Cooling The Hot Spots Where Child Hospitalization Rates Are High: A Neighborhood Approach To Population Health

Competency-based medical education: Connecting training outcomes to patient care

Competency-based medical education (CBME) is a patient-centered and learner-focused approach to education where curricula are delivered in a manner tailored to the individuals' learning needs, and assessment focuses on ensuring trainees achieve requisite and clearly specified learning outcomes. Despite calls to focus assessment on what matters for patients. In this article, the authors explore one aspect of this next era: the use of electronic health record clinical performance indicators, such as Resident-Sensitive Quality Measures (RSQMs) and TRainee Attributable and Automatable Care Evaluations in Real-time (TRACERs), for learner assessment. They elaborate on both the promise and the potential limitations of using such measures in a program of learner assessment.

An Institutional Approach to Equity and Improvement in Child Health Outcomes

Pediatric health inequities are pervasive. Approaches by health care institutions to address inequities often, and increasingly, focus on social needs screening without linked, robust responses. Even when actions in pursuit of health equity do occur within health care institutions, efforts occur in isolation from each other, standing in the way of cross-learning and innovation. Learning network methods hold promise when institutions are confronted with complex, multidimensional challenges. Equity-oriented learning networks may therefore accelerate action to address complex factors that contribute to inequitable pediatric health outcomes, enabling rapid learning along the way. We established an institutional Health Equity Network (HEN) in pursuit of excellent and equitable health outcomes for children and adolescents in our region. The HEN supports action teams seeking to eliminate pediatric health inequities in their clinical settings. Teams deploy targeted interventions to meet patients' and families' needs, addressing both medical and social factors affecting health and wellbeing. The primary, shared HEN measure is the equity gap in hospitalization rates between Black patients and all other patients. The HEN currently has 10 action teams and promotes rapid learning and scaling of interventions via monthly "action period calls" and "solutions labs" focused on successes, challenges, and potential common solutions (eg, scaling of existing medical-legal partnership to subspecialty clinics). In this Advocacy Case Study, we detail the design, implementation, and early outcomes from the HEN, our equity-oriented learning network.

Closing the gap on healthcare quality for equity-deserving groups: a scoping review of equity-focused quality improvement interventions in medicine

INTRODUCTION

Quality improvement (QI) efforts are critical to promoting health equity and mitigating disparities in healthcare outcomes. Equity-focused QI (EF-QI) interventions address the unique needs of equity-deserving groups and the root causes of disparities. This scoping review aims to identify themes from EF-QI interventions that improve the health of equity-deserving groups, to serve as a resource for researchers embarking on QI.

METHODS

In adherence with Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, several healthcare and medical databases were systematically searched from inception to December 2022. Primary studies that report results from EF-QI interventions in healthcare were included. Reviewers conducted screening and data extraction using Covidence. Inductive thematic analysis using NVivo identified key barriers to inform future EF-QI interventions.

RESULTS

Of 5,330 titles and abstracts screened, 36 articles were eligible for inclusion. They reported on EF-QI interventions across eight medical disciplines: primary care, obstetrics, psychiatry, paediatrics, oncology, cardiology, neurology and respirology. The most common focus was racialised communities (15/36; 42%). Barriers to EF-QI interventions included those at the provider level (training and supervision, time constraints) and institution level (funding and partnerships, infrastructure). The last theme critical to EF-QI interventions is sustainability. Only six (17%) interventions actively involved patient partners.

DISCUSSION

EF-QI interventions can be an effective tool for promoting health equity, but face numerous barriers to success. It is unclear whether the demonstrated barriers are intrinsic to the equity focus of the projects or can be generalised to all QI work. Researchers embarking on EF-QI work should engage patients, in addition to hospital and clinic leadership in the design process to secure funding and institutional support, improving sustainability. To the best of our knowledge, no review has synthesised the results of EF-QI interventions in healthcare. Further studies of EF-QI champions are required to better understand the barriers and how to overcome them.

Implementing Inpatient Social Needs Screening in an Urban Tertiary Care Children's Hospital

BACKGROUND AND OBJECTIVES

The American Academy of Pediatrics recommends screening for unmet social needs, and the literature on inpatient screening implementation is growing. Our aim was to use quality improvement methods to implement standardized social needs screening in hospitalized pediatric patients.

METHODS

We implemented inpatient social needs screening using the Model for Improvement. An interprofessional team trialed interventions in a cyclical manner using plan-do-study-act cycles. Interventions included a structured screening questionnaire, standardized screening and referrals workflows, electronic health record (EHR) modifications, and house staff education, deliberate practice, and feedback. The primary outcome measure was the percentage of discharged patients screened for social needs. Screening for social needs was defined as a completed EHR screening questionnaire or a full social work evaluation. Process and balancing measures were collected to capture data on screening questionnaire completion and social work consultations. Data were plotted on statistical process control charts and analyzed for special cause variation.

RESULTS

The mean monthly percentage of patients screened for social needs improved from 20% at baseline to 51% during the intervention period. Special cause variation was observed for the percentage of patients with completed social needs screening, EHR-documented screening questionnaires, and social work consults.

CONCLUSIONS

Social needs screening during pediatric hospitalization can be implemented by using quality improvement methods. The next steps should be focused on sustainability and the spread of screening. Interventions with greater involvement of interdisciplinary health care team members will foster process sustainability and allow for the spread of screening interventions to the wider hospitalized pediatric population.

Characteristics of hospital and health system initiatives to address social determinants of health in the United States: a scoping review of the peer-reviewed literature

Background

Despite the incentives and provisions created for hospitals by the US Affordable Care Act related to value-based payment and community health needs assessments, concerns remain regarding the adequacy and distribution of hospital efforts to address SDOH. This scoping review of the peer-reviewed literature identifies the key characteristics of hospital/health system initiatives to address SDOH in the US, to gain insight into the progress and gaps.

Methods

PRISMA-ScR criteria were used to inform a scoping review of the literature. The article search was guided by an integrated framework of Healthy People SDOH domains and industry recommended SDOH types for hospitals. Three academic databases were searched for eligible articles from 1 January 2018 to 30 June 2023. Database searches yielded 3,027 articles, of which 70 peer-reviewed articles met the eligibility criteria for the review.

Results

Most articles (73%) were published during or after 2020 and 37% were based in Northeast US. More initiatives were undertaken by academic health centers (34%) compared to safety-net facilities (16%). Most (79%) were research initiatives, including clinical trials (40%). Only 34% of all initiatives used the EHR to collect SDOH data. Most initiatives (73%) addressed two or more types of SDOH, e.g., food and housing. A majority (74%) were downstream initiatives to address individual health-related social needs (HRSNs). Only 9% were upstream efforts to address community-level structural SDOH, e.g., housing investments. Most initiatives (74%) involved hot spotting to target HRSNs of high-risk patients, while 26% relied on screening and referral. Most initiatives (60%) relied on internal capacity vs. community partnerships (4%). Health disparities received limited attention (11%). Challenges included implementation issues and limited evidence on the systemic impact and cost savings from interventions.

Conclusion

Hospital/health system initiatives have predominantly taken the form of downstream initiatives to address HRSNs through hot-spotting or screening-and-referral. The emphasis on clinical trials coupled with lower use of EHR to collect SDOH data, limits transferability to safety-net facilities. Policymakers must create incentives for hospitals to invest in integrating SDOH data into EHR systems and harnessing community partnerships to address SDOH. Future research is needed on the systemic impact of hospital initiatives to address SDOH.

Building a regional pediatric asthma learning health system in support of optimal, equitable outcomes

Introduction

Asthma is characterized by preventable morbidity, cost, and inequity. We sought to build an Asthma Learning Health System (ALHS) to coordinate regional pediatric asthma improvement activities.

Methods

We generated quantitative and qualitative insights pertinent to a better, more equitable care delivery system. We used electronic health record data to calculate asthma hospitalization rates for youth in our region. We completed an "environmental scan" to catalog the breadth of asthma-related efforts occurring in our children's hospital and across the region. We supplemented the scan with group-level assessments and focus groups with parents, clinicians, and community partners. We used insights from this descriptive epidemiology to inform the definition of shared aims, drivers, measures, and prototype interventions.

Results

Greater Cincinnati's youth are hospitalized for asthma at a rate three times greater than the U.S. average. Black youth are hospitalized at a rate five times greater than non-Black youth. Certain neighborhoods bear the disproportionate burden of asthma morbidity. Across Cincinnati, there are many asthma-relevant activities that seek to confront this morbidity; however, efforts are largely disconnected. Qualitative insights highlighted the importance of cross-sector coordination, evidence-based acute and preventive care, healthy homes and neighborhoods, and accountability. These insights also led to a shared, regional aim: to equitably reduce asthma-related hospitalizations. Early interventions have included population-level pattern recognition, multidisciplinary asthma action huddles, and enhanced social needs screening and response.

Conclusion

Learning health system methods are uniquely suited to asthma's complexity. Our nascent ALHS provides a scaffold atop which we can pursue better, more equitable regional asthma outcomes.

Effects of social determinants of health on mortality and incident liver-related events and cardiovascular disease in steatotic liver disease

BACKGROUND

Social determinants of health (SDOH) are becoming increasingly recognised as mediators of human health. In the setting of metabolic dysfunction-associated steatotic liver disease (MASLD), most of the literature on SDOH relates to individual-level risk factors. However, there are very limited data on neighbourhood-level SDOH in MASLD.

AIM

To assess whether SDOH impact fibrosis progression in patients who already have MASLD.

METHODS

This was a retrospective cohort study of patients with MASLD seen at Michigan Medicine. The primary predictors were two neighbourhood-level SDOH, 'disadvantage' and 'affluence'. The primary outcomes were mortality, incident liver-related events (LREs) and incident cardiovascular disease (CVD). We modelled these outcomes using Kaplan-Meier statistics for mortality and competing risk analyses for LREs and CVD, using a 1-year landmark.

RESULTS

We included 15,904 patients with MASLD with median follow-up of 63 months. Higher affluence was associated with lower risk of overall mortality (hazard ratio 0.49 [0.37-0.66], p < 0.0001 for higher vs. lower quartile), LREs (subhazard ratio 0.60 [0.39-0.91], p = 0.02) and CVD (subhazard ratio 0.71 [0.57-0.88], p = 0.0018). Disadvantage was associated with higher mortality (hazard ratio 2.08 [95% confidence interval 1.54-2.81], p < 0.0001 for the highest vs. lowest quartile) and incident CVD (subhazard ratio 1.36 [95% confidence interval 1.10-1.68], p < 0.0001). These findings were robust across several sensitivity analyses.

DISCUSSION

Neighbourhood-level SDOH are associated with mortality, incidence of LREs and incident CVD in patients with steatotic liver disease. Interventions aimed at disadvantaged neighbourhoods may improve clinical outcomes.

Child Opportunity Index and Emergent PICU Readmissions: A Retrospective, Cross-Sectional Study of 43 U.S. Hospitals

OBJECTIVES

To examine the association between a validated composite measure of neighborhood factors, the Child Opportunity Index (COI), and emergent PICU readmission during the year following discharge for survivors of pediatric critical illness.

DESIGN

Retrospective cross-sectional study.

SETTING

Forty-three U.S. children's hospitals contributing to the Pediatric Health Information System administrative dataset.

PATIENTS

Children (< 18 yr) with at least one emergent PICU admission in 2018-2019 who survived an index admission.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 78,839 patients, 26% resided in very low COI neighborhoods, 21% in low COI, 19% in moderate COI, 17% in high COI, and 17% in very high COI neighborhoods, and 12.6% had an emergent PICU readmission within 1 year. After adjusting for patient-level demographic and clinical factors, residence in neighborhoods with moderate, low, and very low COI was associated with increased odds of emergent 1-year PICU readmission relative to patients in very high COI neighborhoods. Lower COI levels were associated with readmission in diabetic ketoacidosis and asthma. We failed to find an association between COI and emergent PICU readmission in patients with an index PICU admission diagnosis of respiratory conditions, sepsis, or trauma.

CONCLUSIONS

Children living in neighborhoods with lower child opportunity had an increased risk of emergent 1-year readmission to the PICU, particularly children with chronic conditions such as asthma and diabetes. Assessing the neighborhood context to which children return following critical illness may inform community-level initiatives to foster recovery and reduce the risk of adverse outcomes.

Screening for Social Determinants of Health in the Pediatric Intensive Care Unit: Recommendations for Clinicians

Social determinants of health (SDoH) play a significant role in the health and well-being of children in the United States. Disparities in the risk and outcomes of critical illness have been extensively documented but are yet to be fully explored through the lens of SDoH. In this review, we provide justification for routine SDoH screening as a critical first step toward understanding the causes of, and effectively addressing health disparities affecting critically ill children. Second, we summarize important aspects of SDoH screening that need to be considered before implementing this practice in the pediatric critical care setting.

Use Of Area-Based Socioeconomic Deprivation Indices: A Scoping Review And Qualitative Analysis

There is considerable interest among researchers, clinicians, and policy makers in understanding the impact of place on health. In this scoping review and qualitative analysis, we sought to assess area-level socioeconomic deprivation indices used in public health and health outcomes research in the US. We conducted a systematic scoping review to identify area-level socioeconomic deprivation indices commonly used in the US since 2015. We then qualitatively compared the indices based on the input-variable domains, data sources, index creation characteristics, index accessibility, the geography over which the index is applied, and the nature of the output measure or measures. We identified fifteen commonly used indices of area-level socioeconomic deprivation. There were notable differences in the characteristics of each index, particularly in how they define socioeconomic deprivation based on input-variable domains, the geography over which they are applied, and their output measures. These characteristics can help guide future index selection and application in clinical care, research, and policy decisions.

Examining the Association Between MIS-C and the Child Opportunity Index at a Single Center

OBJECTIVE

To describe associations between the Child Opportunity Index (COI) and multisystem inflammatory syndrome of childhood (MIS-C) diagnosis among hospitalized children.

METHODS

We used a retrospective case control study design to examine children ≤21 years hospitalized at a single, tertiary care children's hospital between March 2020 and June 2021. Our study population included children diagnosed with MIS-C (n = 111) and a control group of children hospitalized for MIS-C evaluation who had an alternative diagnosis (n = 61). Census tract COI was the exposure variable, determined using the patient's home address mapped to the census tract. Our outcome measure was MIS-C diagnosis. Odds ratios measured associations between COI and MIS-C diagnosis.

RESULTS

Our study population included 111 children diagnosed with MIS-C and 61 children evaluated but ruled out for MIS-C. The distribution of census tract overall COI differed significantly between children diagnosed with MIS-C compared with children with an alternate diagnosis (P = .03). Children residing in census tracts with very low to low overall COI (2.82, 95% confidence interval [CI]: 1.29-6.17) and very low to low health/environment COI (4.69, 95% CI 2.21-9.97) had significantly higher odds of being diagnosed with MIS-C compared with children living in moderate and high to very high COI census tracts, respectively.

CONCLUSION

Census tract child opportunity is associated with MIS-C diagnosis among hospitalized children suggesting an important contribution of place-based determinants in the development of MIS-C.

Re-Envisioning an Early Years System of Care towards Equity in Canada: A Critical, Rapid Review

Background: Many children in high-income countries, including Canada, experience unjust and preventable health inequities as a result of social and structural forces that are beyond their families’ immediate environment and control. In this context, early years programs, as a key population health initiative, have the potential to play a critical role in fostering family and child wellbeing. Methods: Informed by intersectionality, this rapid literature review captured a broad range of international, transdisciplinary literature in order to identify promising approaches for orienting early years systems of care towards equity in Canada. Results: Findings point to the need for a comprehensive, integrated and socially responsive early years system that has top-down political vision, leadership and accountability and bottom-up community-driven tailoring with an explicit focus on health promotion and maternal, family and community wellness using relational approaches. Conclusions: Advancing child health equity in wealthy countries requires structural government-level changes that support cross-ministerial and intersectoral alliances. Employing intersectionality in this rapid review promotes contextualized and nuanced understandings of what is needed in order to advance a responsive, comprehensive and quality early years system of equity-oriented care. Further research is needed to prevent child health inequities that are disproportionally experienced by Indigenous and racialized children in wealthy countries such as Canada. olicy and research recommendations that have relevance for high-income countries in diverse global contexts are discussed.

Social Determinants of Health and At-Risk Rates for Pediatric Asthma Morbidity

BACKGROUND AND OBJECTIVES

Compared with population-based rates, at-risk rates (ARRs) account for underlying variations of asthma prevalence. When applied with geospatial analysis, ARRs may facilitate more accurate evaluations of the contribution of place-based social determinants of health (SDOH) to pediatric asthma morbidity. Our objectives were to calculate ARRs for pediatric asthma-related emergency department (ED) encounters and hospitalizations by census-tract in Washington, the District of Columbia (DC) and evaluate their associations with SDOH.

METHODS

This population-based, cross-sectional study identified children with asthma, 2 to 17 years old, living in DC, and included in the DC Pediatric Asthma Registry from January 2018 to December 2019. ED encounter and hospitalization ARRs (outcomes) were calculated for each DC census-tract. Five census-tract variables (exposures) were selected by using the Healthy People 2030 SDOH framework: educational attainment, vacant housing, violent crime, limited English proficiency, and families living in poverty.

RESULTS

During the study period, 4321 children had 7515 ED encounters; 1182 children had 1588 hospitalizations. ARRs varied 10-fold across census-tracts for both ED encounters (64-728 per 1000 children with asthma) and hospitalizations (20-240 per 1000 children with asthma). In adjusted analyses, decreased educational attainment was significantly associated with ARRs for ED encounters (estimate 12.1, 95% confidence interval [CI] 8.4 to 15.8, P <.001) and hospitalizations (estimate 1.2, 95% CI 0.2 to 2.2, P = .016). Violent crime was significantly associated with ARRs for ED encounters (estimate 35.3, 95% CI 10.2 to 60.4, P = .006).

CONCLUSION

Place-based interventions addressing SDOH may be an opportunity to reduce asthma morbidity among children with asthma.

Application of Place-Based Methods to Lung Transplant Medicine

Lung transplantation is an increasingly common lifesaving therapy for patients with fatal lung diseases, but this intervention has a critical limitation as median survival after LT is merely 5.5 years. Despite the profound impact of place-based factors on lung health, this has not been rigorously investigated in LT recipients-a vulnerable population due to the lifelong need for daily life-sustaining immunosuppression medications. There have also been longstanding methodological gaps in transplant medicine where both time and place have not been measured; gaps which could be filled by the geospatial sciences. As part of an exploratory analysis, we studied recipients transplanted at our center over a two-year period. The main outcome was at least one episode of rejection within the first year after transplant. We found recipients averaged 1.7 unique residential addresses, a modest relocation rate. Lung rejection was associated with census tracts of predominantly underrepresented minorities or where English was not the primary language as measured by the social vulnerability index. Census tracts likely play an important role in measuring and addressing geographic disparities in transplantation. In a future paradigm, patient spatial data could become an integrated part of real time clinical care to aid in personalized risk stratification and personalized delivery of healthcare.

A scoping review of the use of quality improvement methods by community organizations in the United States, Australia, New Zealand, and Canada to improve health and well-being in community settings

Background

Health-care facilities have used quality improvement (QI) methods extensively to improve quality of care. However, addressing complex public health issues such as coronavirus disease 2019 and their underlying structural determinants requires community-level innovations beyond health care. Building community organizations’ capacity to use QI methods is a promising approach to improving community health and well-being.

Objectives

We explore how community health improvement has been defined in the literature, the extent to which community organizations have knowledge and skill in QI and how communities have used QI to drive community-level improvements.

Methods

Per a published study protocol, we searched Scopus, Web of Science, and Proquest Health management for articles between 2000 and 2019 from USA, Australia, New Zealand, and Canada. We included articles describing any QI intervention in a community setting to improve community well-being. We screened, extracted, and synthesized data. We performed a quantitative tabulation and a thematic analysis to summarize results.

Results

Thirty-two articles met inclusion criteria, with 31 set in the USA. QI approaches at the community level were the same as those used in clinical settings, and many involved multifaceted interventions targeting chronic disease management or health promotion, especially among minority and low-income communities. There was little discussion on how well these methods worked in community settings or whether they required adaptations for use by community organizations. Moreover, decision-making authority over project design and implementation was typically vested in organizations outside the community and did not contribute to strengthening the capability of community organizations to undertake QI independently.

Conclusion

Most QI initiatives undertaken in communities are extensions of projects in health-care settings and are not led by community residents. There is urgent need for additional research on whether community organizations can use these methods independently to tackle complex public health problems that extend beyond health-care quality.

A Framework for Cross-Sector Partnerships to Address Childhood Adversity and Improve Life Course Health

Childhood adversity and its structural causes drive lifelong and intergenerational inequities in health and well-being. Health care systems increasingly understand the influence of childhood adversity on health outcomes but cannot treat these deep and complex issues alone. Cross-sector partnerships, which integrate health care, food support, legal, housing, and financial services among others, are becoming increasingly recognized as effective approaches address health inequities. What principles should guide the design of cross-sector partnerships that address childhood adversity and promote Life Course Health Development (LCHD)? The complex effects of childhood adversity on health development are explained by LCHD concepts, which serve as the foundation for a cross-sector partnership that optimizes lifelong health. We review the evolution of cross-sector partnerships in health care to inform the development of an LCHD-informed partnership framework geared to address childhood adversity and LCHD. This framework outlines guiding principles to direct partnerships toward life course-oriented action: (1) proactive, developmental, and longitudinal investment; (2) integration and codesign of care networks; (3) collective, community and systemic impact; and (4) equity in praxis and outcomes. Additionally, the framework articulates foundational structures necessary for implementation: (1) a shared cross-sector theory of change; (2) relational structures enabling shared leadership, trust, and learning; (3) linked data and communication platforms; and (4) alternative funding models for shared savings and prospective investment. The LCHD-informed cross-sector partnership framework presented here can be a guide for the design and implementation of cross-sector partnerships that effectively address childhood adversity and advance health equity through individual-, family-, community-, and system-level intervention.

Social care practices and perspectives among U.S. pediatric emergency medicine fellowship programs

BACKGROUND

The emergence of social emergency medicine-the incorporation of social context into the structure and practice of emergency care-has brought forth greater embracement of the social determinants of health by medical professionals, yet workforce practices and training have remained elusive. Academic literature particularly in the field of pediatric emergency medicine (PEM) fellowship training is lacking relative to general pediatrics and adult emergency medicine.

METHODS

The primary objective of this study was to assess the social care knowledge, perspectives, and training of PEM program directors (PDs) and fellows across a national cross-sectional sample. A secondary aim was to uncover key actionable areas for the development of social care curricula in PEM training programs. A social care practices assessment tool was developed via snowball sampling interviews among clinician researcher experts and disseminated to PEM PDs and fellows nationally in accredited academic PEM training institutions.

RESULTS

A total of 153 participants-44 PDs (49% response rate) and 109 fellows (28%)-completed the assessment tool. Responses among PDs and fellows were highly concordant. Only 12% reported regular use of a standardized social needs screening tool. The majority felt unprepared to assist families with social needs and less than half felt comfortable talking to families about social need. At the same time, social care was highly valued by 73% of participants. All participants felt that providing social care training during PEM fellowship would be beneficial. PDs and fellows identified five priority areas for PEM curricular development.

CONCLUSIONS

PEM PDs and fellows have an overall favorable perception of social care yet report significant deficits in current practice organization and training. This study is part of a larger national collaborative advocacy project to organize and advance social care delivery across academic PEM training institutions through evidence-based approaches, best practices, and expert consensus.

An Entrustable Professional Activity Addressing Racism and Pediatric Health Inequities

Racism and discrimination are the root of many pediatric health inequities and are well described in the literature. Despite the pervasiveness of pediatric health inequities, we have failed to adequately educate and prepare general pediatricians and pediatric subspecialists to address them. Deficiencies within education across the entire continuum and in our health care systems as a whole contribute to health inequities in unacceptable ways. To address these deficiencies, the field of pediatrics, along with other specialties, has been on a journey toward a more competency-based approach to education and assessment, and the framework created for the future is built on entrustable professional activities (EPAs). Competency-based medical education is one approach to addressing the deficiencies within graduate medical education and across the continuum by allowing educators to focus on the desired equitable patient outcomes and then develop an approach to teaching and assessing the tasks, knowledge, skills, and attitudes needed to achieve the goal of optimal, equitable patient care. To that end, we describe the development and content of a revised EPA entitled: Use of Population Health Strategies and Quality Improvement Methods to Promote Health and Address Racism, Discrimination, and Other Contributors to Inequities Among Pediatric Populations. We also highlight the ways in which this EPA can be used to inform curricula, assessments, professional development, organizational systems, and culture change.

Inequality and child health: dynamic population health interventions

PURPOSE OF REVIEW

Established social gradients across a wide range of child health issues including obesity, anxiety, infectious diseases, injuries, prematurity and low birth weight suggest that much illness is avoidable and there is an imperative to intervene in this whole of society issue. This review examines recent advances in understanding of the pathways to health and health inequalities and their application to interventions to improve health equity.

RECENT FINDINGS

Children's health develops over the life course in ways that are profoundly influenced by their entire developmental ecosystem including individual, family, community and system-level factors. Interventions to address child health inequalities must include action on the structural determinants of health, a greater focus on family and community health development, and attention to the acquisition of developmental capabilities. Nascent dynamic population health initiatives that address whole developmental ecosystems such as All Children Thrive, Better Start Bradford and Generation V, hold real promise for achieving child health equity.

SUMMARY

Pathways to health inequalities are driven by social and structural determinants of health. Interventions to address inequalities need to be driven less by older biomedical models, and more by prevailing ecological and complex systems models incorporating a life course health development approach.

Social Risk Interventions and Health Care Utilization for Pediatric Asthma: A Systematic Review and Meta-analysis

IMPORTANCE

Social determinants of health (SDOH) correlate with pediatric asthma morbidity, yet whether interventions addressing social risks are associated with asthma outcomes among children is unclear.

OBJECTIVE

To catalog asthma interventions by the social risks they address and synthesize their associations with asthma-related emergency department (ED) visits and hospitalizations among children.

DATA SOURCES

PubMed, Scopus, PsycINFO, SocINDEX, CINAHL, and references of included full-text articles were searched from January 1, 2008, to June 16, 2021.

STUDY SELECTION

Included articles were US-based studies evaluating the associations of interventions addressing 1 or more social risks with asthma-related ED visits and hospitalizations among children. The systematic review included 38 of the original 641 identified articles (6%), and the meta-analysis included 19 articles (3%).

DATA EXTRACTION AND SYNTHESIS

Data extraction followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. The SDOH intervention clusters were identified by grouping studies according to the social risks they addressed, using the Healthy People 2020 SDOH framework. Random-effects models created pooled risk ratios (RRs) as the effect estimates.

MAIN OUTCOMES AND MEASURES

Patients with ED visits or hospitalizations were the primary outcomes. Subgroup analyses were conducted by an SDOH intervention cluster. Sensitivity analyses were conducted for each, removing outlier studies and studies failing to meet the minimum quality threshold.

RESULTS

In total, 38 studies were included in the systematic review, with 19 of these studies providing data for the meta-analysis (5441 participants). All interventions addressed 1 or more of the health, environment, and community domains; no interventions focused on the economy or education domains. In the primary analysis, social risk interventions were associated with decreased ED visits (RR, 0.68; 95% CI, 0.57-0.81; I2 = 70%) and hospitalizations (RR, 0.50; 95% CI, 0.37-0.68; I2 = 69%). In subgroup analyses, the health, environment, and community intervention cluster produced the lowest RR for ED visits (RR, 0.53; 95% CI, 0.44-0.64; I2 = 50%) and for hospitalizations (RR, 0.33; 95% CI, 0.20-0.55; I2 = 71%) compared with other intervention clusters. Sensitivity analyses did not alter primary or subgroup effect estimates.

CONCLUSIONS AND RELEVANCE

The results of this systematic review and meta-analysis indicate that social risk interventions are associated with decreased asthma-related ED visits and hospitalizations among children. These findings suggest that addressing social risks may be a crucial component of pediatric asthma care to improve health outcomes.

Association Between Neighborhood Disadvantage and Pediatric Readmissions

OBJECTIVE

Although individual-level social determinants of health (SDH) are known to influence 30-day readmission risk, contextual-level associations with readmission are poorly understood among children. This study explores associations between neighborhood disadvantage measured by Area Deprivation Index (ADI) and pediatric 30-day readmissions.

METHODS

This retrospective cohort study included discharges of patients aged < 20 years from Maryland's 2013-2016 all-payer dataset. The ADI, which quantifies 17 indicators of neighborhood socioeconomic disadvantage within census block groups, is used as a proxy for contextual-level SDH. Readmissions were identified with the 30-day Pediatric All-Condition Readmissions measure. Associations between ADI and readmission were identified with generalized estimating equations adjusted for patient demographics and clinical severity (Chronic Condition Indicator [CCI], Pediatric Medical Complexity Algorithm [PMCA], Index Hospital All Patients Refined Diagnosis Related Groups [APR-DRG]), and hospital discharge volume.

RESULTS

Discharges (n = 138,998) were mostly female (52.7%), publicly insured (55.1%), urban-dwelling (93.0%), with low clinical severity levels (0-1 CCIs [82.3%], minor APR-DRG severity [48.4%]). Overall readmission rate was 4.0%. Compared to the least disadvantaged ADI quartile, readmissions for the most disadvantaged quartile were significantly more likely (aOR 1.19, 95% CI 1.09-1.30). After adjustment, readmissions were associated with public insurance and indicators of medical complexity (higher number of CCIs, complex-chronic disease PMCA, and APR-DRG severity).

CONCLUSION

In this all-payer, statewide sample, living in the most socioeconomically disadvantaged neighborhoods independently predicted pediatric readmission. While the relative magnitude of neighborhood disadvantage was modest compared to medical complexity, disadvantage is modifiable and thus represents an important consideration for prevention and risk stratification efforts.

Assessing the Strategies That Children's Hospitals Adopt to Engage the Social Determinants of Health in US Cities

CONTEXT

There is growing evidence that social factors contribute disproportionately to health outcomes in the United States as compared with health care services. As a result, nonprofit hospitals are incorporating strategies to address social needs into their Internal Revenue Service (IRS)-mandated community benefit work. Much of the research base on this subject, however, has focused on the efforts of adult-serving hospitals.

OBJECTIVE

The aim of this study was to determine whether communities surrounding children's hospitals are unique with regard to social needs and categorize how children's hospitals are addressing social needs in their IRS-mandated community benefit work.

METHODS

Using county-level health and economic data, we compared community characteristics of children's hospital counties with the national average. We then coded and analyzed the community benefit reports of all nonprofit children's hospitals in the United States to categorize the different strategies that hospitals adopt to address social needs.

RESULTS

Children's hospitals (N = 168) serve communities with greater social needs than the national average. In terms of community benefit investments, children's hospitals were more likely to identify social needs in their community health needs assessment than adult-serving hospitals, but still less than half identified or addressed 1 or more social needs. Children's hospitals were more likely to adopt interventions that address broader population health rather than strategies that focus on clinical services or children and adolescents in particular.

CONCLUSIONS

Pediatric health care institutions have a profound opportunity to reduce health disparities by altering the social environments in which children develop. Policy makers and scholars should provide support and resources to increase community benefit investments in this area.

Addressing Social Adversity to Improve Outcomes for Children After Liver Transplant

The social determinants of health, defined as the conditions in which we live, learn, work, and play, undoubtedly impact health outcomes. Social adversity in childhood perpetuates over the life course and has consequences extending into adulthood. This link between social adversity and adverse outcomes extends to children undergoing liver transplant, with children from socioeconomically deprived neighborhoods experiencing a greater burden of morbidity and mortality after transplant. Yet, we lack an in-depth understanding of how to address social adversity for these children. Herein, we lay out a strategy to develop and test interventions to address social adversity for children undergoing liver transplant. To do so, we believe that more granular data on how specific social risk factors (e.g., food insecurity) impact outcomes for children after liver transplant are needed. This will provide the liver transplant community with knowledge on the most pressing problems. Then, using the National Academies of Sciences, Engineering, and Medicine's framework for integrating social needs into medical care, the health system can start to develop and test health system interventions. We believe that attending to our patients' social adversity will realize improved outcomes for children undergoing liver transplant.

Pediatricians Contributing to Poverty Reduction Through Clinical-Community Partnership and Collective Action: A Narrative Review

Poverty affects child health and well-being in short- and long-term ways, directly and indirectly influencing a range of health outcomes through linked social and environmental challenges. Given these links, pediatricians have long advocated for poverty reduction in both clinical settings and society. Pediatricians and others who work in pediatric settings are well-suited to address poverty given frequent touchpoints with children and families and the trust that develops over repeated encounters. Many pediatricians also recognize the need for cross-sector engagement, mobilization, and innovation in building larger collaborative efforts to combat the harmful effects of poverty. A range of methods, like co-design, community organizing, and community-engaged quality improvement, are necessary to achieve measurable progress. Moreover, advancing meaningful representation and inclusion of those from underrepresented racial and ethnic minority groups will augment efforts to address poverty within and equity across communities. Such methods promote and strengthen key clinical-community partnerships poised to address poverty's upstream root causes and its harmful consequences downstream. This article focuses on those clinical-community intersections and cross-sector, multi-disciplinary programs like Medical-Legal Partnerships, Medical-Financial Partnerships, clinic-based food pantries, and embedded behavioral health services. Such programs and partnerships increase access to services difficult for children living in poverty to obtain. Partnerships can also broaden to include community-wide learning networks and asset-building coalitions, poised to accelerate meaningful change. Pediatricians and allied professionals can play an active role; they can convene, catalyze, partner, and mobilize to create solutions designed to mitigate the harmful effects of poverty on child health.

Poverty Related Education in Pediatrics: Current State, Gaps and Call to Action

Children are the poorest age group in our country, with 1 in 6, or 12 million, living in poverty. This sobering statistic became even more appalling in spring 2020 when COVID-19 magnified existing inequities. These inequities are particularly important to pediatricians, because poverty, along with racism and other interrelated social factors, significantly impact overall child health and well-being. It is imperative that pediatric educators redouble their efforts to train learners to recognize and address health inequities related to poverty and all of its counterparts. In this paper, we describe the current state of poverty-related training in pediatric undergraduate, graduate, and continuing medical education as well as opportunities for growth. We highlight gaps in the current curricula, particularly around the intersectionality between poverty and racism, as well as the need for robust evaluation. Using a logic model framework, we outline content, learning strategies, and outcomes for poverty-related education. We include opportunities for the deployment of best practice learning strategies and the incorporation of newer technologies to deliver the content. We assert that collaboration with community partners is critical to shape the depth and breadth of education. Finally, we emphasize the paramount need for high-quality faculty development and accessible career paths to create the cadre of role models and mentors necessary to lead this work. We conclude with a call for collaboration between institutions, accrediting bodies, and policymakers to promote meaningful, outcome-oriented, poverty-related education, and training throughout the medical education continuum.

Housing and Neighborhoods as Root Causes of Child Poverty

Understanding how housing inequities among families with children are rooted in structural racism is important for identifying opportunities to engage in ongoing and collective work as pediatricians to lift children out of poverty. This article discusses the complex mechanisms between housing and child and family health outcomes, and offers potential solutions linking housing, health programs, and policy solutions. Beginning with a review of historical antecedents of housing policy and their impact on health inequities, the authors outlines policies and structures directly linked to disproportionate housing instability and inequities in health outcomes among children. This article examines four key domains of housing - affordability, stability, quality, and neighborhood - and their relationship to child and family health. Finally, the authors present multidimensional solutions for advancing health equity.

We are part of the problem: the role of children's hospitals in addressing health inequity

Racism is an ongoing public health crisis that undermines health equity for all children in hospitals across our nation. The presence and impact of institutionalized racism contributes to health inequity and is under described in the medical literature. In this review, we focus on key interdependent areas to foster inclusion, diversity, and equity in Children's Hospitals, including 1) promotion of workforce diversity 2) provision of anti-racist, equitable hospital patient care, and 3) prioritization of academic scholarship focused on health equity research, quality improvement, medical education, and advocacy. We discuss the implications for clinical and academic practice.Plain Language Summary: Racism in Children's Hospitals harms children. We as health-care providers and hospital systems are part of the problem. We reviewed the literature for the best ways to foster inclusion, diversity, and equity in hospitals. Hospitals can be leaders in improving child health equity by supporting a more diverse workforce, providing anti-racist patient care, and prioritizing health equity scholarship.

Center variation in long-term outcomes for socioeconomically deprived children

Neighborhood socioeconomic deprivation is associated with adverse outcomes after pediatric liver transplant. We sought to determine if this relationship varies by transplant center. Using SRTR, we included patients <18 years transplanted 2008-2013 (N = 2804). We matched patient ZIP codes to a deprivation index (range [0,1]; higher values indicate increased socioeconomic deprivation). A center-level patient-mix deprivation index was defined by the distribution of patient-level deprivation. Centers (n = 66) were classified as high or low deprivation if their patient-mix deprivation index was above or below the median across centers. Center quality was classified as low or high graft failure if graft survival rates were better or worse than the overall 10-year graft survival rate. Primary outcome was patient-level graft survival. We used random-effect Cox models to evaluate center-level covariates on graft failure. We modeled center quality using stratified Cox models. In multivariate analysis, each 0.1 increase in the patient-mix deprivation index was associated with increased hazard of graft failure (HR 1.32; 95%CI: 1.05, 1.66). When stratified by center quality, patient-mix deprivation was no longer significant (HR 1.07, 95%CI: 0.89, 1.28). Some transplant centers care for predominantly high deprivation children and maintain excellent outcomes. Revealing and replicating these centers' practice patterns should enable more equitable outcomes.

The Child Opportunity Index 2.0 and Hospitalizations for Ambulatory Care Sensitive Conditions

BACKGROUND AND OBJECTIVES

Hospitalizations for ambulatory care sensitive conditions (ACSCs) are thought to be avoidable with high-quality outpatient care. Morbidity related to ACSCs has been associated with socioeconomic contextual factors, which do not necessarily capture the complex pathways through which a child's environment impacts health outcomes. Our primary objective was to test the association between a multidimensional measure of neighborhood-level child opportunity and pediatric hospitalization rates for ACSCs across 2 metropolitan areas.

METHODS

This was a retrospective population-based analysis of ACSC hospitalizations within the Kansas City and Cincinnati metropolitan areas from 2013 to 2018. Census tracts were included if located in a county where Children's Mercy Kansas City or Cincinnati Children's Hospital Medical Center had >80% market share of hospitalizations for children <18 years. Our predictor was child opportunity as defined by a composite index, the Child Opportunity Index 2.0. Our outcome was hospitalization rates for 8 ACSCs.

RESULTS

We included 604 943 children within 628 census tracts. There were 26 977 total ACSC hospitalizations (46 hospitalizations per 1000 children; 95% confidence interval [CI]: 45.4-46.5). The hospitalization rate for all ACSCs revealed a stepwise reduction from 79.9 per 1000 children (95% CI: 78.1-81.7) in very low opportunity tracts to 31.2 per 1000 children (95% CI: 30.5-32.0) in very high opportunity tracts (P < .001). This trend was observed across cities and diagnoses.

CONCLUSIONS

Links between ACSC hospitalizations and child opportunity extend across metropolitan areas. Targeting interventions to lower-opportunity neighborhoods and enacting policies that equitably bolster opportunity may improve child health outcomes, reduce inequities, and decrease health care costs.

Neighborhood Conditions and Recurrent Emergency Department Utilization by Children in the United States

OBJECTIVE

To determine the associations of social and physical neighborhood conditions with recurrent emergency department (ED) utilization by children in the US.

STUDY DESIGN

This cross-sectional study was conducted with the National Survey of Children's Health from 2016 to 2018 to determine the associations of neighborhood characteristics of cohesion, safety, amenities, and detractors with the proportions of children aged 1-17 years with recurrent ED utilization, defined as 2 or more ED visits during the past 12 months. A multivariable regression model was used to determine the independent association of each neighborhood characteristic with recurrent ED utilization controlling for individual-level characteristics.

RESULTS

In this study of 98 711 children weighted to a population of 70 million nationally, children had significantly greater rates of recurrent ED utilization if they lived in neighborhoods that were not cohesive, were not safe, or had detractors present (all P < .001). With adjustment for individual-level covariates and the other neighborhood characteristics, only neighborhood detractors were independently associated with recurrent ED utilization (1 detractor: aOR 1.32, 95% CI 1.03-1.68; 2 or 3 detractors: aOR 1.37, 95% CI 1.04-1.81).

CONCLUSIONS

Among neighborhood characteristics, the presence of physical detractors such as rundown housing and vandalism was most strongly associated with recurrent ED utilization by children. Negative attributes of the built environment may be a potential target for neighborhood-level, place-based interventions to alleviate disparities in child healthcare utilization.

Following through: Interventions to improve long-term outcomes of preterm infants

The inequalities in income, wealth, and opportunity so deeply ingrained in our society's history of enslavement, genocide, racism, and discrimination are root causes of health disparities. Follow through is a comprehensive approach that begins before birth and continues into childhood, where health professionals, families, and communities partner to meet the social as well as medical needs of infants and families to achieve health equity. This article discusses potentially better practices for follow through, offering neonatal care providers tangible ways to address social determinants of health, the conditions in which people are born, grow, work, live, and age and the systems that creates these conditions.

Using rising tides to lift all boats: Equity-focused quality improvement as a tool to reduce neonatal health disparities

Evidence of health disparities affecting newborns abounds. Although quality improvement (QI) methodology is often suggested as a tool to advance health equity, the impact of QI initiatives on disparities is variable. QI work may mitigate, worsen, or perpetuate existing disparities. QI projects designed without an intentional focus on equity promotion may foster intervention-generated inequalities that further disadvantage vulnerable groups. This article reviews disparities in perinatal and neonatal care, the impact of QI on health disparities, and the concept of "Equity-Focused Quality Improvement" (EF-QI). EF-QI differs from QI with an equity lens in that it is action-oriented and centered around equity. EF-QI initiatives purposely integrate equity throughout the fabric of the project and are inclusive, collaborative efforts that foreground and address the needs of disadvantaged populations. EF-QI principles are applicable at every stage of project conception, execution, analysis, and dissemination, and may provide opportunities for reducing disparities in neonatal care.

Understanding Variation In Nonurgent Pediatric Emergency Department Use In Communities With Concentrated Disadvantage

Children in communities with concentrated socioeconomic and structural disadvantage tend to have elevated rates of nonurgent visits to emergency departments (EDs). Using a spatial regression model of 264 census block groups in Pittsburgh, Pennsylvania, we investigated sociodemographic and structural factors associated with lower-than-expected ("low utilization") versus higher-than-expected ("high utilization") nonurgent ED visit rates among children in block groups with concentrated disadvantage. Compared with high-utilization block groups, low-utilization block groups had higher percentages of households with two adults, high school graduates, access to vehicles, sound housing quality, and owner-occupied housing. Notably, low-utilization block groups did not differ significantly from high-utilization block groups either in the percentage of households located within very close proximity to public transit or primary care or in children's health insurance coverage rates. Stakeholders wishing to reduce pediatric nonurgent ED visits among families in communities of concentrated disadvantage should consider strategies to mitigate financial, time, transportation, and health literacy constraints that may affect families' access to primary care.

Neighborhood socioeconomic deprivation is associated with worse patient and graft survival following pediatric liver transplantation

Long-term outcomes remain suboptimal following pediatric liver transplantation; only one third of children have normal biochemical liver function without immunosuppressant comorbidities 10 years posttransplant. We examined the association between an index of neighborhood socioeconomic deprivation with graft and patient survival using the Scientific Registry of Transplant Recipients. We included children <19 years who underwent liver transplantation between January 1, 2008 to December 31, 2013 (n = 2868). Primary exposure was a neighborhood socioeconomic deprivation index-linked via patient home ZIP code-with a range of 0-1 (values nearing 1 indicate neighborhoods with greater socioeconomic deprivation). Primary outcome measures were graft failure and death, censored at 10 years posttransplant. We modeled survival using Cox proportional hazards. In univariable analysis, each 0.1 increase in the deprivation index was associated with a 14.3% (95% confidence interval [CI]): 3.8%-25.8%) increased hazard of graft failure and a 12.5% (95% CI: 2.5%-23.6%) increased hazard of death. In multivariable analysis adjusted for race, each 0.1 increase in the deprivation index was associated with a 11.5% (95% CI: 1.6%-23.9%) increased hazard of graft failure and a 9.6% (95% CI: -0.04% to 20.7%) increased hazard of death. Children from high deprivation neighborhoods have diminished graft and patient survival following liver transplantation. Greater attention to neighborhood context may result in improved outcomes for children following liver transplantation.

Engagement science: The core of dissemination, implementation, and translational research science

Stakeholder engagement is acknowledged as central to dissemination and implementation (D&I) of research that generates and answers new clinical and health service research questions. There is both benefit and risk in conducting stakeholder engagement. Done wrong, it can damage trust and adversely impact study results, outcomes, and reputations. Done correctly with sensitivity, inclusion, and respect, it can significantly facilitate improvements in research prioritization, communication, design, recruitment strategies, and ultimately provide results useful to improve population and individual health. There is a recognized science of stakeholder engagement, but a general lack of knowledge that matches its strategies and approaches to particular populations of interest based on history and characteristics. This article reviews stakeholder engagement, provides several examples of its application across the range of translational research, and recommends that Clinical Translational Science Awards, with their unique geographical, systems, and historical characteristics, actively participate in deepening our understanding of stakeholder engagement science and methods within implementation and dissemination research. These recommendations include (a) development of an inventory of successful stakeholder engagement strategies; (b) coordination and intentionally testing a variety of stakeholder engagement strategies; (c) tool kit development; and (d) identification of fundamental motivators and logic models for stakeholder engagement to help align stakeholders and researchers.

Association of a Targeted Population Health Management Intervention with Hospital Admissions and Bed-Days for Medicaid-Enrolled Children

IMPORTANCE

As the proportion of children with Medicaid coverage increases, many pediatric health systems are searching for effective strategies to improve management of this high-risk population and reduce the need for inpatient resources.

OBJECTIVE

To estimate the association of a targeted population health management intervention for children eligible for Medicaid with changes in monthly hospital admissions and bed-days.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study, using difference-in-differences analysis, deployed integrated team interventions in an academic pediatric health system with 31 in-network primary care practices among children enrolled in Medicaid who received care at the health system's hospital and primary care practices. Data were collected from January 2014 to June 2017. Data analysis took place from January 2018 to June 2019.

EXPOSURES

Targeted deployment of integrated team interventions, each including electronic medical record registry development and reporting alongside a common longitudinal quality improvement framework to distribute workflow among interdisciplinary clinicians and community health workers.

MAIN OUTCOMES AND MEASURES

Trends in monthly inpatient admissions and bed-days (per 1000 beneficiaries) during the preimplementation period (ie, January 1, 2014, to June 30, 2015) compared with the postimplementation period (ie, July 1, 2015, to June 30, 2017).

RESULTS

Of 25 460 children admitted to the hospital's health system during the study period, 8418 (33.1%) (3869 [46.0%] girls; 3308 [39.3%] aged ≤1 year; 5694 [67.6%] black) were from in-network practices, and 17 042 (67.9%) (7779 [45.7%] girls; 6031 [35.4%] aged ≤1 year; 7167 [41.2%] black) were from out-of-network practices. Compared with out-of-network patients, in-network patients experienced a decrease of 0.39 (95% CI, 0.10-0.68) monthly admissions per 1000 beneficiaries (P = .009) and 2.20 (95% CI, 0.90-3.49) monthly bed-days per 1000 beneficiaries (P = .001). Accounting for disproportionate growth in the number of children with medical complexity who were in-network to the health system, this group experienced a monthly decrease in admissions of 0.54 (95% CI, 0.13-0.95) per 1000 beneficiaries (P = .01) and in bed-days of 3.25 (95% CI, 1.46-5.04) per 1000 beneficiaries (P = .001) compared with out-of-network patients. Annualized, these differences could translate to a reduction of 3600 bed-days for a population of 93 000 children eligible for Medicaid.

CONCLUSIONS AND RELEVANCE

In this quality improvement study, a population health management approach providing targeted integrated care team interventions for children with medical and social complexity being cared for in a primary care network was associated with a reduction in service utilization compared with an out-of-network comparison group. Standardizing the work of care teams with quality improvement methods and integrated information technology tools may provide a scalable strategy for health systems to mitigate risk from a growing population of children who are eligible for Medicaid.