Socioeconomic Barriers to Care for Pediatric Airways Utilizing Geographic Information Systems.

OBJECTIVE: Geographic information systems (GIS) provide a unique set of tools to spatially analyze health care and identify patterns of health outcomes to help optimize delivery. Our goal is to create maps of pediatric tracheostomy patients using GIS to assess socioeconomic and other factors that impact postoperative care after discharge to home. METHODS: A retrospective study was performed on patients (≤21 years old) who underwent tracheostomy at a tertiary care pediatric hospital from January 1, 2015 to December 31, 2020. Using GIS, we geocoded patient addresses and conducted spatial analyses of the relationship between patients and access to health care providers as well as vulnerable population factors including poverty, educational attainment, and single-parent households. RESULTS: A total of 156 patients were included. Patients initially discharged to transitional care (108/156, 69.2%) had significantly higher likelihood of presenting to the ED regardless of socioeconomic status (OR: 2.28, 95% CI: 1.03-5.05; p = 0.042). There was no relationship between ED visit rate and median household income, poverty level, and percentage of uneducated adults (p = 0.490; p = 0.424; p = 0.752). Median distance to the tertiary care pediatric hospital was significantly longer for patients with no ED visit (median = 61.28 miles; SD = 50.90) compared with those with an ED visit (median = 37.75 miles; SD = 35.92) (p = 0.002). CONCLUSION: The application of GIS could provide geo-localized data to better understand the healthcare barriers to access for children with tracheostomies. This study uniquely integrates medical record data with socioeconomic factors and social determinants of health. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:1919-1925, 2024.

Geospatial Analysis of Food Deserts and Their Impact on Health Outcomes in Children with Cystic Fibrosis.

Food insecurity (FI) is defined as "the limited or uncertain access to adequate food." One root cause of FI is living in a food desert. FI rates among people with cystic fibrosis (CF) are higher than the general United States (US) population. There is limited data on the association between food deserts and CF health outcomes. We conducted a retrospective review of people with CF under 18 years of age at a single pediatric CF center from January to December 2019 using demographic information and CF health parameters. Using a Geographic Information System, we conducted a spatial overlay analysis at the census tract level using the 2015 Food Access Research Atlas to assess the association between food deserts and CF health outcomes. We used multivariate logistic regression analysis and adjusted for clinical covariates and demographic covariates, using the Child Opportunity Index (COI) to calculate odds ratios (OR) with confidence intervals (CI) for each health outcome. People with CF living in food deserts and the surrounding regions had lower body mass index/weight-for-length (OR 3.18, 95% CI: 1.01, 9.40, p ≤ 0.05 (food desert); OR 4.41, 95% CI: 1.60, 12.14, p ≤ 0.05 (600 ft buffer zone); OR 2.83, 95% CI: 1.18, 6.76, p ≤ 0.05 (1200 ft buffer zone)). Food deserts and their surrounding regions impact pediatric CF outcomes independent of COI. Providers should routinely screen for FI and proximity to food deserts. Interventions are essential to increase access to healthy and affordable food.

Annual SO2 exposure, asthma, atopy, and lung function in Puerto Rican children.

BACKGROUND: Long-term effects of sulfur dioxide (SO2 ) exposure on children, a vulnerable population, are largely unknown. Further, how long-term SO2 affects Puerto Rican children living in the island of Puerto Rico, a group with high asthma prevalence, is unclear. We evaluated the effects of annual average 1-hour daily maximum SO2 average on asthma, atopy, total immunoglobulin E (IgE), and lung function in Puerto Rican children. METHODS: A cohort of 678 children (351 with asthma, 327 without asthma) was recruited in Puerto Rico from 2009 to 2010. Annual average 1-hour daily maximum SO2 exposure was interpolated utilizing publicly available monitoring data. Multivariable logistic and linear regression was used for the analysis of asthma, atopy (defined as an IgE ≥0.35 IU/mL to at least one of five common aero-allergens), total IgE, and lung function measures (forced vital capacity [FVC], forced expiratory volume in 1 second [FEV1], and FEV1/FVC ratio). RESULTS: Annual SO2 exposure (per 1 ppb) was significantly associated with asthma (odds ratio [OR] = 1.42; 95% confidence interval [CI] = 1.05-1.91) and atopy (OR = 1.35; 95% CI = 1.02-1.78). Such exposure was also significantly associated with lower FEV1/FVC in all children (ß = -1.42; 95% CI = -2.78 to -0.08) and in children with asthma (ß = -2.39; 95% CI= -4.31 to -0.46). Annual SO2 exposure was not significantly associated with total IgE, FEV1, or FVC. CONCLUSIONS: Among Puerto Rican children in Puerto Rico, long-term SO2 exposure is linked to asthma and atopy. In these children, long-term SO2 exposure is also associated with reduced FEV1/FVC, particularly in those with asthma.

Increasing Burden of Lyme Carditis in United States Children's Hospitals.

We sought to characterize the shifting epidemiology and resource utilization of Lyme disease and associated carditis in US children's hospitals. We hypothesized that the Lyme carditis burden has increased and that hospitalizations for Lyme carditis are costlier than those for Lyme disease without carditis. The PHIS database was queried for Lyme disease encounters between January 1, 2007 and December 31, 2013. Additional diagnostic codes consistent with carditis identified Lyme carditis cases. Demographic, clinical, and resource utilization data were analyzed. All costs were adjusted to 2014 US dollars. Lyme disease was identified in 3620 encounters with 189 (5%) associated with carditis. Lyme disease (360 cases in 2007 vs. 672 in 2013, p = 0.01) and Lyme carditis (17 cases in 2007 vs. 40 in 2013, p = 0.03) both significantly increased in frequency. This is primarily accounted for by their increase within the Midwest region. Carditis frequency among cases of Lyme disease was stable (p = 0.15). Encounters for Lyme carditis are dramatically costlier than those for Lyme disease without carditis [median $9104 (3741-19,003) vs. 922 (238-4987), p < 0.001] The increase in Lyme carditis cases in US children's hospitals is associated with an increased Lyme disease incidence, suggesting that there has not been a change in its virulence or cardiac tropism. The increasing number of serious cardiac events and costs associated with Lyme disease emphasize the need for prevention and early detection of disease and control of its spread.

Referral Regions for Time-Sensitive Acute Care Conditions in the United States.

STUDY OBJECTIVE: Regional, coordinated care for time-sensitive and high-risk medical conditions is a priority in the United States. A necessary precursor to coordinated regional care is regions that are actionable from clinical and policy standpoints. The Dartmouth Atlas of Health Care, the major health care referral construct in the United States, uses regions that cross state and county boundaries, limiting fiscal or political ownership by key governmental stakeholders in positions to create incentive and regulate regional care coordination. Our objective is to develop and evaluate referral regions that define care patterns for patients with acute myocardial infraction, acute stroke, or trauma, yet also preserve essential political boundaries. METHODS: We developed a novel set of acute care referral regions using Medicare data in the United States from 2011. For acute myocardial infraction, acute stroke, or trauma, we iteratively aggregated counties according to patient home location and treating hospital address, using a spatial algorithm. We evaluated referral political boundary preservation and spatial accuracy for each set of referral regions. RESULTS: The new set of referral regions, the Pittsburgh Atlas, had 326 distinct regions. These referral regions did not cross any county or state borders, whereas 43.1% and 98.1% of all Dartmouth Atlas hospital referral regions crossed county and state borders. The Pittsburgh Atlas was comparable to the Dartmouth Atlas in measures of spatial accuracy and identified larger at-risk populations for all 3 conditions. CONCLUSION: A novel and straightforward spatial algorithm generated referral regions that were politically actionable and accountable for time-sensitive medical emergencies.

Transportation characteristics associated with non-arrivals to paediatric clinic appointments: a retrospective analysis of 51 580 scheduled visits.

BACKGROUND: Prior work has not studied the effects of transportation accessibility and patient factors on clinic non-arrival. OBJECTIVES: Our objectives were: (1) to evaluate transportation characteristics and patient factors associated with clinic non-arrival, (2) to evaluate the comparability of bus and car drive time estimates, and (3) to evaluate the combined effects of transportation accessibility and income on scheduled appointment non-arrival. METHODS: We queried electronic administrative records at an urban general pediatrics clinic. We compared patient and transportation characteristics between arrivals and non-arrivals for scheduled appointments using multivariable modeling. RESULTS: There were 15 346 (29.8%) clinic non-arrivals. In separate car and bus multivariable models that controlled for patient and transit characteristics, we identified significant interactions between income and drive time, and clinic non-arrival. Patients in the lowest quartile of income who were also in the longest quartile of travel time by bus had an increased OR of clinic non-arrival compared with patients in the lowest quartile of income and shortest quartile of travel time by bus (1.55; P<0.01). Similarly, patients in the lowest quartile of income who were also in the longest quartile of travel time by car had an increased OR of clinic non-arrival compared with patients in the lowest quartile of income and shortest quartile of travel time by car (1.21, respectively; P<0.01). CONCLUSIONS: Clinic non-arrival is associated with the interaction of longer travel time and lower income.

Proximity to a Major Road and Plasma Cytokines in School-Aged Children.

Traffic-related air pollution (TRAP) may affect immune responses, including those in the TH2 and TH17 pathways. To examine whether TRAP is associated with plasma level of TH17-, TH1-, and TH2-related cytokines in children with and without asthma, a cross-sectional study of 577 children (ages 6-14 years) with (n = 294) and without (n = 283) asthma in San Juan (Puerto Rico) was performed. Residential distance to a major road was estimated using geocoded home addresses for study participants. A panel of 14 cytokines, enriched for the TH17 pathway, was measured in plasma. Asthma was defined as physician-diagnosed asthma and current wheeze. Multivariable linear regression was used to examine the association of residential distance to a major road (a marker of TRAP), asthma, and cytokine levels. Among all participating children, residential proximity to a major road was significantly associated with increased plasma level of IL-31, even after adjustment for relevant covariates and correction for multiple testing. The presence of asthma modified the estimated effect of the residential distance to a major road on plasma TNF-α (P for interaction = 0.00047). Although living farther from a major road was significantly associated with lower TNF-α level in control subjects, no such decrease was seen in children with asthma. In a direct comparison of cases and control subjects, children with asthma had significantly higher levels of IL-1ß, IL-22, and IL-33 than control subjects. TRAP is associated with increased levels of proinflammatory cytokines among Puerto Rican children, who belong to an ethnic group with high risk for asthma.

Geographic access to high capability severe acute respiratory failure centers in the United States.

OBJECTIVE: Optimal care of adults with severe acute respiratory failure requires specific resources and expertise. We sought to measure geographic access to these centers in the United States. DESIGN: Cross-sectional analysis of geographic access to high capability severe acute respiratory failure centers in the United States. We defined high capability centers using two criteria: (1) provision of adult extracorporeal membrane oxygenation (ECMO), based on either 2008-2013 Extracorporeal Life Support Organization reporting or provision of ECMO to 2010 Medicare beneficiaries; or (2) high annual hospital mechanical ventilation volume, based 2010 Medicare claims. SETTING: Nonfederal acute care hospitals in the United States. MEASUREMENTS AND MAIN RESULTS: We defined geographic access as the percentage of the state, region and national population with either direct or hospital-transferred access within one or two hours by air or ground transport. Of 4,822 acute care hospitals, 148 hospitals met our ECMO criteria and 447 hospitals met our mechanical ventilation criteria. Geographic access varied substantially across states and regions in the United States, depending on center criteria. Without interhospital transfer, an estimated 58.5% of the national adult population had geographic access to hospitals performing ECMO and 79.0% had geographic access to hospitals performing a high annual volume of mechanical ventilation. With interhospital transfer and under ideal circumstances, an estimated 96.4% of the national adult population had geographic access to hospitals performing ECMO and 98.6% had geographic access to hospitals performing a high annual volume of mechanical ventilation. However, this degree of geographic access required substantial interhospital transfer of patients, including up to two hours by air. CONCLUSIONS: Geographic access to high capability severe acute respiratory failure centers varies widely across states and regions in the United States. Adequate referral center access in the case of disasters and pandemics will depend highly on local and regional care coordination across political boundaries.

Accuracy of prehospital transport time estimation.

OBJECTIVES: Estimates of prehospital transport times are an important part of emergency care system research and planning; however, the accuracy of these estimates is unknown. The authors examined the accuracy of three estimation methods against observed transport times in a large cohort of prehospital patient transports. METHODS: This was a validation study using prehospital records in King County, Washington, and southwestern Pennsylvania from 2002 to 2006 and 2005 to 2011, respectively. Transport time estimates were generated using three methods: linear arc distance, Google Maps, and ArcGIS Network Analyst. Estimation error, defined as the absolute difference between observed and estimated transport time, was assessed, as well as the proportion of estimated times that were within specified error thresholds. Based on the primary results, a regression estimate was used that incorporated population density, time of day, and season to assess improved accuracy. Finally, hospital catchment areas were compared using each method with a fixed drive time. RESULTS: The authors analyzed 29,935 prehospital transports to 44 hospitals. The mean (± standard deviation [±SD]) absolute error was 4.8 (±7.3) minutes using linear arc, 3.5 (±5.4) minutes using Google Maps, and 4.4 (±5.7) minutes using ArcGIS. All pairwise comparisons were statistically significant (p < 0.01). Estimation accuracy was lower for each method among transports more than 20 minutes (mean [±SD] absolute error was 12.7 [±11.7] minutes for linear arc, 9.8 [±10.5] minutes for Google Maps, and 11.6 [±10.9] minutes for ArcGIS). Estimates were within 5 minutes of observed transport time for 79% of linear arc estimates, 86.6% of Google Maps estimates, and 81.3% of ArcGIS estimates. The regression-based approach did not substantially improve estimation. There were large differences in hospital catchment areas estimated by each method. CONCLUSIONS: Route-based transport time estimates demonstrate moderate accuracy. These methods can be valuable for informing a host of decisions related to the system organization and patient access to emergency medical care; however, they should be employed with sensitivity to their limitations.

Pediatric craniofacial fractures due to violence: comparing violent and nonviolent mechanisms of injury.

BACKGROUND: This study examines the epidemiologic data of pediatric craniofacial fractures secondary to violence, comparing these data to craniofacial fractures sustained from all other causes. METHODS: A retrospective review was completed on all patients who presented to the emergency department of a major urban children's hospital from 2000 to 2005 with a craniofacial fracture. Data were compared between patients with fractures due to violent and nonviolent mechanisms. Socioeconomic analysis was performed using Geographic Information System mapping and 2000 US Census data by postal code. RESULTS: One thousand five hundred twenty-eight patients were diagnosed with skull and/or facial fractures. Isolated skull fractures were excluded, leaving 793 patients in the study. Ninety-eight children were injured due to violence, and 695 were injured from a nonviolent cause. Patients with violence-related fractures were more likely to be older, male, and nonwhite and live in a socioeconomically depressed area. A greater number of patients with violence-related injuries sustained nasal and mandible angle fractures, whereas more patients with non-violence-related injuries sustained skull and orbital fractures. Those with violence-related craniofacial fractures had a lower percentage of associated multiorgan system injuries and a lower rate of hospital admissions and intensive care unit admissions. The rate of open reduction and internal fixation for craniofacial fractures was similar in both groups. CONCLUSIONS: Patients with violence-related fractures had fewer associated serious injuries and lower morbidity and lived in a more socioeconomically depressed area. The information gained from this descriptive study improves our ability to characterize this population of pediatric patients and to identify the associated constellation of injuries in such fractures.