Child Opportunity Index 2.0 and acute care utilization among children with medical complexity.

BACKGROUND: Disproportionately high acute care utilization among children with medical complexity (CMC) is influenced by patient-level social complexity. OBJECTIVE: The objective of this study was to determine associations between ZIP code-level opportunity and acute care utilization among CMC. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional, multicenter study used the Pediatric Health Information Systems database, identifying encounters between 2016-2019. CMC aged 28 days to <16 years with an initial emergency department (ED) encounter or inpatient/observation admission in 2016 were included in primary analyses. MAIN OUTCOME AND MEASURES: We assessed associations between the nationally-normed, multi-dimensional, ZIP code-level Child Opportunity Index 2.0 (COI) (high COI = greater opportunity), and total utilization days (hospital bed-days + ED discharge encounters). Analyses were conducted using negative binomial generalized estimating equations, adjusting for age and distance from hospital and clustered by hospital. Secondary outcomes included intensive care unit (ICU) days and cost of care. RESULTS: A total of 23,197 CMC were included in primary analyses. In unadjusted analyses, utilization days decreased in a stepwise fashion from 47.1 (95% confidence interval: 45.5, 48.7) days in the lowest COI quintile to 38.6 (36.9, 40.4) days in the highest quintile (p < .001). The same trend was present across all outcome measures, though was not significant for ICU days. In adjusted analyses, patients from the lowest COI quintile utilized care at 1.22-times the rate of those from the highest COI quintile (1.17, 1.27). CONCLUSIONS: CMC from low opportunity ZIP codes utilize more acute care. They may benefit from hospital and community-based interventions aimed at equitably improving child health outcomes.

The Association of the Childhood Opportunity Index on Pediatric Readmissions and Emergency Department Revisits.

OBJECTIVE: Reutilization following discharge is costly to families and the health care system. Singular measures of the social determinants of health (SDOH) have been shown to impact utilization; however, the SDOH are multifactorial. The Childhood Opportunity Index (COI) is a validated approach for comprehensive estimation of the SDOH. Using the COI, we aimed to describe the association between SDOH and 30-day revisit rates. METHODS: This retrospective study included children 0 to 17 years within 48 children's hospitals using the Pediatric Health Information System from 1/1/2019 to 12/31/2019. The main exposure was a child's ZIP code level COI. The primary outcome was unplanned readmissions and emergency department (ED) revisits within 30 days of discharge. Primary outcomes were summarized by COI category and compared using chi-square or Kruskal-Wallis tests. Adjusted analysis used generalized linear mixed effects models with adjustments for demographics, clinical characteristics, and hospital clustering. RESULTS: Of 728,997 hospitalizations meeting inclusion criteria, 30-day unplanned returns occurred for 96,007 children (13.2%). After adjustment, the patterns of returns were significantly associated with COI. For example, 30-day returns occurred for 19.1% (95% confidence interval [CI]: 18.2, 20.0) of children living within very low opportunity areas, with a gradient-like decrease as opportunity increased (15.5%, 95% CI: 14.5, 16.5 for very high). The relative decrease in utilization as COI increased was more pronounced for ED revisits. CONCLUSIONS: Children living in low opportunity areas had greater 30-day readmissions and ED revisits. Our results suggest that a broader approach, including policy and system-level change, is needed to effectively reduce readmissions and ED revisits.

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.

Association of Income Inequality With Pediatric Hospitalizations for Ambulatory Care-Sensitive Conditions.

Importance: The level of income inequality (ie, the variation in median household income among households within a geographic area), in addition to family-level income, is associated with worsened health outcomes in children. Objective: To determine the influence of income inequality on pediatric hospitalization rates for ambulatory care-sensitive conditions (ACSCs) and whether income inequality affects use of resources per hospitalization for ACSCs. Design, Setting, and Participants: This retrospective, cross-sectional analysis used the 2014 State Inpatient Databases of the Healthcare Cost and Utilization Project of 14 states to evaluate all hospital discharges for patients aged 0 to 17 years (hereafter referred to as children) from January 1 through December 31, 2014. Exposures: Using the 2014 American Community Survey (US Census), income inequality (Gini index; range, 0 [perfect equality] to 1.00 [perfect inequality]), median household income, and total population of children aged 0 to 17 years for each zip code in the 14 states were measured. The Gini index for zip codes was divided into quartiles for low, low-middle, high-middle, and high income inequality. Main Outcomes and Measures: Rate, length of stay, and charges for pediatric hospitalizations for ACSCs. Results: A total of 79 275 hospitalizations for ACSCs occurred among the 21 737 661 children living in the 8375 zip codes in the 14 included states. After adjustment for median household income and state of residence, ACSC hospitalization rates per 10 000 children increased significantly as income inequality increased from low (27.2; 95% CI, 26.5-27.9) to low-middle (27.9; 95% CI, 27.4-28.5), high-middle (29.2; 95% CI, 28.6-29.7), and high (31.8; 95% CI, 31.2-32.3) categories (P < .001). A significant, clinically unimportant longer length of stay was found for high inequality (2.5 days; 95% CI, 2.4-2.5 days) compared with low inequality (2.4 days; 95% CI, 2.4-2.5 days; P < .001) zip codes and between charges ($765 difference among groups; P < .001). Conclusions and Relevance: Children living in areas of high income inequality have higher rates of hospitalizations for ACSCs. Consideration of income inequality, in addition to income level, may provide a better understanding of the complex relationship between socioeconomic status and pediatric health outcomes for ACSCs. Efforts aimed at reducing rates of hospitalizations for ACSCs should consider focusing on areas with high income inequality.