Understanding Disparities in the Pediatric ICU: A Scoping Review.

BACKGROUND AND OBJECTIVES: Health disparities are pervasive in pediatrics. We aimed to describe disparities among patients who are likely to be cared for in the PICU and delineate how sociodemographic data are collected and categorized. METHODS: Using MEDLINE as a data source, we identified studies which included an objective to assess sociodemographic disparities among PICU patients in the United States. We created a review rubric, which included methods of sociodemographic data collection and analysis, outcome and exposure variables assessed, and study findings. Two authors reviewed every study. We used the National Institute on Minority Health and Health Disparities Research Framework to organize outcome and exposure variables. RESULTS: The 136 studies included used variable methods of sociodemographic data collection and analysis. A total of 30 of 124 studies (24%) assessing racial disparities used self- or parent-identified race. More than half of the studies (52%) dichotomized race as white and "nonwhite" or "other" in some analyses. Socioeconomic status (SES) indicators also varied; only insurance status was used in a majority of studies (72%) evaluating SES. Consistent, although not uniform, disadvantages existed for racial minority populations and patients with indicators of lower SES. The authors of only 1 study evaluated an intervention intended to mitigate health disparities. Requiring a stated objective to evaluate disparities aimed to increase the methodologic rigor of included studies but excluded some available literature. CONCLUSIONS: Variable, flawed methodologies diminish our understanding of disparities in the PICU. Meaningfully understanding and addressing health inequity requires refining how we collect, analyze, and interpret relevant data.

Children with severe sepsis: relationship between community level income and morbidity and mortality.

BACKGROUND: Health disparities surrounding pediatric severe sepsis outcomes remains unclear. We aimed to measure the relationship between indicators of socioeconomic status and mortality, hospital length of stay (LOS), and readmission rates among children hospitalized with severe sepsis. METHODS: Children 0-18 years old, hospitalized with severe sepsis in the Nationwide Readmissions Database (2016-2018) were included. The primary exposure was median household income by ZIP Code of residence, divided into quartiles. RESULTS: We identified 15,214 index pediatric severe sepsis hospitalizations. There was no difference in hospital mortality rate or readmission rate across income quartiles. Among survivors, patients in Q1 (lowest income) had a 2 day longer LOS compared to those in Q4 (Median 10 days [IQR 4-21] vs 8 days [IQR 4-18]; p < 0.0001). However, there was no difference after adjusting for multiple covariates. CONCLUSIONS: Children living in Q1 had a 2 day longer LOS versus their peers in Q4. This was not significant on multivariable analysis, suggesting income quartile is not driving this difference. As pediatric severe sepsis remains an important source of morbidity and mortality in critically ill children, more sensitive metrics of socioeconomic status may better elucidate any disparities. IMPACT: Children with severe sepsis living in the lowest income ZIP Codes may have longer hospital stays compared to peers in higher income communities. More precise metrics of socioeconomic status are needed to better understand health disparities in pediatric severe sepsis.

Paved With Good Intentions: Hospital Visitation Restrictions in the Age of Coronavirus Disease 2019.

Hospital visitation restrictions have been widely implemented during the coronavirus disease 2019 pandemic as a means of decreasing the transmission of coronavirus. While decreasing transmission is an important goal, it is not the only goal that quality healthcare must aim to achieve. Severely restricted visitation policies undermine our ability to provide humane, family-centered care, particularly during critical illness and at the end of life. The enforcement of these policies consequently increases the risk of moral distress and injury for providers. Using our experience in a PICU, we survey the shortcomings of current visitation restrictions. We argue that hospital visitation restrictions can be implemented in ways that are nonmaleficent, but this requires unwavering acknowledgment of the value of social and familial support during illness and death. We advocate that visitation restriction policies be implemented by independent, medically knowledgeable decision-making bodies, with the informed participation of patients and their families.

Neighborhood Poverty and Pediatric Intensive Care Use.

BACKGROUND: Disparities in health service use have been described across a range of sociodemographic factors. Patterns of PICU use have not been thoroughly assessed. METHODS: This was a population-level, retrospective analysis of admissions to the Cincinnati Children's Hospital Medical Center PICU between 2011 and 2016. Residential addresses of patients were geocoded and spatially joined to census tracts. Pediatric patients were eligible for inclusion if they resided within Hamilton County, Ohio. PICU admission and bed-day rates were calculated by using numerators of admissions and bed days, respectively, over a denominator of tract child population. Relationships between tract-level PICU use and child poverty were assessed by using Spearman's ρ and analysis of variance. Analyses were event based; children admitted multiple times were counted as discrete admissions. RESULTS: There were 4071 included admissions involving 3129 unique children contributing a total of 12 297 PICU bed days. Child poverty was positively associated with PICU admission rates (r = 0.59; P < .001) and bed-day rates (r = 0.47; P < .001). When tracts were grouped into quintiles based on child poverty rates, the PICU bed-day rate ranged from 23.4 days per 1000 children in the lowest poverty quintile to 81.9 days in the highest poverty quintile (P < .001). CONCLUSIONS: The association between poverty and poor health outcomes includes pediatric intensive care use. This association exists for children who grow up in poverty and around poverty. Future efforts should characterize the interplay between patient- and neighborhood-level risk factors and explore neighborhood-level interventions to improve child health.

Disease prevention & health promotion: what's critical care got to do with it?

Health systems are increasingly investing in efforts to prevent disease and promote health for populations. By and large, these prevention-related interventions have not been inclusive of critical care and the intensive care unit (ICU). However, we suggest that there is value-to patients, families, health systems, and society at large-in extending this continuum into the ICU setting and including the ICU in disease prevention and health promotion efforts. Including the ICU in this continuum allows the critical care perspective to inform (I) advocacy for prevention; (II) efforts to improve disparities in health and health care; (III) mitigation of the negative effects of critical illness and injury as well as ICU exposure; and (IV) promotion of health and well-being in the community. As disease prevention and health promotion rise as priorities within health systems, critical care can and should join, even help lead, the effort.