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

Evaluation of Neighborhood Resources and Pediatric Status Epilepticus Outcomes in the Intensive Care Unit Across the United States

This study aimed to investigate outcomes for children with underlying epilepsy admitted to an intensive care unit for status epilepticus in relation to Child Opportunity Index. Data were obtained from the Pediatric Health Information System for patients aged 1 month to 21 years admitted to the intensive care unit for a primary diagnosis of epilepsy with status epilepticus. Mixed effects regression models were used to estimate the association between Child Opportunity Index and our outcomes: invasive mechanical ventilation, vasoactive medication administration, and in-hospital mortality. Encounters with very low, low, and moderate Child Opportunity Index levels were more likely to receive invasive mechanical ventilation compared to very high Child Opportunity Index level, though there were no differences for vasoactive medication administration or in-hospital mortality. This demonstration of neighborhood disparities specifically for children with epilepsy presenting in status epilepticus to an intensive care unit should inform future interventions aimed at improving neighborhood resources.

Lower Childhood Opportunity Index is Associated with Delayed Diagnosis of Anorectal Malformations

PURPOSE

Delay in diagnosis of anorectal malformations (ARM) can potentially lead to adverse events. Perineal and rectovestibular fistulas are more likely to be missed on exam compared to other ARM subtypes. We aimed to identify which clinical factors and social determinants of health (SDOH) elements may be associated with missed diagnosis of these ARMs.

METHODS

A retrospective review was performed of all infants with perineal or rectovestibular fistulas seen at a single center from 2014 to 2023. Delayed diagnosis was defined as those made beyond the second day of life. Data were collected regarding birth hospital NICU acuity, location of diagnosis, clinical factors, adverse sequelae, and SDOH, including Child Opportunity Index (COI). Categorical variables were analyzed via Fisher's Exact Test. Ordinal variables were analyzed using Cochran-Armitage Test for Trend.

RESULTS

A total of 172 patients were diagnosed with perineal or rectovestibular fistula during the time period, of which 31.9% had delay in diagnosis (Table 1). There was no significant difference in acuity level of the birth hospital, race, ethnicity, insurance type, non-English language preference (NELP), or rural vs. urban setting between delayed and timely diagnosis. As COI increased in the cohort, there was a significant trend toward lower association with delayed diagnosis (Table 1). Those with delayed diagnosis were more likely to present with fecal impaction or have an unplanned pre-operative admission (p<0.001).

CONCLUSION

In this study, patients with lower COI experienced higher likelihood of delayed diagnosis of ARM. Efforts should be made to improve prompt diagnosis in this at-risk population.

LEVEL OF EVIDENCE

III.

Lower Childhood Opportunity Index is Associated With Delayed Diagnosis of Anorectal Malformations

PURPOSE

Delay in diagnosis of anorectal malformations (ARM) can potentially lead to adverse events. Perineal and rectovestibular fistulas are more likely to be missed on exam compared to other ARM subtypes. We aimed to identify which clinical factors and social determinants of health (SDOH) elements may be associated with missed diagnosis of these ARMs.

METHODS

A retrospective review was performed of all infants with perineal or rectovestibular fistulas seen at a single center from 2014 to 2023. Delayed diagnosis was defined as those made beyond the second day of life. Data were collected regarding birth hospital NICU acuity, location of diagnosis, clinical factors, adverse sequelae, and SDOH, including Child Opportunity Index (COI). Categorical variables were analyzed via Fisher's Exact Test. Ordinal variables were analyzed using Cochran-Armitage Test for Trend.

RESULTS

A total of 172 patients were diagnosed with perineal or rectovestibular fistula during the time period, of which 31.9 % had delay in diagnosis (Table 1). There was no significant difference in acuity level of the birth hospital, race, ethnicity, insurance type, non-English language preference (NELP), or rural vs. urban setting between delayed and timely diagnosis. As COI increased in the cohort, there was a significant trend toward lower association with delayed diagnosis. Those with delayed diagnosis were more likely to present with fecal impaction or have an unplanned pre-operative admission (p < 0.001).

CONCLUSION

In this study, patients with lower COI experienced higher likelihood of delayed diagnosis of ARM. Efforts should be made to improve prompt diagnosis in this at-risk population.

LEVEL OF EVIDENCE

III.

Child Opportunity Index is Not Associated With Cleanliness in Patients With Anorectal Malformations Treated at Pediatric Colorectal Centers: A Multi-Institutional Study

BACKGROUND

Individually collected social determinants of health (SDOH) have been associated with negative outcomes in children with anorectal malformations (ARMs). Our aim was to assess whether the Child Opportunity Index (COI) is associated with bowel management strategy and fecal cleanliness in patients with ARM managed at specialized pediatric colorectal centers. We hypothesized that children from low COI would have lower rates of cleanliness.

METHODS

A multi-institutional retrospective review evaluated children ≥4 years old with ARM treated at centers participating in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC), excluding patients with ostomies. The primary exposure was COI, obtained by ZIP code. The primary outcome was fecal cleanliness, defined as ≤1 weekly stool accident. Additional variables evaluated included demographics, ARM severity, bowel management type, medical comorbidities, and complications in those undergoing antegrade continence enema procedures. COI groups were compared for trend (p-value ≤0.05 as significant).

RESULTS

The cohort included 550 patients, most (75.1%) residing in moderate, high, or very high opportunity areas. There were no differences in ARM severity between COI groups. Stratified by age, there were no differences in fecal cleanliness (p = 0.788) or bowel management strategy (p = 0.224) by COI. There were few overall complications from ACE placement (12.3%), but ACE complications were more common in children from low-opportunity areas (22.2% vs 2.9%; p = 0.01).

CONCLUSION

Contrary to hypothesized, children with anorectal malformations managed at tertiary institutions within PCPLC do not differ by COI in bowel management strategy or fecal cleanliness outcome. Further investigation into individual disparities may be more important in these patients.

LEVEL OF EVIDENCE

III = retrospective comparative study.

Association of the child opportunity index with in-hospital mortality and persistence of organ dysfunction at one week after onset of Phoenix Sepsis among children admitted to the pediatric intensive care unit with suspected infection

The social determinants of health (SDoH) are fundamental factors that contribute to overall health and health-related outcomes. Children living in lower socioeconomic areas have a higher risk of critical illness and worse outcomes compared to children living in more socioeconomically advantaged areas. In this work, we determine whether the Child Opportunity Index (COI 3.0), a multi-dimensional child-specific indicator of neighborhood environment, is associated with in-hospital mortality or persistence of a Phoenix Sepsis Score  ≥  2 at one week following Phoenix Sepsis onset in children admitted to pediatric intensive care units (PICUs) with suspected infection. We performed a retrospective cohort analysis of 63,824 patients with suspected or confirmed infection admission diagnosis in two PICUs in Atlanta, Georgia with a Georgia residential address that could be geocoded and linked to a census tract. The primary outcome was the composite of in-hospital mortality or persistence of a Phoenix Sepsis Score  ≥  2 at one week following Phoenix Sepsis onset. Model performance measures of interest were the area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC). Models developed with electronic medical record (EMR) data using Egleston (EG) or Scottish Rite (SR) as the training site achieved AUROCs of 0.81-0.84 (95% CI range: 0.8-0.85) and 0.82-0.82 (95% CI range: 0.81-0.83) and AUPRCs of 0.59-0.68 (95% CI range: 0.58-0.69) and 0.62-0.64 (95% CI range: 0.61-0.65) respectively. Despite significant differences in COI 3.0 characteristics and overall in-hospital mortality of children with Phoenix suspected infection between the EG and SR PICUs, the addition of COI 3.0 did not improve the overall model performance metrics. While children admitted to both PICUs were more often from COI 3.0 neighborhoods in the lowest two quintiles, these neighborhood features had less of an impact on the model's predictive performance compared to patient physiologic and biologic features available in the EMR.

The Child Opportunity Index and Children's Health: A Meta-Analysis

CONTEXT

Quantifying the impact of place on pediatric health is difficult given the diverse methodologies used to measure place-based social determinants. However, the Child Opportunity Index (COI) is increasingly used to study these relationships.

OBJECTIVE

To synthesize associations between the COI and pediatric health.

DATA SOURCES

Fifteen databases, 4 gray literature sources, and diversitydatakids.org searched from 2014 to 2024.

STUDY SELECTION

US-based observational studies that evaluated children, the COI, and at least 1 pediatric health outcome.

DATA EXTRACTION

Protocol registered with PROSPERO (CRD42023418407). Random-effects models created pooled odds ratios (ORs) comparing very low/low COI to high/very high COI for mortality, emergency department (ED) use, and hospital use. Clinically relevant subgroups were explored.

RESULTS

Most studies (n = 61 of 85; 72%) reported inverse associations between the COI and an adverse outcome. Lower COI was associated with higher odds of mortality (OR, 1.50; 95% CI, 1.31-1.94; tau squared [τ2] = 0.045; 15 associations from 13 studies). Overall, ED visits were similar (OR, 1.38; 95% CI, 0.97-1.95; τ2 = 0.312; 10 associations from 6 studies), but the subgroup of all-cause ED visits were significantly higher among children with lower COI (OR, 1.66; 95% CI, 1.19-2.31; τ2 = 0.198; 7 associations from 5 studies). Select hospitalization subgroups (medical, surgical/trauma, and >30-day rehospitalizations) were significantly associated with COI, but not overall hospitalizations (OR, 1.15; 95% CI, 0.96-1.36; τ2 = 0.090; 12 studies).

LIMITATIONS

Meta-analyses were unadjusted.

CONCLUSIONS

Place is a risk factor for children's mortality and select measures of health care use. Shifting the focus from identifying place-based disparities to cocreating community-engaged strategies that mitigate disparities may effectively advance children's health equity.

Area-Level Socioeconomic Disadvantage and Post-PICU Outcomes in Children With an Acquired Brain Injury: Single-Center Retrospective Cohort, 2016-2023

OBJECTIVES

To examine associations between measures of area-level socioeconomic disadvantage and disability outcomes in children with acquired brain injuries (ABIs) after PICU hospitalization.

DESIGN

Retrospective cohort study.

SETTING

Tertiary academic children's hospital.

PATIENTS

Children 3-19 years old admitted to the PICU for ABI (2016-2023) who completed a post-PICU follow-up clinic visit 1-3 months after discharge.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

In 455 children with ABI, median age of 10.8 years (interquartile range, 6.6-14.2 yr), we measured area-level socioeconomic disadvantage with the Child Opportunity Index (COI; higher scores equal less disadvantage) and Area Deprivation Index (ADI; higher scores equal more disadvantage) referenced to state. COI was categorized by quintile (very low to very high) and ADI was grouped into the lowest three, middle four, and highest three deciles. New disability was defined as greater than or equal to 1 point increase from baseline in Functional Status Scale total score at follow-up. New disability was present in 97 of 455 children (21.3%). New disability, low COI, and high ADI were independently associated with severity of illness. Multivariable logistic regression controlling for demographic and clinical covariates showed very high vs. very low COI was associated with 60% lesser odds of new disability at follow-up (adjusted odds ratio [aOR], 0.41; 95% CI, 0.17-0.99). We failed to identify such an association comparing the low to high ADI group (aOR, 0.59; 95% CI, 0.30-1.16), but we are unable to exclude the possibility that living in advantaged areas was associated with up to 70% lesser odds of new disability at follow-up.

CONCLUSIONS

In children with ABI, we have found that area-level socioeconomic disadvantage is associated with greater odds of post-PICU disability, when controlling for other demographic and severity of illness characteristics. Future research is needed to identify modifiable targets to reduce disparities in PICU outcomes after ABI.

Accountable Care Organizations, Child Opportunity Index, and Complicated Appendicitis in Children

INTRODUCTION

Child Opportunity Index (COI) is associated with complicated appendicitis (CA) in children. Value-based care through an accountable care organization (ACO) may modify this association. We aimed to determine if enrollment in our state's ACO, Partners For Kids (PFK), modified the association between COI and CA.

METHODS

Using a single-institution, retrospective review of children with public insurance undergoing appendectomy for acute appendicitis, COI and clinical confounders were compared by simple versus CA. Multivariable logistic regression models using COI, insurance, and age were fit with and without interaction terms to determine if PFK enrollment modified the association between COI and CA.

RESULTS

Among 1337 children, 31.0% had CA. Most (78.6%) were enrolled in PFK; this was not different between simple and CA. CA was associated with younger median age (7.0 y versus 8.0 y, P < 0.001). As overall COI quintile decreased (lower opportunity), the percentage of children with CA increased (P = 0.01). On multivariable regression controlling for age, PFK, and COI, only Very Low COI and age remained significantly associated with CA. The association between COI and CA was not modified by PFK enrollment. COI and PFK enrollment were not associated with postoperative complications, except children with PFK had fewer 30-d readmissions (4.2% versus 14.6%, P < 0.001) compared to those with other public insurance.

CONCLUSIONS

Low COI was associated with higher CA, and this association was not modified by enrollment in an ACO, suggesting that ACO enrollment alone may not be sufficient in addressing social determinants of health among children with CA.

Features of children with critical asthma hospitalized in a pediatric intensive care unit: Results from the ICU-3A study

INTRODUCTION

Despite improvements in long-term asthma treatment, an increasing number of children are being hospitalized in pediatric intensive care units (PICU) for asthma. The main objective of this study was to describe a recent cohort of children hospitalized in PICU for asthma to identify risk factors associated with a need for respiratory support, and multiple PICU stays.

METHODS

We conducted a retrospective cohort study in three PICUs in Paris (intensive care units 3A Study), using medical files of children hospitalized for asthma between February 2019 and October 2020. Need for respiratory support was defined by the need for high-flow nasal cannula or mechanical ventilation (MV) (either noninvasive [NIV] or invasive [IMV]).

RESULTS

During the study period, 252 stays corresponding to 234 patients were analyzed. MV was required in 17.5% of stays, for significantly younger patients (2.37 vs. 4.18 years, p = 0.002). On multivariate analysis, a higher risk of progression to a need for respiratory support was found for children requiring magnesium sulfate or oxygen therapy ≥6 L/mn before PICU admission (RR 4.48; CI95% [1.85-10.89]; p = 0.001, and RR 2.86; CI95% [1.13-7.22]; p = 0.03, respectively), and those with atelectasis detected on chest radiography (RR 3.38; CI95% [1.43-8.00]; p < 0.01). Multiple PICU stays were associated with greater social deprivation (RR for French Deprivation Index 1.25; CI95% [1.03-1.51]; p = 0.03).

CONCLUSION

Children experiencing social deprivation are at greater risk of multiple PICU stays for severe asthma. After transfer to PICU, children with chest radiograph detected atelectasis on admission are at higher risk of needing respiratory support.

Comparative Analysis of Indices for Social Determinants of Health in Pediatric Surgical Populations

Importance

Conclusions vary substantially among studies examining associations between area-based social determinants of health (SDOH) and pediatric health disparities based on the selected patient population and SDOH index. Most national studies use zip codes, which encompass a wide distribution of communities, limiting the generalizability of findings.

Objectives

To characterize the distributions of composite SDOH indices for pediatric surgical patients within a national sample of academic children's hospitals and to assess SDOH index precision in classifying patients at similar levels of disadvantage.

Design, Setting, and Participants

This multicenter retrospective cohort study included patients younger than 18 years who underwent surgery from January 1, 2016, to December 31, 2021, at 8 American College of Surgeons National Surgical Quality Improvement Program Pediatric children's hospitals. Data were analyzed November 15, 2023, to September 25, 2024.

Exposures

Exposures included the Social Vulnerability Index (SVI), Area Deprivation Index (ADI), and Child Opportunity Index (COI), which are composite scores of SDOH factors within a geographic area. A standardized, high-fidelity process was developed to link individual patients to SDOH indices at the US census tract and census block group level.

Main Outcomes and Measures

The primary outcome was composite SDOH index distribution, which was assessed using interrater reliability scores. Substantial agreement was defined as a Cohen κ statistic higher than 0.60.

Results

Of 55 865 included patients, 54.6% were male; 34.8% were infants and toddlers (0-3 years of age), 39.0% were school age (4-12 years), and 26.2% were adolescents (13-17 years). A total of 3468 patients (6.2%) could not be matched to either an SVI, ADI, or COI. Patients with missing geocodes were more likely to be Hispanic (20.1% vs 17.1%; P < .001) and have Medicaid insurance (48.1% vs 44.6%; P < .001) compared with patients with addresses that could be geocoded. With all institutions grouped, SDOH indices showed only minor variations. However, within each institution and among institutions, indices varied considerably, especially the ADI. Indices had low-to-fair interrater reliability within institutions (κ range, 0.15-0.33), indicating that each index classified individual patients differently according to disadvantage.

Conclusions and Relevance

In this multicenter retrospective cohort study of 55 865 pediatric surgical patients, 3 different composite measures of SDOH classified disadvantage for individual patients differently. The SDOH index components should be understood and carefully considered prior to inclusion of a composite measure in the analysis of children's surgical outcomes.

The association between composite measures of social vulnerability and PICU admission for status asthmaticus

BACKGROUND

Current knowledge of the impact of socioeconomic factors on the risk of admission to the pediatric intensive care unit (PICU) for asthma is limited. Using composite measures of social vulnerability-Social Vulnerability Index (SVI) and Child Opportunity Index (COI) 2.0-we compared patients admitted for status asthmaticus to the PICU and pediatric ward at Children's Hospital Los Angeles (CHLA). We hypothesized patients with a high SVI and low COI are at higher risk for PICU admission.

METHODS

Patients were identified using ICD-10 codes for asthma. Primary outcome was admission to PICU versus ward for status asthmaticus. Patient-registered residential street addresses were geocoded and spatially joined to SVI and COI 2.0 data at the census tract level. Univariate and regression analyses using the patient's SVI, COI 2.0, and admission location were conducted.

RESULTS

From January 2017 to March 2022, there were 2458 admissions matched to addresses from 1983 distinct patients. The overall median SVI for all patients was 0.86 (IQR 0.6, 0.9). Overall median COI was 25.0 (IQR 10, 50). There was no difference in SVI or COI for admission to the PICU versus the ward. However, children requiring multiple hospital admissions for asthma were associated with higher SVI and lower COI.

CONCLUSIONS

Children admitted to CHLA for asthma had an elevated SVI and low COI. There was no difference between admission locations based on SVI or COI scores. This indicates we care for children at increased socioeconomic risk, but this did not increase PICU use for asthma.

Health Disparities in the Management and Outcomes of Critically Ill Children and Neonates: A Scoping Review

To date, health disparities in critically ill children have largely been studied within, not across, specific intensive care unit (ICU) settings, thus impeding collaboration which may help advance the care of critically ill children. The aim of this scoping review is to summarize the literature intentionally designed to examine health disparities, across 3 primary ICU settings (neonatal ICU, pediatric ICU, and cardiac ICU) in the United States. We included over 50 studies which describe health disparities across race and/or ethnicity, area-level indices, insurance status, socioeconomic position, language, and distance.

Assessing Social Determinants of Health During Critical Illness: Implications and Methodologies

A growing body of literature has identified social determinants of health (SDoH) as potential contributors to health disparities in pediatric critical illness. Pediatric critical care providers should use validated screening tools to identify unmet social needs and ensure appropriate referral through multisector partnerships. Pediatric critical care researchers should consider factors outside of race and insurance status and explore the association between neighborhood-level factors and disparate health outcomes during critical illness. Measuring and addressing the SDoH at the individual and neighborhood level are important next steps in mitigating health disparities for critically ill pediatric patients.

Association of the Child Opportunity Index and Inpatient Illness Severity in the United States, 2018-2019

OBJECTIVE

Children residing in impoverished neighborhoods have reduced access to health care resources. Our objective was to identify potential associations between Child Opportunity Index (COI), a composite score of neighborhood characteristics, and inpatient severity of illness and clinical trajectory among United States (US) children.

METHODS

This retrospective cohort study assessed data using the Pediatric Health Information System Registry from 2018 to 2019. Primary exposure variable was COI level (range: very low [CO1 1], low [COI 2], moderate [COI 3], high [COI 4], and very high [COI 5]). Markers of inpatient clinical severity included index mortality, Pediatric Intensive Care Unit (PICU) admission, invasive mechanical ventilation (IMV), and hospital length of stay (LOS). Subgroup analysis of COI and clinical outcome variation by United States Census Geographic Regions was conducted. Adjusted regression analysis was utilized to understand associations between COI and inpatient clinical severity outcomes.

RESULTS

Of the 132,130 encounters, 44% resided in very low or low COI neighborhoods. In adjusted models, very low COI was associated with increased mortality (aOR: 1.35, 95% CI: 1.05-1.74, P = .018), PICU admission (aOR: 1.06, 95% CI: 1.02-1.11, P = 0.014), IMV (aOR: 1.12, 95% CI: 1.04-1.21, P = .002), and higher hospital LOS (P = .045). Regional variation by COI depicted the East North Central region having the highest rate of mortality (20.5%), P < .001, and PICU admissions (23%), P = .014.

CONCLUSIONS

Our multicenter, retrospective study highlights the interaction between neighborhood-level deprivation and worsened health disparities, indicating a need for prospective study.

The Childhood Opportunity Index's Association with Adverse Pregnancy and Newborn Outcomes in Nulliparous Persons

OBJECTIVE

 The objective of the study was to determine if using a novel measure of social determinants of health, the Childhood Opportunity Index (COI), at the time of delivery was associated with development of adverse pregnancy outcomes (APO) in nulliparous pregnant persons.

STUDY DESIGN

 Data were extracted from the 779 participants from a single nuMoM2b (Nulliparous Pregnancy Outcomes Study: monitoring mothers-to-be) study site, a prospective cohort study designed to identify contributors to APOs. Residential address information at delivery was linked to the location's COI. The overall composite and component scores in education, health and environmental, and socioeconomic indices were recorded. APOs of interest included preterm birth, hypertensive disorders of pregnancy, small for gestational age at birth, stillbirth, and gestational diabetes. Participant characteristics were compared by COI category and the association of COI with APOs was analyzed by logistic regression, controlling for age and self-reported race/ethnicity.

RESULTS

 The overall COI distribution was very low (45%), low (17%), moderate (10%), high (15%), and very high (13%). A total of 329 (43.5%) participants experienced at least one APO. Overall COI was associated with developing an APO (p = 0.02). Each component score was also associated with developing APOs and with race/ethnicity (p < 0.05). Compared with higher COI categories, an overall low or very low categorized location was independently associated with developing an APO (odds ratio: 1.636, 95% confidence interval: 1.16-2.31). Adjusting for gestational age at birth, those in lower COI areas had newborns with lower birth weight, birth length, and head circumference (estimate [95% confidence interval] birth weight: -0.0005 g [-0.0008 to -0.0001]; length: -0.065 cm [-0.124 to -0.0091]; head circumference: -0.123 cm [-0.208 to -0.045]). COI was not associated with other newborn outcomes.

CONCLUSION

 COI, a marker for social determinants of health, is independently associated with APOs. The COI may be a tool for risk stratification for pregnant people to help with APO-reducing strategies.

KEY POINTS

· The COI is a neighborhood-level marker for social determinants of health.. · The COI at time of delivery is associated with APO and newborn birth weight, length, and head circumference.. · The COI may be usable in pregnancy clinics to help identify resource needs to optimize outcomes for pregnant individuals and newborns..

Child Opportunity Index and Pediatric Intensive Care Outcomes: A Multicenter Retrospective Study in the United States

OBJECTIVES

To evaluate for associations between a child's neighborhood, as categorized by Child Opportunity Index (COI 2.0), and 1) PICU mortality, 2) severity of illness at PICU admission, and 3) PICU length of stay (LOS).

DESIGN

Retrospective cohort study.

SETTING

Fifteen PICUs in the United States.

PATIENTS

Children younger than 18 years admitted from 2019 to 2020, excluding those after cardiac procedures. Nationally-normed COI category (very low, low, moderate, high, very high) was determined for each admission by census tract, and clinical features were obtained from the Virtual Pediatric Systems LLC (Los Angeles, CA) data from each site.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Among 33,901 index PICU admissions during the time period, median patient age was 4.9 years and PICU mortality was 2.1%. There was a higher percentage of admissions from the very low COI category (27.3%) than other COI categories (17.2-19.5%, p < 0.0001). Patient admissions from the high and very high COI categories had a lower median Pediatric Index of Mortality 3 risk of mortality (0.70) than those from the very low, low, and moderate COI groups (0.71) ( p < 0.001). PICU mortality was lowest in the very high (1.7%) and high (1.9%) COI groups and highest in the moderate group (2.5%), followed by very low (2.3%) and low (2.2%) ( p = 0.001 across categories). Median PICU LOS was between 1.37 and 1.50 days in all COI categories. Multivariable regression revealed adjusted odds of PICU mortality of 1.30 (95% CI, 0.94-1.79; p = 0.11) for children from a very low versus very high COI neighborhood, with an odds ratio [OR] of 0.996 (95% CI, 0.993-1.00; p = 0.05) for mortality for COI as an ordinal value from 0 to 100. Children without insurance coverage had an OR for mortality of 3.58 (95% CI, 2.46-5.20; p < 0.0001) as compared with those with commercial insurance.

CONCLUSIONS

Children admitted to a cohort of U.S. PICUs were often from very low COI neighborhoods. Children from very high COI neighborhoods had the lowest risk of mortality and observed mortality; however, odds of mortality were not statistically different by COI category in a multivariable model. Children without insurance coverage had significantly higher odds of PICU mortality regardless of neighborhood.

Social Drivers of Health and Pediatric Extracorporeal Membrane Oxygenation Outcomes

BACKGROUND

Relationships between social drivers of health (SDoH) and pediatric health outcomes are highly complex with substantial inconsistencies in studies examining SDoH and extracorporeal membrane oxygenation (ECMO) outcomes. To add to this literature with emerging novel SDoH measures, and to address calls for institutional accountability, we examined associations between SDoH and pediatric ECMO outcomes.

METHODS

This single-center retrospective cohort study included children (<18 years) supported on ECMO (2012-2021). SDoH included Child Opportunity Index (COI), race, ethnicity, payer, interpreter requirement, urbanicity, and travel-time to hospital. COI is a multidimensional estimation of SDoH incorporating traditional (eg, income) and novel (eg, healthy food access) neighborhood attributes ([range 0-100] higher indicates healthier child development). Outcomes included in-hospital mortality, ECMO run duration, and length of stay (LOS).

RESULTS

540 children on ECMO (96%) had a calculable COI. In-hospital mortality was 44% with median run duration of 125 hours and ICU LOS 29 days. Overall, 334 (62%) had cardiac disease, 92 (17%) neonatal respiratory failure, 93 (17%) pediatric respiratory failure, and 21 (4%) sepsis. Median COI was 64 (interquartile range 32-81), 323 (60%) had public insurance, 174 (34%) were from underrepresented racial groups, 57 (11%) required interpreters, 270 (54%) had urban residence, and median travel-time was 89 minutes. SDoH including COI were not statistically associated with outcomes in univariate or multivariate analysis.

CONCLUSIONS

We observed no significant difference in pediatric ECMO outcomes according to SDoH. Further research is warranted to better understand drivers of inequitable health outcomes in children, and potential protective mechanisms.