIGN

National cohort study.

SETTING

The 18 hospital referral areas for children in Norway.

PARTICIPANTS

All Norwegian children aged 1-16 years in the period 2008-2016 and their parents.

MAIN OUTCOME MEASURES

Age- and gender-adjusted admission rates and probability of admission.

RESULTS

Of 1 538 189 children, 156 087 (10.2%) had at least one admission in the study period. There was a nearly twofold (1.9) variation in admission rates between the hospital referral areas (3113 per 100 000 children, 95% CI: 3056 to 3169 vs 1627, 95% CI: 1599 to 1654). Area level variances in multilevel analysis did not change after adjusting for parental level of education. Children of parents with low level of education (maternal level of education, low vs high) had the highest admission rates (2016: 2587, 95% CI: 2512 to 2662 vs 1810, 95% CI: 1770 to 1849), the highest probability of being admitted (OR: 1.18, 95% CI: 1.16 to 1.20), the highest number of admissions (incidence rate ratio: 1.05, 95% CI: 1.01 to 1.10) and admissions with lower cost (-0.5%, 95% CI: -1.2% to 0.3%).

CONCLUSIONS

Substantial geographic variation in hospital admission rates for children was found, but was not explained by parental educational level. Children of parents with low educational level had the highest admission probability, and the highest number of admissions, but the lowest cost of admissions. Our results suggest that the variation between the educational groups is not due to differences in medical needs, and may be characterised as unwarranted. However, the manner in which health professionals communicate and interact with parents with different educational levels might play an important role.

Associations between Deprivation, Geographic Location, and Access to Pediatric Kidney Care in the United Kingdom

BACKGROUND AND OBJECTIVES

Pre-emptive kidney transplantation is advocated as best practice for children with kidney failure who are transplant eligible; however, it is limited by late presentation. We aimed to determine whether socioeconomic deprivation and/or geographic location (distance to the center and rural/urban residence) are associated with late presentation, and to what degree these factors could explain differences in accessing pre-emptive transplantation.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A cohort study using prospectively collected United Kingdom Renal Registry and National Health Service Blood and Transplant data from January 1, 1996 to December 31, 2016 was performed. We included children aged >3 months to ≤16 years at the start of KRT. Multivariable logistic regression models were used to determine associations between the above exposures and our outcomes: late presentation (defined as starting KRT within 90 days of first nephrology review) and pre-emptive transplantation, with a priori specified covariates.

RESULTS

Analysis was performed on 2160 children (41% females), with a median age of 3.8 years (interquartile range, 0.2-9.9 years) at first nephrology review. Excluding missing data, 478 were late presenters (24%); 565 (26%) underwent pre-emptive transplantation, none of whom were late presenting. No association was seen between distance or socioeconomic deprivation with late presentation, in crude or adjusted analyses. Excluding late presenters, greater area affluence was associated with higher odds of pre-emptive transplantation, (odds ratio, 1.20 per quintile greater affluence; 95% confidence interval, 1.10 to 1.31), with children of South Asian (odds ratio, 0.52; 95% confidence interval, 0.36 to 0.76) or Black ethnicity (odds ratio, 0.31; 95% confidence interval, 0.12 to 0.80) less likely to receive one. A longer distance to the center was associated with pre-emptive transplantation on crude analyses; however, this relationship was attenuated (odds ratio, 1.02 per 10 km; 95% confidence interval, 0.99 to 1.05) in the multivariable model.

CONCLUSIONS

Socioeconomic deprivation or geographic location are not associated with late presentation in children in the United Kingdom. Geographic location was not independently associated with pre-emptive transplantation; however, children from more affluent areas were more likely to receive a pre-emptive transplant.

Prevalence, hospital admissions and costs of child chronic conditions: A population-based study

AIM

To determine population-based prevalence, hospital use and costs for children admitted to hospital with chronic conditions.

METHODS

We used hospital admissions data for children aged <16 years, 2002-2013 in New South Wales, Australia.

RESULTS

Of all admissions, 35% (n = 692 514) included a diagnosis of a chronic condition. In 2013, prevalence was 25.1 per 1000 children. Children with greater socio-economic disadvantage or living in regional and remote areas had lower prevalence, but a higher proportion of emergency admissions. Prevalence rates were highest for respiratory and neurological conditions (9.4, 7.4 per 1000, respectively). Mental health conditions were most common in older children. Admissions involving chronic conditions had longer length of stay (3.0 vs. 1.6 days), consumed more bed-days (50% of total) and involved 43% of total hospital costs.

CONCLUSION

Differences in prevalence and use of hospital services suggest inequities in access and need for more appropriate and equitable models of care.

Comparing Resource Use in Medical Admissions of Children With Complex Chronic Conditions

BACKGROUND

Children with complex chronic conditions (CCCs) utilize a disproportionate share of hospital resources.

OBJECTIVE

We asked whether some hospitals display a significantly different pattern of resource utilization than others when caring for similar children with CCCs admitted for medical diagnoses.

RESEARCH DESIGN

Using Pediatric Health Information System data from 2009 to 2013, we constructed an inpatient Template of 300 children with CCCs, matching these to 300 patients at each hospital, thereby performing a type of direct standardization.

SUBJECTS

Children with CCCs were drawn from a list of the 40 most common medical principal diagnoses, then matched to patients across 40 Children's Hospitals.

MEASURES

Rate of intensive care unit admission, length of stay, resource cost.

RESULTS

For the Template-matched patients, when comparing resource use at the lower 12.5-percentile and upper 87.5-percentile of hospitals, we found: intensive care unit utilization was 111% higher (6.6% vs. 13.9%, P<0.001); hospital length of stay was 25% higher (2.4 vs. 3.0 d/admission, P<0.001); and finally, total cost per patient varied by 47% ($6856 vs. $10,047, P<0.001). Furthermore, some hospitals, compared with their peers, were more efficient with low-risk patients and less efficient with high-risk patients, whereas other hospitals displayed the opposite pattern.

CONCLUSIONS

Hospitals treating similar patients with CCCs admitted for similar medical diagnoses, varied greatly in resource utilization. Template Matching can aid chief quality officers benchmarking their hospitals to peer institutions and can help determine types of their patients having the most aberrant outcomes, facilitating quality initiatives to target these patients.

Social gradients in health and social care costs: Analysis of linked electronic health records in Kent, UK

OBJECTIVES

Research into the socio-economic patterning of health and social care costs in the UK has so far been limited to examining only particular aspects of healthcare. In this study, we explore the social gradients in overall healthcare and social care costs, as well as in the disaggregated costs by cost category.

STUDY DESIGN

We calculated the social gradient in health and social care costs by cost category using a linked electronic health record data set for Kent, a county in South East England. We performed a cross-sectional analysis on a sample of 323,401 residents in Kent older than 55 years to assess the impact of neighbourhood deprivation on mean annual per capita costs in 2016/17.

METHODS

Patient-level costs were estimated from activity data for the financial year 2016/17 and were extracted alongside key patient characteristics. Mean costs were calculated for each area deprivation quintile based on the index of multiple deprivation of the neighbourhood (lower super output area) in which the patient lived. Cost subcategories were analysed across primary care, secondary care, social care, community care and mental health.

RESULTS

The mean annual per capita cost increased with deprivation across each deprivation quintile, with a cost of £1205 in the most affluent quintile, compared with £1623 in the most deprived quintile, a 35% cost increase. Social gradients were found across all cost subcategories.

CONCLUSIONS

Health inequalities in the population older than 55 years in Kent are associated with health and social care costs of £109m, equivalent to 15% of the estimated total expenditure in this age group. Such significant costs suggest that appropriate interventions to reduce socio-economic inequalities have the potential to substantially improve population health and, depending on how much investment they require, may even result in cost savings.

Evaluation of Health in Pregnancy grants in Scotland: a natural experiment using routine data

Background

Pregnancy and the period around birth are critical for the development and improvement of population health as well as the health of mothers and babies, with outcomes such as birthweight influencing adult health.

Objectives

We evaluated the clinical effectiveness and cost-effectiveness of the Health in Pregnancy (HiP) grants in Scotland, looking for differential outcomes when the scheme was in place, as well as before its implementation and after its withdrawal.

Design

The HiP grants were evaluated as a natural experiment using interrupted time series analysis. We had comparison groups of women who delivered before the grants were introduced and after the grants were withdrawn.

Setting

Scotland, UK.

Participants

A total of 525,400 singleton births delivered between 24 and 44 weeks in hospitals across Scotland between 1 January 2004 and 31 December 2014.

Intervention

The HiP grant was a universal, unconditional cash transfer of £190 for women in Great Britain and Northern Ireland reaching 25 weeks of pregnancy if they had sought health advice from a doctor or midwife. The grant was introduced for women with a due date on or after 6 April 2009 and subsequently withdrawn for women reaching the 25th week of pregnancy on or after 1 January 2011. The programme was paid for by Her Majesty’s Treasury.

Main outcome measures

Our primary outcome measure was birthweight. Secondary outcome measures included maternal behaviour, measures of size, measures of stage and birth outcomes.

Data sources

The data came from the Scottish maternity and neonatal database held by the Information and Services Division at the NHS National Services Scotland.

Results

There was no statistically significant effect on birthweight, with births during the intervention period being, on average, 2.3 g [95% confidence interval (CI) –1.9  to 6.6 g] lighter than would have been expected had the pre-intervention trend continued. Mean gestational age at booking (i.e. the first antenatal appointment with a health-care professional) decreased by 0.35 weeks (95% CI 0.29 to 0.41 weeks) and the odds of booking before 25 weeks increased by 10% [odds ratio (OR) 1.10, 95% CI 1.02 to 1.18] during the intervention but decreased again post intervention (OR 0.91, 95% CI 0.83 to 1.00). The odds of neonatal death increased by 84% (OR 1.84, 95% CI 1.22 to 2.78) and the odds of having an emergency caesarean section increased by 7% (OR 1.07, 95% CI 1.03 to 1.10) during the intervention period.

Conclusions

The decrease in the odds of booking before 25 weeks following withdrawal of the intervention makes it likely that the HiP grants influenced maternal health-care-seeking behaviour. It is unclear why neonatal mortality and emergency caesarean section rates increased, but plausible explanations include the effects of the swine flu outbreak in 2009 and the global financial crisis. The study is limited by its non-randomised design. Future research could assess an eligibility threshold for payment earlier than the 25th week of pregnancy.

Funding

The National Institute for Health Research Public Health Research programme. The Social and Public Health Sciences Unit is core funded by the Medical Research Council (MC_UU_12017/13) and the Scottish Government Chief Scientist Office (SPHSU13).

Use of hospital-based health care services among children aged 1 through 9 years who were born very preterm - a population-based study

BACKGROUND

Very preterm (VPT) children, with a birth weight below 1500 g or delivered before 32 weeks of gestational age, are at increased risk of poorer long-term health outcomes and higher rates of hospitalization in childhood. However, considerable variation exists in the need for in-hospital care within this population. We assessed the utilization and distribution of hospital-based care from ages 1 through 9 years for a nationwide population.

METHODS

This was a population-based cohort of VPT children born in the period 2001-2009. We evaluated their utilization of hospital care in 2008-2010, when aged 1-9 years old. Outcomes were the incidence of hospital admissions and outpatient visits. We used Poisson regression models with multiple imputation of missing data.

RESULTS

Children born VPT had more hospital admissions compared with the general population of children aged 1-9 years. The rates of hospital admissions and outpatient visits were strongly related to clinical characteristics of the child at birth and age at admission/outpatient visit but to only a variable and minor degree to characteristics pertaining to maternal health, the sociodemographic factors, and geographical proximity to hospital services.

CONCLUSIONS

Prior to this study, hospital utilization during the period 5-9 years old has been poorly documented. We found that excess utilization of hospital resources on average declines with increasing age. We also noted substantial differences in the use of hospital care across age groups and clinical factors for VPT children. The added information from the health status of mothers, social background, and geographic measures of access was limited.

Length of paediatric inpatient stay, socio-economic status and hospital configuration: a retrospective cohort study

BACKGROUND

Variation in paediatric inpatient length of stay exists - whether this is driven by differences in patient characteristics or health service delivery is unclear. We will test the hypotheses that higher levels of deprivation are associated with prolonged length of stay and that differences in prolonged length of stay across 2 hospitals will be explained by demographic, clinical and process factors.

METHODS

This is a retrospective cohort study of 2889 children aged less than 16 years admitted from 1st April 2009 to 30^th March 2010. Administrative data were used from two UK hospitals whose Accident and Emergency (A&E) departments were paediatric and adult physician led respectively. The main outcome was prolonged length of stay defined as greater than or equal to the mean (1.8 days). Sensitivity analyses defined prolonged length of stay as greater than the median (1 day). Demographic, clinical and process characteristics were examined. Socio-economic position was measured by Income Deprivation Affecting Children Index. Multivariable logistic and linear regression analyses were performed.

RESULTS

We did not find a consistent association between length of stay and socio-economic position, using a variety of definitions of length of stay. In contrast, adjusted for age, gender, socio-economic position, ethnicity, final diagnosis, number of hospital admissions, source of admission, and timing of admission, admission to the adult led A&E hospital was more strongly associated with prolonged length of stay (Odds Ratio 1.41, 95% Confidence Interval 1.16, 1.71).

CONCLUSION

Local variation in paediatric inpatient length of stay was not explained by demographic, clinical or process factors, but could have been due to residual confounding by medical complexity. Length of stay was not consistently associated with socio-economic position suggesting that length of stay is a function of health service not the determinants of health. Analyses of these types of data would be strengthened by measures of complexity and adverse events.

Effect of socioeconomic disadvantage, remoteness and Indigenous status on hospital usage for Western Australian preterm infants under 12 months of age: a population-based data linkage study

OBJECTIVES

Our primary objective was to determine the incidence of hospital admission and emergency department presentation in Indigenous and non-Indigenous preterm infants aged postdischarge from birth admission to 11 months in Western Australia. Secondary objectives were to assess incidence in the poorest infants from remote areas and to determine the primary causes of hospital usage in preterm infants.

DESIGN

Prospective population-based linked data set.

SETTING AND PARTICIPANTS

All preterm babies born in Western Australia during 2010 and 2011.

MAIN OUTCOME MEASURES

All-cause hospitalisations and emergency department presentations.

RESULTS

There were 6.9% (4211/61 254) preterm infants, 13.1% (433/3311) Indigenous preterm infants and 6.5% (3778/57 943) non-Indigenous preterm infants born in Western Australia. Indigenous preterm infants had a higher incidence of hospital admission (adjusted incident rate ratio (aIRR) 1.24, 95% CI 1.08 to 1.42) and emergency department presentation (aIRR 1.71, 95% CI 1.44 to 2.02) compared with non-Indigenous preterm infants. The most disadvantaged preterm infants (7.8/1000 person days) had a greater incidence of emergency presentation compared with the most advantaged infants (3.1/1000 person days) (aIRR 1.61, 95% CI 1.30 to 2.00). The most remote preterm infants (7.8/1000 person days) had a greater incidence of emergency presentation compared with the least remote preterm infants (3.0/1000 person days; aIRR 1.82, 95% CI 1.49 to 2.22).

CONCLUSIONS

In Western Australia, preterm infants have high hospital usage in their first year of life. Infants living in disadvantaged areas, remote area infants and Indigenous infants are at increased risk. Our data highlight the need for improved postdischarge care for preterm infants.

[Influence of postcode on paediatric admissions in Seville]

INTRODUCTION

The postcode (where the home is situated) is an indicator of socioeconomic status and is associated with morbidity, mortality, and the use of health services. The aim of this study was to analyse its effects on paediatric admissions and to determine the rates of the most common causes of paediatric admissions in Seville.

MATHERIAL AND METHODS

An observational cross-sectional study with two analysis units: under 15 year-old "admissions" in public hospitals in Seville (n=2,660) and "city districts" of Seville (n=11). The independent variable analysed was whether the postcode of the admitted patients was within a Regional Government designated "area with social transformation needs". The analysis of the admissions was performed using X²-test, Fisher test and Student-t test, with the description of rates using the calculation of crude and specific rates, and by rate ratio.

RESULTS

Children living in districts with a lower socioeconomic status were on average 7 months younger (P<.001), and they were significantly more likely to be admitted via the emergency department (P<.001). There was no statistical difference detected in either the length of hospital stay or mortality. The crude admission rate ratio was higher in districts with a lower socioeconomic status (1.8), with a higher specific rate ratio detected in admissions due to asthma, respiratory infections, inguinal hernia, and epilepsy/convulsions.

CONCLUSIONS

Paediatric hospital admission rates of the main diagnoses were higher in districts with a lower socioeconomic status. Children living in these districts were more likely to be admitted younger and via the emergency department.

The rise and fall of hospitalizations for skin infections in New Zealand, 2004-2014: trends by ethnicity and socioeconomic deprivation

Since the 1990s, New Zealand (NZ) has seen an increasing incidence of paediatric skin infections leading to hospitalization. We sought to describe the epidemiology of these infections over time. Hospital discharge data were analysed for all children admitted to any NZ public hospital from 2004 to 2014. We found the age-standardized incidence of hospitalizations due to skin infections increased during this period from 522/100 000 in 2004 to a peak of 644/100 000 in 2011, after which it declined to 524/100 000 in 2014. This decline in incidence was driven primarily by the decline in hospitalization rates in high-risk groups including children living in the most deprived areas as well as Māori and Pacific children. Recent targeted policies focused on improving healthcare access through school-based and primary care-based interventions in these high-risk groups could potentially explain the decline in hospitalization rates. However, even with the closing of the inequality gap, significant socioeconomic and ethnic health disparities persist.

Effects of Pre-Natal Vitamin D Supplementation with Partial Correction of Vitamin D Deficiency on Early Life Healthcare Utilisation: A Randomised Controlled Trial

Background

Some observational studies have suggested that higher prenatal Vitamin D intake may be associated with improved health outcomes in childhood. However there have been mixed results in this area with some negative studies, especially for effects on atopic and respiratory outcomes. We examined the effect of prenatal Vitamin D on healthcare utilisation in the first three years of life.

Methods

In an ethnically stratified randomised controlled trial conducted at St Mary’s Hospital London, 180 women at 27 weeks gestation were allocated to no Vitamin D, 800 IU ergocalciferol daily until delivery, or a single oral bolus of 200,000 IU cholecalciferol. Participants were randomised in blocks of 15 using computer-generated numbers and investigators were blinded to group assignment. Supplementation increased maternal and cord blood 25(OH) vitamin D concentrations, but levels remained lower than current recommendations. Primary health economic outcome was overall cost of unscheduled healthcare utilisation in the first three years of life as documented in the child’s electronic health record. Secondary outcomes included cost attributable to: primary and secondary healthcare visits, respiratory and atopic complaints, cost in years 1, 2 and 3 of life and cost and frequency of prescribed medication. All costs were calculated as pounds sterling. Differences between groups were analysed using unpaired t-test or Mann-Whitney U test, and analysis of variance for adjusted analyses.

Results

We assessed 99/180 (55%) complete electronic health records, control (n = 31), daily (n = 36) and bolus (n = 32). We found no difference in total healthcare utilisation costs between the control and daily (mean difference in costs in pounds sterling 1.02, 95%CI -1.60, 1.65; adjusted 1.07, 95%CI -1.62, 1.86) or control and bolus groups (mean difference -1.58, 95%CI -2.63, 1.06; adjusted –1.40, 95%CI -2.45, 1.24). There were no adverse effects of supplementation reported during the trial.

Conclusions

We found no evidence that prenatal vitamin D supplementation from 27 weeks gestation to delivery, at doses which failed to completely correct maternal vitamin D deficiency, influence overall healthcare utilisation in children in the first 3 years.

Trial Registration

Controlled-Trials.com ISRCTN68645785

The development of differences in hospital costs accross income groups in Finland from 1998 to 2010

OBJECTIVE

To quantify differences in hospital costs between socioeconomic groups and the development over time.

METHODS

Register data on somatic specialised hospital admissions for patients aged between 25 and 84 in Finland in 1998-2010 were used with income data individually linked to them. The cost of an admission was calculated by multiplying the number of a patient's inpatient days by the inpatient day cost of the patient's DRG. We calculated age-standardised admission costs per resident and per user as well as costs per inpatient day and concentration indices separately for men and women.

RESULTS

Hospital admission costs reduced with increasing income. The difference between the extreme income quintiles was more than 50% throughout the study period, and this difference widened. However, the cost per inpatient day was more than 20% higher in the highest income group. The differences between income groups were the most prominent in disease categories involving surgery.

CONCLUSIONS

The growth between socioeconomic groups in hospital costs is presumably mainly due to increasing differences in morbidity. More attention needs to be paid to prevention of health inequalities and access to and content of primary care among low-income groups in order to decrease the need for hospitalisations.

Community household income and resource utilization for common inpatient pediatric conditions

BACKGROUND AND OBJECTIVE

Child health is influenced by biomedical and socioeconomic factors. Few studies have explored the relationship between community-level income and inpatient resource utilization for children. Our objective was to analyze inpatient costs for children hospitalized with common conditions in relation to zip code-based median annual household income (HHI).

METHODS

Retrospective national cohort from 32 freestanding children's hospitals for asthma, diabetes, bronchiolitis and respiratory syncytial virus, pneumonia, and kidney and urinary tract infections. Standardized cost of care for individual hospitalizations and across hospitalizations for the same patient and condition were modeled by using mixed-effects methods, adjusting for severity of illness, age, gender, and race. Main exposure was median annual HHI. Posthoc tests compared adjusted standardized costs for patients from the lowest and highest income groups.

RESULTS

From 116,636 hospitalizations, 4 of 5 conditions had differences at the hospitalization and at the patient level, with lowest-income groups having higher costs. The individual hospitalization level cost differences ranged from $187 (4.1%) to $404 (6.4%). Patient-level cost differences ranged from $310 to $1087 or 6.5% to 15% higher for the lowest-income patients. Higher costs were typically not for laboratory, imaging, or pharmacy costs. In total, patients from lowest income zip codes had $8.4 million more in hospitalization-level costs and $13.6 million more in patient-level costs.

CONCLUSIONS

Lower community-level HHI is associated with higher inpatient costs of care for 4 of 5 common pediatric conditions. These findings highlight the need to consider socioeconomic status in health care system design, delivery, and reimbursement calculations.

Low income/socio-economic status in early childhood and physical health in later childhood/adolescence: a systematic review

To systematically review the literature on the relationship between early childhood low income/socioeconomic status (SES) and physical health in later childhood/adolescence, to identify gaps in the literature and to suggest new avenues for research. A systematic search of electronic databases from their start date to November 2011 was conducted to identify prospective longitudinal studies in industrialized countries with a measure of low income/SES in the first 5 years of life and physical health outcomes in later childhood or adolescence. STROBE criteria were used to assess study quality. Risk estimates were expressed as odds ratios with 95 % confidence intervals where possible. Heterogeneity of studies precluded meta-analysis. Nine studies fulfilled the inclusion criteria. Significant associations of early childhood low income/SES with activity-limiting illness, parent-reported poor health status, acute and recurrent infections, increasing BMI percentile and hospitalization were reported. Results for parent-reported asthma were less consistent: there was a significant association with low income/SES in early childhood in 2 studies but null findings in 3 others. This systematic review of the association of early childhood low income/SES with physical health status in later childhood and adolescence shows that, in contrast to the extensive literature on the impact of poor childhood social circumstances on adult health, the evidence base is limited. The literature points to some associations of early low income/SES with later poor health status, but many key research questions remain unanswered. Implications for further research are considered.

Relationships between deprivation and duration of children's emergency admissions for breathing difficulty, feverish illness and diarrhoea in North West England: an analysis of hospital episode statistics

BACKGROUND

In the United Kingdom there has been a long term pattern of increases in children's emergency admissions and a substantial increase in short stay unplanned admissions. The emergency admission rate (EAR) per thousand population for breathing difficulty, feverish illness and diarrhoea varies substantially between children living in different Primary Care Trusts (PCTs). However, there has been no examination of whether disadvantage is associated with short stay unplanned admissions at PCT-level. The aim of this study was to determine whether differences between emergency hospital admission rates for breathing difficulty, feverish illness and diarrhoea are associated with population-level measures of multiple deprivation and child well-being, and whether there is variation by length of stay and age.

METHODS

Analysis of hospital episode statistics and secondary analysis of Index of Multiple Deprivation (IMD) 2007 and Local Index of Child Well-being (CWI) 2009 in ten adjacent PCTs in North West England. The outcome measure for each PCT was the emergency admission rate to hospital for breathing difficulty, feverish illness and diarrhoea.

RESULTS

23,496 children aged 0-14 were discharged following emergency admission for breathing difficulty, feverish illness and/or diarrhoea during 2006/07. The emergency admission rate ranged from 27.9 to 62.7 per thousand. There were no statistically significant relationships between shorter (0 to 3 day) hospitalisations and the IMD or domains of the CWI. The rate for hospitalisations of 4 or more days was associated with the IMD (Kendall's tau(b) = 0.64) and domains of the CWI: Environment (tau(b) = 0.60); Crime (tau(b) = 0.56); Material (tau(b) = 0.51); Education (tau(b) = 0.51); and Children in Need (tau(b) = 0.51). This pattern was also evident in children aged under 1 year, who had the highest emergency admission rates. There were wide variations between the proportions of children discharged on the day of admission at different hospitals.

CONCLUSIONS

Differences between rates of the more common shorter (0 to 3 day) hospitalisations were not explained by deprivation or well-being measured at PCT-level. Indices of multiple deprivation and child well-being were only associated with rates of children's emergency admission for breathing difficulty, feverish illness and diarrhoea for hospitalisations of 4 or more days.

Socio-economic inequities in children's injury rates: has the gradient changed over time?

INTRODUCTION

Changing socio-economic gradients in adult health over time have been documented, but little research has investigated temporal changes in child health gradients. Childhood hospitalizations for injury have fallen over the last two decades; whether the socio-economic gradient in childhood injury has changed is unknown.

METHODS

Population-based hospital discharge data were used to calculate rates of hospitalization for injury from 1986/87 through 2005/06 for all children under 20 years of age in Manitoba (average yearly number of hospitalizations = 326,357). Information on socio-economic status (SES) came from area-level census data and was assigned by residential postal codes. Generalized linear models with generalized estimating equations were employed to describe the relation between SES and injury rates and whether this relation changed over time. All-cause injuries were examined as well as injuries for motor vehicle collisions (MVCs), other vehicle injuries, self-inflicted injuries, assault, poisoning, injuries caused by machinery, sports injuries and falls.

RESULTS

Injury hospitalizations for children decreased steadily over the study period, from 1.07% to 0.51%. SES significantly predicted injury hospitalizations (p < 0.0001), children with lower SES showing higher rates. A significant SES by year interaction (p < 0.0001) indicated that the SES gradient for injury hospitalizations increased over time. Analysis by type of injury found a significant SES by year interaction for MVCs, self-inflicted injuries and falls; for MVCs and self-inflicted injuries the pattern (increasing SES gradient) was similar to that of hospitalization for all-cause injury. The pattern for falls was inconsistent.

CONCLUSION

Despite the overall drop in injury hospitalizations over time, the SES gradient in hospitalized injury rates has increased.

Socioeconomic inequalities in survival and provision of neonatal care: population based study of very preterm infants

OBJECTIVES

To assess socioeconomic inequalities in survival and provision of neonatal care among very preterm infants.

DESIGN

Prospective cohort study in a geographically defined population.

SETTING

Former Trent health region of the United Kingdom (covering about a twelfth of UK births).

PARTICIPANTS

All infants born between 22+0 and 32+6 weeks' gestation from 1 January 1998 to 31 December 2007 who were alive at the onset of labour and followed until discharge from neonatal care.

MAIN OUTCOME MEASURES

Survival to discharge from neonatal care per 1000 total births and per 1000 very preterm births. Neonatal care provision for very preterm infants surviving to discharge measured with length of stay, provision of ventilation, and respiratory support. Deprivation measured with the UK index of multiple deprivation 2004 score at super output area level.

RESULTS

7449 very preterm singleton infants were born in the 10 year period. The incidence of very preterm birth was nearly twice as high in the most deprived areas compared with the least deprived areas. Consequently rates of mortality due to very preterm birth per 1000 total births were almost twice as high in the most deprived areas compared with the least deprived (incidence rate ratio 1.94, 95% confidence interval 1.62 to 2.32). Mortality rates per 1000 very preterm births, however, showed little variation across all deprivation fifths (incidence rate ratio for most deprived fifth versus least deprived 1.02, 0.86 to 1.20). For infants surviving to discharge from neonatal care, measures of length of stay and provision of ventilation and respiratory support were similar across all deprivation fifths.

CONCLUSIONS

The burden of mortality and morbidity is greater among babies born to women from deprived areas because of increased rates of very preterm birth. After very preterm birth, however, survival rates and neonatal care provision is similar for infants from all areas.

Poverty and cumulative hospitalization in infancy and early childhood in the Quebec birth cohort: a puzzling pattern of association

OBJECTIVE

We anticipate a negative gradient between income and hospitalization, since income is positively associated with good health. In a previous cross-sectional study, we reported an unexpected pattern of association between poverty and hospitalization for 5-month-old infants in Quebec. This study re-examines the poverty-hospitalization relationship within a longitudinal population study of the same birth cohort aged 3.5 years.

METHOD

Life table analysis, multivariable proportional hazard regression, and multivariable logistic regression were performed on data from the first four waves of the Quebec Longitudinal Study of Child Development (QLSCD). Probabilities of hospitalization were estimated by poverty status. The hazard ratios (HR) (Cox-regression) for duration of poverty (frequency of insufficient income) and severity of poverty (combining frequency and level of income insufficiency) were estimated, controlling for predisposing, enabling, and need determinants of hospitalization.

RESULTS

At 3.5 years, 31% of children had been hospitalized at least once. Compared with children whose families had constantly sufficient income, children with intermittent poverty exhibited higher hospitalization risks (HR = 1.30; 95%CI = 1.04-1.64) while chronically poor children exhibited comparable hospitalization hazards (HR = 0.97; 95%CI = 0.73-1.27). Hospitalization risks for children in the severest poverty group resembled that of the non-poor group (HR = 0.99; 95%CI = 0.66-1.49), while children in less severely poor families were more likely to be hospitalized (HR = 1.26; 95%CI = 0.99-1.60).

CONCLUSION

Results suggest hospitalization barriers for children living in chronic and severe poverty. If these barriers exist in a universal health care system, they may originate with primary care service organization or hospital care referral procedures.

Urbanicity-related Variation in Help-seeking and Services Utilization among Preschool-age Children with Autism in Taiwan

The present study examines urbanicity-related differences in help-seeking process among preschool children with autism and investigates the factors associated with utilization of autism-related services within the year of diagnosis. Using the 1997-2004 National Health Insurance Research Database (NHIRD) in Taiwan, we identified a total of 3495 autistic children born in 1997-1999 and 13964 matched controls. Results indicate that suburban and rural autism tended to receive the diagnosis at an older age and to have a longer diagnosis process as compared with urban counterparts. Male gender, a younger age of diagnosis, and being diagnosed by psychiatric specialty strongly predict subsequent greater utilization of autism-specific services (all p < 0.05). Health policy makers and other service providers should address the needs of children with early-onset neurodevelopmental disorders in rural areas, particularly those from disadvantaged families.

Socioeconomic status and length of hospital stay in children with vaso-occlusive crises of sickle cell disease

OBJECTIVE

To examine the association between socioeconomic status and length of hospital stay for vaso-occlusive crises in children with sickle cell disease.

METHODS

19,174 discharges (aged 1-20 years), with a primary diagnosis of sickle cell disease with crisis were analyzed from the Healthcare Cost and Utilization Project Kid Inpatient Database 2000. Socioeconomic status was assessed using an area-based measure, median household income by ZIP code and an individual-level measure, insurance status. We adjusted for age, gender, hospital location/teaching status, presence of pneumonia, number of diagnoses on record and number of procedures performed. Negative binomial regression models using generalized estimating equations (GEE) were used to assess length of stay.

RESULTS

Socioeconomic status as measured by income was not associated with length of stay (incidence rate ratio (highest versus lowest category) = 1.04 (95% CI: 0.98, 1.11)). In contrast, socioeconomic status as measured by insurance was associated with length of stay [adjusted incidence rate ratio = 1.04 (95% CI: 1.01, 1.08)), although the magnitude of this difference is small and not likely to be clinically important.

CONCLUSIONS

We found no evidence to suggest that socioeconomic status has any clinically important effect on length of hospital stay in children with vaso-occlusive crises in sickle cell disease.

Methodological challenges posed by economic evaluations of early childhood intervention programmes

Early childhood intervention programmes have emerged in recent years with the aim of fostering the cognitive and social-emotional functioning and physical health of preschool children and enhancing their emerging competencies. This article presents a structured critical appraisal of economic evaluations of early childhood intervention programmes. It highlights a range of methodological issues in the field. These include: the fidelity of the evaluation process; the selection of the appropriate comparison group given the complexity of care routinely provided; the appropriate perspective and coverage of the study; methodological concerns relating to cost and benefit measurement and valuation; analytical requirements relating to the form of sensitivity analysis and the decision rules adopted by decision makers; and the interpretation of the results in the light of contextual factors. It is concluded that more transparent methodological guidance is required for analysts conducting economic evaluations of early childhood intervention programmes in particular and of public health interventions in general. Greater multidisciplinary collaboration between social scientists should also enhance the development of ground-breaking methods in this field.