Association of neighborhood opportunity and pediatric hospitalization rates in the United States

We examined associations between a validated, multidimensional measure of social determinants of health and population-based hospitalization rates among children <18 years across 18 states from the 2017 Healthcare Cost and Utilization Project State Inpatient Databases and the US Census. The exposure was ZIP code-level Child Opportunity Index (COI), a composite measure of neighborhood resources and conditions that matter for children's health. The cohort included 614,823 hospitalizations among a population of 29,244,065 children (21.02 hospitalizations per 1000). Adjusted hospitalization rates decreased significantly and in a stepwise fashion as COI increased (p < .001 for each), from 26.56 per 1000 (95% confidence interval [CI] 26.41-26.71) in very low COI areas to 14.76 per 1000 (95% CI 14.66-14.87) in very high COI areas (incidence rate ratio 1.8; 95% CI 1.78-1.81). Decreasing neighborhood opportunity was associated with increasing hospitalization rates among children in 18 US states. These data underscore the importance of social context and community-engaged solutions for health systems aiming to eliminate care inequities.

Child Opportunity Index and Rehospitalization for Ambulatory Care Sensitive Conditions at US Children's Hospitals

OBJECTIVE

Child Opportunity Index (COI) measures neighborhood contextual factors (education, health and environment, social and economic) that may influence child health. Such factors have been associated with hospitalizations for ambulatory care sensitive conditions (ACSC). Lower COI has been associated with higher health care utilization, yet association with rehospitalization(s) for ACSC remains unknown. Our objective is to determine the association between COI and ACSC rehospitalizations.

METHODS

Multicenter retrospective cohort study of children ages 0 to 17 years with a hospital admission for ambulatory care sensitive conditions in 2017 or 2018. Exposure was COI. Outcome was rehospitalization within 1 year of index admission (analyzed as any or ≥2 rehospitalization) for ACSC. Logistic regression models adjusted for age, sex, severity, and complex and mental health conditions.

RESULTS

The study included 184 478 children. Of hospitalizations, 28.3% were by children from very low COI and 16.5% were by children from very high COI neighborhoods. In risk-adjusted models, ACSC rehospitalization was higher for children from very low COI than very high COI neighborhoods; any rehospitalization occurred for 18.7% from very low COI and 13.5% from very high COI neighborhoods (adjusted odds ratio 1.14 [1.05-1.23]), whereas ≥2 rehospitalization occurred for 4.8% from very low COI and 3.2% from very high COI neighborhoods (odds ratio 1.51 [1.29-1.75]).

CONCLUSIONS

Children from neighborhoods with low COI had higher rehospitalizations for ACSCs. Further research is needed to understand how hospital systems can address social determinants of health in the communities they serve to prevent rehospitalizations.

Neighborhood Childhood Opportunity, Race/Ethnicity, and Surgical Outcomes in Children With Congenital Heart Disease

BACKGROUND

Racial and ethnic disparities in outcomes for children with congenital heart disease (CHD) coexist with disparities in educational, environmental, and economic opportunity.

OBJECTIVES

We sought to determine the associations between childhood opportunity, race/ethnicity, and pediatric CHD surgery outcomes.

METHODS

Pediatric Health Information System encounters aged <18 years from 2016 to 2022 with International Classification of Diseases-10th edition codes for CHD and cardiac surgery were linked to ZIP code-level Childhood Opportunity Index (COI), a score of neighborhood educational, environmental, and socioeconomic conditions. The associations of race/ethnicity and COI with in-hospital surgical death were modeled with generalized estimating equations and formal mediation analysis. Neonatal survival after discharge was modeled by Cox proportional hazards.

RESULTS

Of 54,666 encounters at 47 centers, non-Hispanic Black (Black) (OR: 1.20; P = 0.01), Asian (OR: 1.75; P < 0.001), and Other (OR: 1.50; P < 0.001) groups had increased adjusted mortality vs non-Hispanic Whites. The lowest COI quintile had increased in-hospital mortality in unadjusted and partially adjusted models (OR: 1.29; P = 0.004), but not fully adjusted models (OR: 1.14; P = 0.13). COI partially mediated the effect of race/ethnicity on in-hospital mortality between 2.6% (P = 0.64) and 16.8% (P = 0.029), depending on model specification. In neonatal multivariable survival analysis (n = 13,987; median follow-up: 0.70 years), the lowest COI quintile had poorer survival (HR: 1.21; P = 0.04).

CONCLUSIONS

Children in the lowest COI quintile are at risk for poor outcomes after CHD surgery. Disproportionally increased mortality in Black, Asian, and Other populations may be partially mediated by COI. Targeted investment in low COI neighborhoods may improve outcomes after hospital discharge. Identification of unmeasured factors to explain persistent risk attributed to race/ethnicity is an important area of future exploration.

Neighborhood Opportunity and Mortality Among Children and Adults in Their Households

BACKGROUND AND OBJECTIVES

Research has linked neighborhood opportunity to health outcomes in children and adults; however, few studies have examined neighborhood opportunity and mortality risk among children and their caregivers. The objective of this study was to assess associations of neighborhood opportunity and mortality risk in children and their caregivers over 11 years.

METHODS

Participants included 1 025 000 children drawn from the Mortality Disparities in American Communities study, a cohort developed by linking the 2008 American Community Survey to the National Death Index and followed for 11 years. Neighborhood opportunity was measured using the Child Opportunity Index, a measure designed to capture compounding inequities in access to opportunities for health.

RESULTS

Using hazard models, we observed inverse associations between Child Opportunity Index quintile and deaths among child and caregivers. Children in very low opportunity neighborhoods at baseline had 1.30 times the risk of dying over follow-up relative to those in very high opportunity neighborhoods (95% confidence interval [CI], 1.15-1.45), and this excess risk attenuated after adjustment for household characteristics (hazard ratio, 1.15; 95% CI, 0.98-1.34). Similarly, children in very low opportunity neighborhoods had 1.57 times the risk of experiencing the death of a caregiver relative to those in very high opportunity neighborhoods (95% CI, 1.50-1.64), which remained after adjustment (hazard ratio, 1.30; 95% CI, 1.23-1.38).

CONCLUSIONS

Our analyses advance understanding of the adverse consequences of inequitable neighborhood contexts for child well-being and underscore the potential importance of place-based policies for reducing disparities in child and caregiver mortality.

Neighborhood Child Opportunity and Emergency Department Utilization

The Child Opportunity Index measures the structural neighborhood context that may influence a child's healthy development. We examined relationships between the Child Opportunity Index and emergency department utilization.

BACKGROUND AND OBJECTIVES

The Child Opportunity Index (COI) is a multidimensional measure of structural neighborhood context that may influence a child's healthy development. Our objective was to determine if COI is associated with children's emergency department (ED) utilization using a national sample.

METHODS

This was a retrospective cohort study of the Pediatric Health Information Systems, a database from 49 United States children's hospitals. We analyzed children aged 0 to 17 years with ED visits from January 1, 2018, to December 31, 2019. We modeled associations between COI and outcomes using generalized regression models that adjusted for patient characteristics (eg, age, clinical severity). Outcomes included: (1) low-resource intensity (LRI) ED visits (visits with no laboratories, imaging, procedures, or admission), (2) ≥2 or ≥3 ED visits, and (3) admission.

RESULTS

We analyzed 6 810 864 ED visits by 3 999 880 children. LRI visits were more likely among children from very low compared with very high COI (1 LRI visit: odds ratio [OR] 1.35 [1.17-1.56]; ≥2 LRI visits: OR 1.97 [1.66-2.33]; ≥3 LRI visits: OR 2.4 [1.71-3.39]). ED utilization was more likely among children from very low compared with very high COI (≥2 ED visits: OR 1.73 [1.51-1.99]; ≥3 ED visits: OR 2.22 [1.69-2.91]). Risk of hospital admission from the ED was lower for children from very low compared with very high COI (OR 0.77 [0.65-0.99]).

CONCLUSIONS

Children from neighborhoods with low COI had higher ED utilization overall and more LRI visits, as well as visits more cost-effectively managed in primary care settings. Identifying neighborhood opportunity-related drivers can help us design interventions to optimize child health and decrease unnecessary ED utilization and costs.

Connecting past to present: Examining different approaches to linking historical redlining to present day health inequities

In the 1930’s, the Home Owner Loan Corporation (HOLC) drafted maps to quantify variation in real estate credit risk across US city neighborhoods. The letter grades and associated risk ratings assigned to neighborhoods discriminated against those with black, lower class, or immigrant residents and benefitted affluent white neighborhoods. An emerging literature has begun linking current individual and community health effects to government redlining, but each study faces the same measurement problem: HOLC graded area boundaries and neighborhood boundaries in present-day health datasets do not match. Previous studies have taken different approaches to classify present day neighborhoods (census tracts) in terms of historical HOLC grades. This study reviews these approaches, examines empirically how different classifications fare in terms of predictive validity, and derives a predictively optimal present-day neighborhood redlining classification for neighborhood and health research.

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.

Racial And Ethnic Inequities In Children's Neighborhoods: Evidence From The New Child Opportunity Index 2.0

Neighborhoods influence children's health, so it is important to have measures of children's neighborhood environments. Using the Child Opportunity Index 2.0, a composite metric of the neighborhood conditions that children experience today across the US, we present new evidence of vast geographic and racial/ethnic inequities in neighborhood conditions in the 100 largest metropolitan areas in the US. Child Opportunity Scores range from 20 in Fresno, California, to 83 in Madison, Wisconsin. However, more than 90 percent of the variation in neighborhood opportunity happens within metropolitan areas. In 35 percent of these areas the Child Opportunity Gap (the difference between Child Opportunity Scores in very low- and very high-opportunity neighborhoods) is higher than across the entire national neighborhood distribution. Nationally, the Child Opportunity Score for White children (73) is much higher than for Black (24) and Hispanic (33) children. To improve children's health and well-being, the health sector must move beyond a focus on treating disease or modifying individual behavior to a broader focus on neighborhood conditions. This will require the health sector to both implement place-based interventions and collaborate with other sectors such as housing to execute mobility-based interventions.

Economic Downturns and Inequities in Birth Outcomes: Evidence From 149 Million US Births

Using birth certificate data for nearly all registered US births from 1976 to 2016 and monthly data on state unemployment rates, we reexamined the link between macroeconomic variation and birth outcomes. We hypothesized that economic downturns reduce exposure to work-related stressors and pollution while increasing exposure to socioeconomic stressors like job loss. Because of preexisting inequalities in health and other resources, we expected that less-educated mothers and black mothers would be more exposed to macroeconomic variation. Using fixed-effect regression models, we found that a 1-percentage-point increase in state unemployment during the first trimester of pregnancy increased the probability of preterm birth by 0.1 percentage points, while increases in the state unemployment rate during the second/third trimester reduced the probability of preterm birth by 0.06 percentage points. During the period encompassing the Great Recession, the magnitude of these associations doubled in size. We found substantial variation in the impact of economic conditions across different groups, with highly educated white women least affected and less-educated black women most affected. The results highlight the increased relevance of economic conditions for birth outcomes and population health as well as continuing, large inequities in the exposure and impact of macroeconomic fluctuations on birth outcomes.

Increasing ambient temperature reduces emotional well-being

This study examines the impact of ambient temperature on emotional well-being in the U.S. population aged 18+. The U.S. is an interesting test case because of its resources, technology and variation in climate across different areas, which also allows us to examine whether adaptation to different climates could weaken or even eliminate the impact of heat on well-being. Using survey responses from 1.9 million Americans over the period from 2008 to 2013, we estimate the effect of temperature on well-being from exogenous day-to-day temperature variation within respondents' area of residence and test whether this effect varies across areas with different climates. We find that increasing temperatures significantly reduce well-being. Compared to average daily temperatures in the 50-60°F (10-16°C) range, temperatures above 70°F (21°C) reduce positive emotions (e.g. joy, happiness), increase negative emotions (e.g. stress, anger), and increase fatigue (feeling tired, low energy). These effects are particularly strong among less educated and older Americans. However, there is no consistent evidence that heat effects on well-being differ across areas with mild and hot summers, suggesting limited variation in heat adaptation.

Who suffers during recessions? Economic downturns, job loss, and cardiovascular disease in older Americans

Job loss in the years before retirement has been found to increase risk of cardiovascular disease (CVD), but some studies suggest that CVD mortality among older workers declines during recessions. We hypothesized that recessionary labor market conditions were associated with reduced CVD risk among persons who did not experience job loss and increased CVD risk among persons who lost their jobs. In our analyses, we used longitudinal, nationally representative data from Americans 50 years of age or older who were enrolled in the Health and Retirement Study and surveyed every 2 years from 1992 to 2010 about their employment status and whether they had experienced a stroke or myocardial infarction. To measure local labor market conditions, Health and Retirement Study data were linked to county unemployment rates. Among workers who experienced job loss, recessionary labor market conditions at the time of job loss were associated with a significantly higher CVD risk (hazard ratio = 2.54, 95% confidence interval: 1.39, 4.65). In contrast, among workers who did not experience job loss, recessionary labor market conditions were associated with a lower CVD risk (hazard ratio = 0.50, 95% confidence interval: 0.31, 0.78). These results suggest that recessions might be protective in the absence of job loss but hazardous in the presence of job loss.

The long-term mortality impact of combined job strain and family circumstances: A life course analysis of working American mothers

BACKGROUND

Work stress and family composition have been separately linked with later-life mortality among working women, but it is not known how combinations of these exposures impact mortality, particularly when exposure is assessed cumulatively over the life course. We tested whether, among US women, lifelong work stress and lifelong family circumstances would jointly predict mortality risk.

PROCEDURES

We studied formerly working mothers in the US Health and Retirement Study (HRS) born 1924-1957 (n = 7352). We used sequence analysis to determine five prototypical trajectories of marriage and parenthood in our sample. Using detailed information on occupation and industry of each woman's longest-held job, we assigned each respondent a score for job control and job demands. We calculated age-standardized mortality rates by combined job demands, job control, and family status, then modeled hazard ratios for death based on family constellation, job control tertiles, and their combination.

RESULTS

Married women who had children later in life had the lowest mortality risks (93/1000). The highest-risk family clusters were characterized by spells of single motherhood (132/1000). Generally, we observed linear relationships between job control and mortality hazard within each family trajectory. But while mortality risk was high for all long-term single mothers, we did not observe a job control-mortality gradient in this group. The highest-mortality subgroup was previously married women who became single mothers later in life and had low job control (HR 1.91, 95% CI 1.38,2.63).

PRACTICAL IMPLICATIONS

Studies of associations between psychosocial work characteristics and health might consider heterogeneity of effects by family circumstances. Worksite interventions simultaneously considering both work and family characteristics may be most effective in reducing health risks.

Recessions, job loss, and mortality among older US adults

OBJECTIVES

We analyzed how recessions and job loss jointly shape mortality risks among older US adults.

METHODS

We used data for 50 states from the Health and Retirement Study and selected individuals who were employed at ages 45 to 66 years during 1992 to 2011. We assessed whether job loss affects mortality risks, whether recessions moderate the effect of job loss on mortality, and whether individuals who do and do not experience job loss are differentially affected by recessions.

RESULTS

Compared with individuals not experiencing job loss, mortality risks among individuals losing their job in a recession were strongly elevated (hazard ratio = 1.6; 95% confidence interval = 1.1, 2.3). Job loss during normal times or booms is not associated with mortality. For employed workers, we found a reduction in mortality risks if local labor market conditions were depressed, but this result was not consistent across different model specifications.

CONCLUSIONS

Recessions increase mortality risks among older US adults who experience job loss. Health professionals and policymakers should target resources to this group during recessions. Future research should clarify which health conditions are affected by job loss during recessions and whether access to health care following job loss moderates this relation.