Sociodemographic factors and Child Opportunity Index disparities associated with missed care opportunities in pediatric patients with lymphoma and leukemia referred for FDG-PET/CT.

BACKGROUND: Little data exists on the association of missed care opportunities (MCOs) in children referred for nuclear medicine/nuclear oncology imaging examinations and socioeconomic disparities. OBJECTIVE: To determine the prevalence of MCOs in children with lymphoma/leukemia scheduled for fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) and the impact of sociodemographic factors and Child Opportunity Index (COI). MATERIALS AND METHODS: Retrospective analysis of MCOs in children with lymphoma/leukemia scheduled for FDG-PET/CT (2012 to 2022) was performed. In univariate analysis, patient, neighborhood, and appointment data were assessed across MCOs and completed appointments. Logistic regression evaluated independent effects of patient-, neighborhood-, and appointment-level factors with MCOs. Two-sided P-value < .05 was considered statistically significant. RESULTS: In 643 FDG-PET/CT appointments (n = 293 patients; median age 15 years (IQR 11.0-17.0 years); 37.9% female), there were 20 MCOs (3.1%) involving 16 patients. Only 8.2% appointments involved Black/African American non-Hispanic/Latino patients, yet they made up a quarter of total MCOs. Patients living in neighborhoods with very low or low COI experienced significantly higher MCOs versus zip codes with very high COI (6.9% vs. 0.8%; P = 0.02). Logistic regression revealed significantly increased likelihood of MCOs for patients aged 18 to 21 [odds ratio (OR) 4.50; 95% CI 1.53-13.27; P = 0.007], Black/African American non-Hispanic/Latino (OR 3.20; 95% CI 1.08-9.49; P = 0.04), zip codes with very low or low COI (OR 9.60; 95% CI 1.24-74.30; P = 0.03), and unknown insurance status. CONCLUSION: Children with lymphoma/leukemia, living in zip codes with very low or low COI, and who identified as Black/African American non-Hispanic/Latino experienced more MCOs. Our study supports the need to address intersecting sociodemographic, neighborhood, and health system factors that will improve equitable access to necessary healthcare imaging for children.

Effects of Sociodemographic and Child Opportunity Index on Pediatric Plastic and Oral and Maxillofacial Surgical Volume Trends in the COVID-19 Pandemic.

Background: The coronavirus disease 2019 (COVID-19) pandemic caused disruptions to pediatric surgical care. Although surgical capacity has returned to the prepandemic state, barriers to surgical access may still exist for children who are medically underserved. We assessed pediatric plastic and oral and maxillofacial surgical volumes by sociodemographic characteristics before and during the COVID-19 pandemic. Methods: A 72-month retrospective cohort analysis of 10,681 pediatric plastic and oral and maxillofacial procedures between 2016 and 2021 was conducted. Multivariable logistic regression and interrupted time series analyses were used to analyze surgical volume trends by sociodemographic groups and Child Opportunity Index (COI). Results: Compared with prepandemic, patients undergoing procedures were more likely to be older than 18 years (P < 0.001) and Hispanic/Latino (adjusted odds ratio 1.38; 95% confidence interval, 1.14-1.68; P < 0.01). Surgical volume trends among patients from the lowest COI levels were lower than where they were estimated to have been if the pandemic did not occur (P = 0.040). Patients who spoke a primary language other than English or Spanish (P = 0.02) and patients with the lowest COI levels (P = 0.04) continued to have unrecovered surgical volumes. Conclusions: There were differences in the sociodemographic case-mix of patients undergoing plastic and oral and maxillofacial surgical procedures before and during the pandemic, and surgical volumes did not recover at the same rate for all patients. Further research can determine why certain sociodemographic groups and patients with low COI levels had decreased surgical access compared with prepandemic trends, and develop interventions focused on equitable pediatric surgical access.

Sociodemographic Missed-care Predictors for Pediatric Orthopaedic Telemedicine During COVID-19.

BACKGROUND: Increased telehealth services may not benefit communities already lacking access to care. Race, socioeconomic status, and insurance type are known to predict missed-care opportunities (MCO) in health care. We examined differences in pediatric orthopaedic telemedicine MCOs during the COVID-19 pandemic, compared with MCOs of in-person visits in a prepandemic time frame. We hypothesized that groups with known health disparities would experience higher rates of pediatric orthopedic telemedicine MCOs. METHODS: We retrospectively analyzed pediatric orthopaedic telemedicine MCOs during the COVID-19 pandemic lockdown (March-May 2020) and in-person pediatric orthopaedic visit MCOs during a nonpandemic timeframe (March-May 2019). We examined predictors of MCOs including race, ethnicity, language, insurance status, and other socioeconomic determinants of health. RESULTS: There were 1448 telemedicine appointments in the pandemic cohort and 8053 in-person appointments in the prepandemic cohort. Rates of telemedicine MCOs (12.5%; n=181) were significantly lower than in-person MCOs (19.5%; n=1566; P<0.001). Telemedicine appointments with public insurance or without insurance (P<0.001) and being Black or Hispanic/Latinx (P=0.003) were associated with MCOs. There were significant differences between in-person MCOs and telemedicine MCOs among all predictors studied, except for orthopaedic subspecialty team and patient's social vulnerability index. CONCLUSIONS: Patients with telemedicine appointments during the COVID-19 pandemic were less likely to experience MCOs than patients with in-person visits during the nonpandemic timeframe. However, when controlling for socioeconomic factors including race, ethnicity, and insurance type, disparities found for in-person visits persisted with the shift to telemedicine. Pediatric orthopaedists should be aware that the use of telemedicine does not necessarily improve access for our most vulnerable patients. LEVEL OF EVIDENCE: Level III.

Comparison of 2 Patient-Reported Outcome Measures in Brachial Plexus Birth Injury: A Systematic Validation Study.

BACKGROUND: Patient-reported outcome (PRO) measures are integral to clinical practice. While new instruments bring updated methodology and delivery methods, they must be compared with existing measures to ensure that they are comparable with currently used instruments and allow ongoing comparison. In this study, we evaluated 2 PRO measures for patients with brachial plexus birth injury (BPBI): the legacy Pediatric Outcomes Data Collection Instrument (PODCI) and the newer Patient-Reported Outcomes Measurement Information System (PROMIS). We hypothesized that the PROMIS and PODCI would be correlated, with high convergent validity, and that PROMIS assessment would have higher discriminant validity and take less time to complete than the PODCI. METHODS: A cross-sectional prospective study was undertaken at a tertiary referral center. Subjects (n = 50) completed the PODCI and PROMIS, both as short form (SF) and computer-adaptive testing (CAT) measures, in randomized order. Patient and parent questionnaires were completed according to subject age. Physicians completed upper-extremity (UE) physical function tests. Correlations between PODCI and PROMIS scores were analyzed to determine convergent validity, UE subscores were analyzed relative to physical function scores to assess discriminant validity, and completion times were calculated to determine survey time to completion. RESULTS: High convergent validity was found between the parent-reported PODCI, PROMIS SF, and PROMIS CAT measures. A ceiling effect was found for the PODCI but not for the PROMIS. The PROMIS CAT had better discriminant validity than either the PROMIS SF or PODCI. Patient and parent outcome scores did not highly correlate. Survey time to completion varied by PRO measure and method of delivery. CONCLUSIONS: There was high convergent validity between the UE domains of the PROMIS and PODCI, with a lower time to completion for the PROMIS SF. Although results show that the PROMIS CAT may take longer to complete, there are notable benefits to its adoption, including high convergent validity with the PODCI and better discriminant validity than the PODCI and PROMIS SF measures.

Functional Elbow Range of Motion in Children and Adolescents.

BACKGROUND: The functional elbow range of motion in children and adolescents has not been previously reported. In adults, a functional motion arc of 30 to 130 degrees of elbow flexion and 50 degrees of pronation to 50 degrees of supination is well established. Contemporary tasks such as cellular phone use and keyboarding require greater elbow flexion and pronation than the functional motion arc. Whether or not this is true in children has yet to be established. We hypothesize that to perform functional and contemporary tasks, children and adolescents use a greater range of elbow motion and forearm rotation as compared with adults. METHODS: Twenty-eight subjects performed 8 functional tasks and 4 contemporary tasks. Kinematic data were captured using a 3-dimensional motion analysis system as previously described. Mean and SD was collected for elbow flexion, extension, pronation, and supination. Unpaired t tests were performed to compare elbow kinematics of children 6- to 11-year-old (n=14) to that of adolescents 12- to 17-year-old (n=14), with a significance criterion of P-value <0.05. RESULTS: The mean arc of motion to achieve functional tasks was 28 to 146 degrees of elbow extension/flexion and 54 degrees of supination to 65 degrees of pronation. Contemporary tasks utilized 40 to 148 degrees of elbow extension/flexion and 49 degrees of supination to 65 degrees of pronation. A greater supination/pronation arc (107 degrees) and greater elbow flexion (148 degrees) were used to bring a cellular phone to the ear, whereas greater pronation (65 degrees) was used to type on a keyboard. Statistically significant differences were observed between children and adolescents in each of the 12 tasks, with the exception of using a fork. CONCLUSIONS: A motion arc of 30 to 130 degrees of elbow flexion and 50 to 50 degrees of pronation/supination is sufficient to achieve most positional and functional tasks in children and adolescents. However, specific contemporary tasks such as the use of a cellular phone and typing on a keyboard utilize more elbow flexion and pronation. Awareness of greater use of flexion and pronation to achieve contemporary tasks may help guide surgeons in the care of patients with posttraumatic elbow and forearm deformities and contractures. LEVEL OF EVIDENCE: Level II-investigation of a diagnostic test.