Place-Based Child Opportunity at Birth and Child Development from Infancy to Age 4.

OBJECTIVE: The objective of this study was to evaluate whether the children's neighborhood quality, as a measure of place-based social determinants of health, is associated with the odds of developmental delay and developmental performance up to the age of 4 years. STUDY DESIGN: Mothers of 5702 children from the Upstate KIDS Study, a longitudinal population-based cohort of children born from 2008 through 2010, provided questionnaire data and a subset of 573 children participated in a clinic visit. The Child Opportunity Index 2.0 was linked to home census tract at birth. Probable developmental delays were assessed by the Ages and Stages Questionnaire up to 7 times between 4 and 36 months, and developmental performance was assessed via the Battelle Developmental Inventory at the age of 4 years. RESULTS: In unadjusted models, higher neighborhood opportunity was protective against developmental delays and was associated with slightly higher development scores at age 4. After adjusting for family-level confounding variables, 10-point higher Child Opportunity Index (on a 100-point scale) remained associated with a lower odds of any developmental delay (OR = .966, 95% CI = .940-.992), and specifically delays in the personal-social domain (OR = .921, 95% CI = .886-.958), as well as better development performance in motor (B = 0.79, 95% CI = 0.11-1.48), personal-social (B = 0.64, 95% CI = 0.003-1.28), and adaptive (B = 0.69, 95% CI = 0.04-1.34) domains at age 4. CONCLUSIONS: Community-level opportunities are associated with some aspects of child development prior to school entry. Pediatric providers may find it helpful to use neighborhood quality as an indicator to inform targeted developmental screening.

The Child Opportunity Index 2.0 and Disparities in Pediatric Cardiorespiratory Fitness.

OBJECTIVE: To evaluate the effect of neighborhood-level characteristics on cardiorespiratory fitness (CRF) via peak oxygen consumption (VO2peak) for healthy pediatric patients. STUDY DESIGN: The institutional cardiopulmonary exercise testing (CPET) database was analyzed retrospectively. All patients aged ≤ 18 years without a diagnosis of cardiac disease and with a maximal effort CPET were included. Patients were divided into three self-identified racial categories: White, Black, and Latinx. The Child Opportunity Index (COI) 2.0 was used to analyze social determinants of health. CRF was evaluated based on COI quintiles and race. Assessment of the effect of COI on racial disparities in CRF was performed using ANCOVA. RESULTS: A total of 1753 CPETs met inclusion criteria. The mean VO2peak was 42.1 ± 9.8 mL/kg/min. The VO2peak increased from 39.1 ± 9.6 mL/kg/min for patients in the very low opportunity cohort to 43.9 ± 9.4 mL/kg/min for patients in the very high opportunity cohort. White patients had higher percent predicted VO2peak compared with both Black and Latinx patients (P < .01 for both comparisons). The racial differences in CRF were no longer significant when adjusting for COI. CONCLUSION: In a large pediatric cohort, COI was associated with CRF. Racial disparities in CRF are reduced when accounting for modifiable risk factors.

Sociodemographic predictors of imaging utilization in children with right lower quadrant pain.

BACKGROUND: Inequities in health care access lead to inequities in outcome. In recent years, health outcome disparities have been documented in children with acute appendicitis and sociodemographic predictors of imaging utilization have not been adequately assessed. OBJECTIVE: The purpose of our study is to assess sociodemographic predictors for the diagnostic imaging of children with right lower quadrant (RLQ) pain. Our hypothesis is that disparities exist in imaging utilization. MATERIALS AND METHODS: Our nationwide retrospective cohort study of the Pediatric Health Information System (PHIS) database queried emergency department encounters for children aged 0-18 years presenting with RLQ pain (ICD code CM R10.31) between January 2018 and September 2023. Primary exposures included neighborhood-level sociodemographic metrics as measured by Child Opportunity Index, race/ethnicity, and insurance status. Outcomes included no diagnostic imaging, diagnostic imaging with radiography alone, ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI). Multivariable logistic regression analyses assessed modality usage with respect to the primary exposures after controlling for demographic (age, gender) and additional (hospital geographic region, time of imaging) covariates. To avoid the perpetuation of bias, reference categories were determined by the lowest numerical value for each covariate. RESULTS: In total, 100,161 patient encounters met inclusion criteria (mean patient age 11.2 years ± 3.9; 59.3%, n = 59,416 females). Imaging utilized was US (78.0%; n = 78,115), CT (16.4%, n = 16,405), no imaging (13.9%, n = 13,894), radiography alone (4.4%, n = 4,429), and MRI (3.1%, n = 3,148). The most predictive factors for no imaging were moderate, low, and very low Child Opportunity Index (aOR 1.25, 1.17, and 1.18 [95% CI 1.10-1.33] compared to very high Child Opportunity Index); Black race/ethnicity (aOR 1.26 [95% CI 1.11-1.44] compared to White or Asian race/ethnicity); and public or other insurance (aOR 1.23 and 1.32 [95% CI 1.18-1.41] compared to commercial insurance). The most predictive factors for radiography alone were Black race/ethnicity (aOR 1.30 [95% CI 1.17-1.45] compared to Hispanic race/ethnicity) and public or other insurance (aOR 1.26 [95% CI 1.11-1.44] compared to commercial). The most predictive factors for US were very-high Child Opportunity Index (aOR 1.16 [95% CI 1.09-1.22] compared to very low Child Opportunity Index); Asian, NH-White, or Hispanic race/ethnicity (aOR 1.33, 1.31, 1.30 [95% CI 1.18-1.40] compared to Black race/ethnicity); and commercial insurance (aOR 1.20 [95% CI 1.16-1.25] compared to public insurance). The most predictive factor for CT was White race/ethnicity (aOR 1.26 [95% CI 1.11-1.43] compared with Asian race/ethnicity) and the most predictive factor for MRI was Hispanic race/ethnicity (aOR 1.49 [95% CI 1.17-1.61] compared with Black race/ethnicity). The greatest predictor of cross-sectional imaging was a hospital's region, with CT most likely in southern hospitals (aOR 4.09 [95% CI 2.17-7.70] compared with northeast hospitals). Patient Child Opportunity Index did not predict the likelihood of cross-sectional imaging with CT or MRI in tertiary pediatric centers. CONCLUSION: Sociodemographic disparities exist in the imaging of children presenting to tertiary pediatric hospitals with RLQ pain. Future studies are needed to analyze the causes of such disparities both on hospital and departmental levels.

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.

The Relationships Among Neighborhood Disadvantage, Mental Health and Developmental Disabilities Diagnoses, and Race/Ethnicity in a U.S. Urban Location.

Childhood health disparities by race have been found. Neighborhood disadvantage, which may result from racism, may impact outcomes. The aim of the study is to describe the distribution of mental health (MH) and developmental disabilities (DD) diagnosis across Child Opportunity Index (COI) levels by race/ethnicity. A cross-sectional study using 2022 outpatient visit data for children < 18 years living in the Louisville Metropolitan Area (n = 115,738) was conducted. Multivariable logistic regression analyses examined the association between diagnoses and COI levels, controlling for sex and age. Almost 18,000 children (15.5%) had a MH or DD (7,905 [6.8%]) diagnosis. In each COI level, the prevalence of MH diagnosis was lower for non-Hispanic (N-H) Black than for N-H White children. In adjusted analyses, there were no significant associations between diagnoses and COI for non-White children for MH or DD diagnoses. The odds of receiving a MH [OR: 1.74 (95% CI: 1.62, 1.87)] and DD [OR: 1.69 (95% CI: 1.51, 1.88)] diagnosis were higher among N-H White children living in Very Low compared to Very High COI areas. Current findings suggest that COI does not explain disparities in diagnosis for non-White children. More research is needed to identify potential multi-level drivers such as other forms of racism. Identifying programs, policies, and interventions to reduce childhood poverty and link children and families to affordable, family-centered, quality community mental and physical health resources is needed to ensure that families can build trusting relationships with the providers while minimizing stigma.

Do Neighborhood Resources Mitigate Family Risk to Preschool Children's Executive Function Skills Growth?

Despite previous studies showing that children's development of executive function (EF) skills is associated with the differing contexts in which children live, evidence about the independent and synergistic effects of families and neighborhoods is limited. Using a sample from a two-cohort longitudinal study of preschoolers from low-income families, we examined whether residential neighborhood resources (measured with the Child Opportunity Index (COI)) moderated the relationship between family cumulative risk and the growth trajectory of children's EF skills. Results from conditional growth curve models indicate family cumulative risk was negatively related to baseline EF skills and the rate of EF skill growth. In contrast, the overall COI and the COI social and economic domain z-score were positively associated with the initial, but not linear, growth of EF skills. We found no evidence of moderator effects. Policies that aim to better target and support the most vulnerable children should consider the unique contribution of family risks and neighborhood resources to child development.

Neighborhood child opportunity is associated with hospital length of stay following pediatric burn injury.

INTRODUCTION: Pediatric burns are associated with socioeconomic disadvantage and lead to significant morbidity. The Child Opportunity Index (COI) is a well-validated measure of neighborhood characteristics associated with healthy child development. We sought to evaluate the relationship between COI and outcomes of burn injuries in children. METHODS: We performed a single-institution retrospective review of pediatric (<16 years) burn admissions between 2015 and 2019. Based on United States residential zip codes, patients were stratified into national COI quintiles. We performed a multivariate Poisson regression analysis to determine the association between COI and increased length of stay. RESULTS: 2095 pediatric burn admissions occurred over the study period. Most children admitted were from very low (n = 644, 33.2 %) and low (n = 566, 29.2 %) COI neighborhoods. The proportion of non-Hispanic Black patients was significantly higher in neighborhoods with very low (44.5 %) compared to others (low:28.8 % vs. moderate:11.9 % vs. high:10.5 % vs. very high:4.3 %) (p < 0.01). Hospital length of stay was significantly longer in patients from very low COI neighborhoods (3.6 ± 4.1 vs. 3.2 ± 4.9 vs. 3.3 ± 4.8 vs. 2.8 ± 3.5 vs. 3.2 ± 8.1) (p = 0.02). On multivariate regression analysis, living in very high COI neighborhoods was associated with significantly decreased hospital length of stay (IRR: 0.51; 95 % CI: 0.45-0.56). CONCLUSION: Children from neighborhoods with significant socioeconomic disadvantage, as measured by the Child Opportunity Index, had a significantly higher incidence of burn injuries resulting in hospital admissions and longer hospital length of stay. Public health interventions focused on neighborhood-level drivers of childhood development are needed to decrease the incidence and reduce hospital costs in pediatric burns. TYPE OF STUDY: Retrospective study LEVEL OF EVIDENCE: Level III.

Change in Child Opportunity Index in Early Childhood Is Associated with Youth BMI Growth.

Background: The neighborhood-level child opportunity index (COI) has been used in policy-based initiatives to identify and improve low-resource neighborhoods in order to impact child health. Understanding of how changes in COI can impact child growth, however, is lacking. Methods: Participants were 1124 children from the Family Life Project, a longitudinal birth cohort of families in rural, high-poverty areas. Youth anthropometrics were measured at eight assessments (ages 2 months through 12 years). Neighborhood COI was obtained at seven assessments (ages 2 months through 5 years) and used to create seven trajectory groups representing a change in COI: stayed low on all seven assessments, stayed moderate, stayed high, left low, declined from moderate, declined from high, and bounced around. Results: As hypothesized, moving from high COI neighborhoods into lower COI neighborhoods was associated with greater BMI growth and increased risk for obesity and severe obesity at 12 years. As hypothesized, the opposite effect, which approached significance at p = 0.056, was found among children who moved from low COI neighborhoods into higher COI neighborhoods. Specifically, moving into higher COI neighborhoods was associated with reduced BMI growth, and lower risk for severe obesity at 12 years. Conclusions: Moving into higher COI neighborhoods may be associated with healthier BMI growth, while the opposite effect may occur when moving into lower COI neighborhoods. Given the use of the COI in public health initiatives and growing evidence for its potential positive impact on child growth, future work is needed to replicate our findings among larger diverse samples.

Child opportunity index is associated with pediatric firearm injury in Philadelphia, Pennsylvania.

Introduction: Firearm injury is the leading cause of death in children. This study uses geospatial mapping to illustrate the burden of pediatric firearm injury in Philadelphia and assesses the relationship between Child Opportunity Index (COI) and injury, hypothesizing that lower COI zip codes would have higher injury and mortality rates. Methods: Pediatric firearm injury data for children aged 0-19 years in Philadelphia, from 2015 to February 2023, was visualized by race/ethnicity, fatal versus non-fatal status, and COI for zip code. COI was then dichotomized as "High" or "Low" based on nationally normed scores and used to compare incidence and odds of mortality. Injury incidence rates by COI were calculated using weighted Poisson regression, to adjust for the total number of children in each COI category. Odds of mortality by COI, adjusted for age, sex and race/ethnicity, were calculated using multivariable logistic regression. Results: Of 2,339 total pediatric firearm injuries, 366 (16%) were fatal. Males (89%), adolescents (95%) and Black children (88%) were predominately affected. Geospatial mapping showed highest burden in North and West Philadelphia, which corresponded with areas of low COI. The incidence rate ratio (IRR) of injury in low COI zip codes was 2.5 times greater than high COI (IRR 2.5 [1.93-3.22]; p < 0.01). After adjusting for age, sex, and race/ethnicity, odds of mortality in low COI zip codes was nearly twice that of high COI zip codes (aOR 1.95 [0.77-4.92]), though did not demonstrate statistical significance (p = 0.16). Conclusion: Child opportunity index is associated with pediatric firearm injury in Philadelphia, Pennsylvania.

Pediatric Trauma Mortality Differs by Neighborhood Opportunity Level.

OBJECTIVE: Traumatic injuries are a leading cause of death in children and a child's neighborhood characteristics can be a risk factor. Our objective was to describe the association between pediatric trauma mortality and Child Opportunity Index (COI). METHODS: A multicenter, retrospective cross-sectional study was conducted across 15 trauma centers from 2010 to 2021 within a large metropolitan county to evaluate trauma activation mortalities involving children <18 years-old. We examined clinical and demographic data from the county trauma registry and linked home zip code to COI, a measure of neighborhood level resources critical for children's development. Proportion of mortalities were compared to the proportion of children within each COI quintile and injury mechanism was evaluated across COI quintile. Analysis was performed using Kruskal-Wallis and chi-square tests (α = 0.05). RESULTS: Of 31,702 pediatric trauma activations, 513 (1.6%) mortalities occurred. Mortalities mostly resulted from assaults (37.0%), pedestrian injuries (26.7%), and motor-vehicle collisions (18.7%). Of all mortalities, 32.6% were firearm related, either from an assault or self-inflicted. A greater proportion of mortalities were children from very low (47.6%) and low (20.9%) COI neighborhoods with fewer from higher (8.8.% and 7.6%) COI-neighborhoods compared to the county's proportion of children within these quintiles (p < 0.001). The injury mechanisms were different, with mortalities of lower COI neighborhoods being associated with assaults (p = 0.005), while mortalities of higher COI neighborhoods were self-inflicted (p = 0.003). CONCLUSION: Lower opportunity neighborhoods had a higher incidence of pediatric trauma mortality. Mortality mechanism varied across neighborhoods with assault greater in lower opportunity neighborhoods and self-inflicted among higher opportunity neighborhoods. LEVEL OF EVIDENCE: Level III.

The Child Opportunity Index and Outcomes After Pediatric Anterior Cruciate Ligament Reconstruction.

Background: Research at the intersection between social determinants of health (SDOH) and orthopaedics remains an area of active exploration, with recent literature demonstrating significant disparities in a wide array of orthopaedic outcomes in patients with different SDOH. Purpose/Hypothesis: The purpose of this study was to use a validated composite measure of SDOH mapped to census tracts (Child Opportunity Index [COI]) to explore disparities in functional outcomes after anterior cruciate ligament (ACL) reconstruction. It was hypothesized that patients with a lower COI score would have delayed surgical care and worse functional outcomes after ACL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: Demographic, surgical, and functional outcomes data were extracted for all patients aged ≤18 years who underwent primary ACL reconstruction at our institution between 2009 and 2019. Strength deficits were calculated, and COI quintile scores were obtained. One-way analysis of variance, the chi-square test, and the Fisher exact test were used to compare variables of interest between the lower 2 quintiles (low group) and the upper 2 quintiles (high group). Results: Of the 1027 patients, 226 (22.0%) were in the low group, while 801 (78.0%) were in the high group. There was a significantly greater time from injury to surgery in the low group than in the high group (98.15 ± 102.65 vs 71.79 ± 101.88 days, respectively; P < .001). The low group had a significantly lower extension-flexion range of motion at 1- and 3-month follow-up (P = .03 and P = .02, respectively) but no difference at 6-month follow-up (P = .27). The low group attended fewer physical therapy visits than the high group (24.82 ± 10.55 vs 37.81 ± 18.07, respectively; P < .001). The low group had significant deficits in quadriceps strength at 3, 6, and 9 months at 180 deg/s (P = .03, P < .001, and P = .01, respectively) and at 6 months at 300 deg/s (P = .002). Conclusion: In this study, we found that the COI was associated with disparities in key clinical outcomes including time to surgery, postoperative range of motion, and postoperative strength.

Neighborhood-Level Social Determinants of Health and Adolescent Mental Health.

OBJECTIVE: Mental health diagnoses among adolescents are increasing in prevalence. Existing literature considers associations between individual-level social determinants of health (SDOH) and adolescent mental health. Neighborhood-level SDOH can have a substantial impact on health. This paper examines associations between neighborhood-level SDOH and mental health diagnoses of anxiety, depression, and suicidal ideation among hospitalized adolescents. METHODS: We used 2018 and 2019 Texas Inpatient Discharge Public Use Data Files linked to the zip-code level Child Opportunity Index 2.0, a composite measure of subdomains which characterize neighborhood-level SDOH, to examine rates of mental health diagnoses and associations with patient characteristics across opportunity level quintiles. RESULTS: The sample included 50,011 adolescents ages 10-19 admitted to the hospital with the mental health diagnoses anxiety, depression, and/or suicide. Most had a single diagnosis; anxiety (12.9%), depression (37.5%), or suicide (13.0%). Hospitalized adolescents 10-14 years old were a plurality (44.2%) of the sample. Most adolescents were White (64.2%) and non-Hispanic (67.4%) and lived in rural areas (29.6%). Adolescents from racial minority populations and those in rural communities with mental health diagnoses had lower opportunity-levels. Higher opportunity levels were associated with greater odds of having an anxiety or suicide diagnosis while a depression diagnosis was associated with a lower opportunity-level. CONCLUSIONS: There are significant differences in adolescent mental health diagnoses associated with neighborhood opportunity-level. While all adolescents can benefit from mental health education, screening, and early interventions, additional resources tailored to neighborhood-level opportunity may prove a more meaningful way to improve population-level mental health outcomes.

Associations Between Neighborhood Resources and Youths' Response to Reward Omission in a Task Modeling Negatively Biased Environments.

OBJECTIVE: Neighborhoods provide essential resources (eg, education, safe housing, green space) that influence neurodevelopment and mental health. However, we need a clearer understanding of the mechanisms mediating these relationships. Limited access to neighborhood resources may hinder youths from achieving their goals and, over time, shape their behavioral and neurobiological response to negatively biased environments blocking goals and rewards. METHOD: To test this hypothesis, 211 youths (aged ∼13.0 years, 48% boys, 62% identifying as White, 75% with a psychiatric disorder diagnosis) performed a task during functional magnetic resonance imaging. Initially, rewards depended on performance (unbiased condition); but later, rewards were randomly withheld under the pretense that youths did not perform adequately (negatively biased condition), a manipulation that elicits frustration, sadness, and a broad response in neural networks. We investigated associations between the Childhood Opportunity Index (COI), which quantifies access to youth-relevant neighborhood features in 1 metric, and the multimodal response to the negatively biased condition, controlling for age, sex, medication, and psychopathology. RESULTS: Youths from less-resourced neighborhoods responded with less anger (p < .001, marginal R2 = 0.42) and more sadness (p < .001, marginal R2 = 0.46) to the negatively biased condition than youths from well-resourced neighborhoods. On the neurobiological level, lower COI scores were associated with a more localized processing mode (p = .039, marginal R2 = 0.076), reduced connectivity between the somatic-motor-salience and the control network (p = .041, marginal R2 = 0.040), and fewer provincial hubs in the somatic-motor-salience, control, and default mode networks (all pFWE < .05). CONCLUSION: The present study adds to a growing literature documenting how inequity may affect the brain and emotions in youths. Future work should test whether findings generalize to more diverse samples and should explore effects on neurodevelopmental trajectories and emerging mood disorders during adolescence. DIVERSITY & INCLUSION STATEMENT: One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. One or more of the authors of this paper received support from a program designed to increase minority representation in science. We actively worked to promote sex and gender balance in our author group. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group.

Delayed diagnosis of new onset pediatric diabetes leading to diabetic ketoacidosis: a retrospective cohort study.

OBJECTIVES: Patients with a delayed diagnosis of diabetes are more likely to present in diabetic ketoacidosis (DKA). The objective of this study was to assess the prevalence, risk factors, and consequences of missed pediatric diabetes diagnoses in emergency departments (EDs) potentially leading to DKA. METHODS: Cases of children under 19 years old with a first-time diagnosis of diabetes mellitus presenting to EDs in DKA were drawn from the Healthcare Cost and Utilization Project database. A total of 11,716 cases were included. A delayed diagnosis of diabetes leading to DKA was defined by an ED discharge in the 14 days prior to the DKA diagnosis. The delayed diagnosis cases were analyzed using multivariate analysis to identify risk factors associated with delay, with the primary exposure being child opportunity index (COI) and secondary exposure being race/ethnicity. Rates of complications were compared across groups. RESULTS: Delayed diagnosis of new onset diabetes leading to DKA occurred in 2.9 %. Delayed diagnosis was associated with COI, with 4.5 , 3.5, 1.9, and 1.5 % occurring by increasing COI quartile (p<0.001). Delays were also associated with younger age and non-Hispanic Black race. Patients with a delayed diagnosis were more likely to experience complications (4.4 vs. 2.2 %, p=0.01) including mechanical ventilation, as well as more frequent intensive care unit admissions and longer length of stays. CONCLUSIONS: Among children with new-onset DKA, 2.9 % had a delayed diagnosis. Delays were associated with complications. Children living in areas with lower child opportunity and non-Hispanic Black children were at higher risk of delays.

Association of the Child Opportunity Index and Inpatient Illness Severity in the United States, 2018-2019.

OBJECTIVE: Children residing in impoverished neighborhoods have reduced access to health care resources. Our objective was to identify potential associations between Child Opportunity Index (COI), a composite score of neighborhood characteristics, and inpatient severity of illness and clinical trajectory among United States (US) children. METHODS: This retrospective cohort study assessed data using the Pediatric Health Information System Registry from 2018 to 2019. Primary exposure variable was COI level (range: very low [CO1 1], low [COI 2], moderate [COI 3], high [COI 4], and very high [COI 5]). Markers of inpatient clinical severity included index mortality, Pediatric Intensive Care Unit (PICU) admission, invasive mechanical ventilation (IMV), and hospital length of stay (LOS). Subgroup analysis of COI and clinical outcome variation by United States Census Geographic Regions was conducted. Adjusted regression analysis was utilized to understand associations between COI and inpatient clinical severity outcomes. RESULTS: Of the 132,130 encounters, 44% resided in very low or low COI neighborhoods. In adjusted models, very low COI was associated with increased mortality (aOR: 1.35, 95% CI: 1.05-1.74, P = .018), PICU admission (aOR: 1.06, 95% CI: 1.02-1.11, P = 0.014), IMV (aOR: 1.12, 95% CI: 1.04-1.21, P = .002), and higher hospital LOS (P = .045). Regional variation by COI depicted the East North Central region having the highest rate of mortality (20.5%), P < .001, and PICU admissions (23%), P = .014. CONCLUSIONS: Our multicenter, retrospective study highlights the interaction between neighborhood-level deprivation and worsened health disparities, indicating a need for prospective study.

Association Between Neighborhood Context and Psychotropic Polypharmacy Use Among High-Need Children.

OBJECTIVE: The authors explored whether neighborhood context is associated with psychotropic polypharmacy and psychotherapy among a cohort of children with high needs for psychiatric and general medical care. METHODS: Electronic health record data from a large health care system were used in a cross-sectional design to examine psychotropic polypharmacy and psychotherapy in 2015-2019 among children ages 2-17 years (N=4,017) with geocoded addresses. Inclusion criteria were a diagnosis of a mental health condition, an intellectual and developmental disability, or a complex medical condition and one or more clinical encounters annually over the study period. Polypharmacy was defined as two or more psychotropic drug class prescriptions concurrently for ≥60 days. Psychotherapy was defined as receipt of any psychotherapy or adaptive behavior treatment. Neighborhood context (health, environment, education, and wealth) was measured with the Child Opportunity Index. Multilevel generalized linear mixed models with random intercept for census tracts were used to assess the associations between individual and neighborhood characteristics and psychotropic polypharmacy and psychotherapy. RESULTS: Moderate (vs. low) child opportunity was associated with higher odds of polypharmacy (adjusted OR [AOR]=1.79, 95% CI=1.19-2.67). High (vs. low) child opportunity was associated with higher odds of psychotherapy (AOR=2.15, 95% CI=1.43-3.21). Black (vs. White) race (AOR=0.51, 95% CI=0.37-0.71) and Hispanic ethnicity (AOR=0.44, 95% CI=0.26-0.73) were associated with lower odds of polypharmacy. CONCLUSIONS: Among high-need children, neighborhood Child Opportunity Index, race, and ethnicity were significantly associated with treatment outcomes in analyses adjusted for clinical factors. The findings underscore concerns about structural disparities and systemic racism and raise questions about access.

Neighborhood Opportunity and Obesity in Early Adolescence: Differential Associations by Sex.

PURPOSE: Though research indicates that certain aspects of adverse neighborhood conditions may influence weight development in childhood and adolescence, it is unknown if the Child Opportunity Index (COI), a composite measure of 29 indicators of neighborhood conditions, is associated with weight outcomes in adolescence. We hypothesized that lower COI would be associated with higher overweight and obesity in cross-sectional and longitudinal modeling in a national sample of 9 year olds and 10 year olds and that this association would be different by sex. METHODS: Using data from the Adolescent Brain Cognitive Development study (n = 11,857), we examined the cross-sectional association between COI quintile and overweight and obesity in 9 year olds and 10 year olds. Additionally, we used hazard ratios to examine incident overweight and obesity across three waves of data collection. RESULTS: Due to the interaction between sex and COI (p < .05), we present sex-specific models. There was a stepwise bivariate association, in which higher COI was associated with lower obesity prevalence. This pattern held in multilevel models, with a stronger association in females. In models adjusted for individual and household characteristics, female adolescents in the lowest quintile COI neighborhoods had 1.81 (95% confidence interval: 1.32, 2.48) times the odds of obesity compared to those in the highest quintile. In longitudinal models, the COI was associated with incident obesity in females only: adjusted hazard ratio = 4.27 (95% confidence interval: 1.50, 12.13) for lowest compared to highest COI. DISCUSSION: Neighborhood opportunity is associated with risk of obesity in pre-adolescence into mid-adolescence. Females may be particularly influenced by neighborhood conditions.

Trends in Gaps of Care for Patients With Congenital Heart Disease: Implications for Social Determinants of Health and Child Opportunity Index.

BACKGROUND: Lifelong continuity of care is essential for patients with congenital heart disease (CHD) to maximize health outcomes; unfortunately, gaps in care (GIC) are common. Trends in GIC and of social determinants of health factors contributing to GIC are poorly understood. METHODS AND RESULTS: This retrospective cohort study included patients with CHD, aged 0 to 34 years, who underwent surgery between January 2003 and May 2020, followed up at a pediatric subspeciality hospital. Patients were categorized as having simple, moderate, and complex CHD based on 2018 American Heart Association and American College of Cardiology guidelines. Social determinants of health, such as race, ethnicity, language, insurance status, and Child Opportunity Index, based on home address zip code, were analyzed. Of 2012 patients with CHD, a GIC of ≥3 years was identified in 56% (n=1119). The proportion of patients with GIC per year increased by 0.51% (P<0.001). Multivariable longitudinal models showed that the odds of GIC were higher for patients who were ≥10.5 years old, had simple CHD, lived out of state, lived farther from care site, received public insurance, had less protection with additional insurance plans, and with low Child Opportunity Index. A separate model for patients with only moderate/complex CHD showed similar findings. Race and ethnicity were not associated with the odds of experiencing GIC over time. CONCLUSIONS: GIC have increased over time for patients with CHD. Social determinants of health, like insurance, access, and neighborhood opportunity, are key risk factors for increasing GIC. Efforts to reduce GIC in patients with CHD should focus on addressing the impact of specific social determinants of health.

Comparison of Neighborhood Disadvantage Indices on Emergency Medical Services Interventions and Outcomes for Pediatric Out-of-Hospital Emergencies.

OBJECTIVE: Measures of neighborhood disadvantage demonstrate correlations to health outcomes in children. We compared differing indices of neighborhood disadvantage with emergency medical services (EMS) interventions in children. METHODS: We performed a retrospective study of EMS encounters for children (<18 years) from approximately 2000 US EMS agencies between 2021 and 2022. Our exposures were the Child Opportunity Index (COI; v2.0), 2021 Area Deprivation Index (ADI), and 2018 Social Vulnerability Index (SVI). We evaluated the agreement in how children were classified with each index using the intraclass correlation coefficient. We used logistic regression to evaluate the association of each index with transport status, presence of cardiac arrest, and condition-specific interventions and assessments. RESULTS: We included 738,892 encounters. The correlation between the indices indicated good agreement (intraclass correlation coefficient=0.75). There was overlap in relationships between the COI, ADI, and SVI for each of the study outcomes, both when visualized as a splined predictor and when using representative odds ratios (OR) comparing the third quartile of each index to the lower quartile (most disadvantaged). For example, the OR of non-transport was 1.12 (95% confidence interval [CI]: 1.10-1.14) for COI, 1.18 (95% CI: 1.16-1.20) for ADI, and 1.22 (95% CI: 1.20-1.23) for SVI. CONCLUSION: The COI, ADI, and SVI had good correlation and demonstrated similar effect size estimates for a variety of clinical outcomes. While investigators should consider potential causal pathways for outcomes when selecting an index for neighborhood disadvantage, the relative strength of association between each index and all outcomes was similar.

Characteristics Associated With Purchasing Sugar-Sweetened Beverages and Bottled Water Among US Households, 2015.

BACKGROUND: Frequent intake of sugar-sweetened beverages (SSBs) among US adults is a public health concern because it has been associated with increased risks for adverse health outcomes such as obesity, type 2 diabetes, and cardiovascular disease. In contrast, drinking plain water (such as tap, bottled, or unsweetened sparkling water) instead of drinking SSBs might provide health benefits by improving diet quality and helping prevent chronic diseases. However, there is limited information on estimated expenditures on SSBs or bottled water among US households. OBJECTIVE: This study examined differences in SSB and bottled water purchasing according to household and geographic area characteristics and estimated costs spent on purchasing SSB and bottled water from retail stores among a nationally representative sample of US households. DESIGN: This study is a secondary analysis of the 2015 Circana (formerly Information Resources Inc) Consumer Network Panel data, which were merged with the US Department of Agriculture nutrition data using the US Department of Agriculture Purchase-to-Plate Crosswalk-2015 dataset (the latest available version of the Purchase-to-Plate Crosswalk at the time the study began), and the Child Opportunity Index 2.0 data. PARTICIPANTS/SETTINGS: A total of 63,610 households, representative of the contiguous US population, consistently provided food and beverage purchase scanner data from retail stores throughout 2015. EXPLANATORY VARIABLES: The included demographic and socioeconomic variables were household head's age, marital status, highest education level, race and ethnicity of the primary shopper in the household, family income relative to the federal poverty level, and presence of children in the household. In addition, descriptors of households' residential areas were included, such as the county-level poverty prevalence, urbanization, census region, and census tract level Child Opportunity Index. MAIN OUTCOME MEASURES: Annual per capita spending on SSB and bottled water and daily per capita SSB calories purchased. STATISTICAL ANALYSIS: Unadjusted and multivariable adjusted mean values of the main outcome measures were compared by household demographic, socioeconomic, and geographic characteristics using linear regression analysis including Circana's household projection factors. RESULTS: Nearly all households reported purchasing SSBs at least once during 2015 and spent on average $47 (interquartile range = $20) per person per year on SSBs, which corresponded to 211 kcal (interquartile range = 125 kcal) of SSBs per person per day. About seven in 10 households reported purchasing bottled water at least once during 2015 and spent $11 (interquartile range = $5) per person on bottled water per year. Both annual per capita SSB and bottled water spending, and daily per capita SSB calories purchased was highest for households whose heads were between 40 and 59 years of age, had low household income, or lived in poor counties, or counties with a low Child Opportunity Index. Annual per capita spending was also higher for households with never married/widowed/divorced head, or at least 1 non-Hispanic Black head, and households without children, or those living in the South. Daily per capita SSB calorie purchases were highest for households where at least 1 head had less than a high school degree, households with at least 1 Hispanic or married head, and households with children or those living in the Midwest. CONCLUSIONS: These findings suggest that households that had lower socioeconomic status had higher annual per capita spending on SSBs and bottled water and higher daily per capita total SSB calories purchased than households with higher socioeconomic status.