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.

The Diagnostic Accuracy of In-Hospital Weight Gain for Differentiating Neglect From Other Failure to Thrive Etiologies.

OBJECTIVES: To investigate the association of in-hospital weight gain with failure to thrive (FTT) etiologies. METHODS: With this retrospective cross-sectional study, we included children <2 years of age hospitalized for FTT between 2009 and 2012 at a tertiary care children's hospital. We excluded children with a gestational age <37 weeks, intrauterine growth restriction, acute illness, or preexisting complex chronic conditions. Average daily in-hospital weight gain was categorized as (1) below average or (2) average or greater for age. χ2, Fisher's exact test, and 1-way analysis of variance tests were used to compare patient demographics, therapies, and FTT etiologies with categorical weight gain; multivariable logistic regression models tested for associations. RESULTS: There were 331 children included. The primary etiologies of FTT were neglect (30.5%), gastroesophageal reflux disease (GERD) (28.1%), child-centered feeding difficulties (22.4%), and organic pathology (19.0%). Average or greater weight gain for age had a specificity of 22.2% and positive predictive value of 33.9% for differentiating neglect from other FTT etiologies. However, sensitivity and negative predictive value were 91.1% and 85.0%, respectively. After adjusting for demographics and therapies received, neglect (P = .02) and child-centered feeding difficulties (P = .01) were more likely to have average or greater weight gain for age compared with organic pathology. Children with GERD gained similarly (P = .11) to children with organic pathology. CONCLUSIONS: In-hospital weight gain was nonspecific for differentiating neglect from other FTT etiologies. Clinicians should exercise caution when using weight gain alone to confirm neglect. Conversely, below average weight gain may be more useful in supporting GERD or organic pathologies but cannot fully rule out neglect.

Potential Opportunities for Prevention or Earlier Diagnosis of Child Physical Abuse in the Inpatient Setting.

OBJECTIVES: To compare rates of previous inpatient visits among children hospitalized with child physical abuse (CPA) with controls as well as between individual abuse types. METHODS: In this study, we used the Pediatric Health Information System administrative database of 44 children's hospitals. Children <6 years of age hospitalized with CPA between January 1, 2011, and September 30, 2015, were identified by discharge codes and propensity matched to accidental injury controls. Rates for previous visit types were calculated per 10 000 months of life. χ2 and Poisson regression were used to compare proportions and rates. RESULTS: There were 5425 children hospitalized for CPA. Of abuse and accident cases, 13.1% and 13.2% had a previous inpatient visit, respectively. At previous visits, abused children had higher rates of fractures (rate ratio [RR] = 3.0 times; P = .018), head injuries (RR = 3.5 times; P = .005), symptoms concerning for occult abusive head trauma (AHT) (eg, isolated vomiting, seizures, brief resolved unexplained events) (RR = 1.4 times; P = .054), and perinatal conditions (eg, prematurity) (RR = 1.3 times; P = .014) compared with controls. Head injuries and symptoms concerning for occult AHT also more frequently preceded cases of AHT compared with other types of abuse (both P < .001). CONCLUSIONS: Infants hospitalized with perinatal-related conditions, symptoms concerning for occult AHT, and injuries are inpatient populations who may benefit from abuse prevention efforts and/or risk assessments. Head injuries and symptoms concerning for occult AHT (eg, isolated vomiting, seizures, and brief resolved unexplained events) may represent missed opportunities to diagnose AHT in the inpatient setting; however, this requires further study.

Medicaid Expenditures Among Children With Noncomplex Chronic Diseases.

BACKGROUND AND OBJECTIVES: Expenditures for children with noncomplex chronic diseases (NC-CDs) are related to disease chronicity and resource use. The degree to which specific conditions contribute to high health care expenditures among children with NC-CDs is unknown. We sought to describe patient characteristics, expenditures, and use patterns of children with NC-CDs with the lowest (≤80th percentile), moderate (81-95th percentile), high (96-99th percentile), and the highest (≥99th percentile) expenditures. METHODS: In this retrospective cross-sectional study, we used the 2014 Truven Medicaid MarketScan Database for claims from 11 states. We included continuously enrolled children (age <18 years) with NC-CDs (n = 1 563 233). We describe per member per year (PMPY) spending and use by each expenditure group for inpatient services, outpatient services, and the pharmacy for physical and mental health conditions. K-means clustering was used to identify expenditure types for the highest expenditure group. RESULTS: Medicaid PMPY spending ranged from $1466 (lowest expenditures) to $57 300 (highest expenditures; P < .001); children in the highest expenditure group were diagnosed with a mental health condition twice as often (72.7% vs 34.1%). Cluster analysis was used to identify 3 distinct groups: 83% with high outpatient mental health expenditures (n = 13 033; median PMPY $18 814), 15% with high inpatient expenditures (n = 2386; median PMPY $92 950), and 1% with high pharmacy expenditures (n = 213; median $325 412). Mental health conditions accounted for half of the inpatient diagnoses in the cluster analysis. CONCLUSIONS: One percent of children with the highest expenditures accounted for 20% of Medicaid expenditures in children with NC-CDs; mental health conditions account for a large proportion of aggregate Medicaid spending in children with NC-CDs.

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.

Multiple Behavior Change Intervention to Improve Detection of Unmet Social Needs and Resulting Resource Referrals.

OBJECTIVE: It is critical that pediatric residents learn to effectively screen families for active and addressable social needs (ie, negative social determinants of health). We sought to determine 1) whether a brief intervention teaching residents about IHELP, a social needs screening tool, could improve resident screening, and 2) how accurately IHELP could detect needs in the inpatient setting. METHODS: During an 18-month period, interns rotating on 1 of 2 otherwise identical inpatient general pediatrics teams were trained in IHELP. Interns on the other team served as the comparison group. Every admission history and physical examination (H&P) was reviewed for IHELP screening. Social work evaluations were used to establish the sensitivity and specificity of IHELP and document resources provided to families with active needs. During a 21-month postintervention period, every third H&P was reviewed to determine median duration of continued IHELP use. RESULTS: A total of 619 admissions met inclusion criteria. Over 80% of intervention team H&Ps documented use of IHELP. The percentage of social work consults was nearly 3 times greater on the intervention team than on the comparison team (P < .001). Among H&Ps with documented use of IHELP, specificity was 0.96 (95% confidence interval 0.87-0.99) and sensitivity was 0.63 (95% confidence interval 0.50-0.73). Social work provided resources for 78% of positively screened families. The median duration of screening use by residents after the intervention was 8.1 months (interquartile range 1-10 months). CONCLUSIONS: A brief intervention increased resident screening and detection of social needs, leading to important referrals to address those needs.