Association of neighborhood opportunity and pediatric hospitalization rates in the United States.

We examined associations between a validated, multidimensional measure of social determinants of health and population-based hospitalization rates among children <18 years across 18 states from the 2017 Healthcare Cost and Utilization Project State Inpatient Databases and the US Census. The exposure was ZIP code-level Child Opportunity Index (COI), a composite measure of neighborhood resources and conditions that matter for children's health. The cohort included 614,823 hospitalizations among a population of 29,244,065 children (21.02 hospitalizations per 1000). Adjusted hospitalization rates decreased significantly and in a stepwise fashion as COI increased (p < .001 for each), from 26.56 per 1000 (95% confidence interval [CI] 26.41-26.71) in very low COI areas to 14.76 per 1000 (95% CI 14.66-14.87) in very high COI areas (incidence rate ratio 1.8; 95% CI 1.78-1.81). Decreasing neighborhood opportunity was associated with increasing hospitalization rates among children in 18 US states. These data underscore the importance of social context and community-engaged solutions for health systems aiming to eliminate care inequities.

Child Opportunity Index 2.0 and acute care utilization among children with medical complexity.

BACKGROUND: Disproportionately high acute care utilization among children with medical complexity (CMC) is influenced by patient-level social complexity. OBJECTIVE: The objective of this study was to determine associations between ZIP code-level opportunity and acute care utilization among CMC. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional, multicenter study used the Pediatric Health Information Systems database, identifying encounters between 2016-2019. CMC aged 28 days to <16 years with an initial emergency department (ED) encounter or inpatient/observation admission in 2016 were included in primary analyses. MAIN OUTCOME AND MEASURES: We assessed associations between the nationally-normed, multi-dimensional, ZIP code-level Child Opportunity Index 2.0 (COI) (high COI = greater opportunity), and total utilization days (hospital bed-days + ED discharge encounters). Analyses were conducted using negative binomial generalized estimating equations, adjusting for age and distance from hospital and clustered by hospital. Secondary outcomes included intensive care unit (ICU) days and cost of care. RESULTS: A total of 23,197 CMC were included in primary analyses. In unadjusted analyses, utilization days decreased in a stepwise fashion from 47.1 (95% confidence interval: 45.5, 48.7) days in the lowest COI quintile to 38.6 (36.9, 40.4) days in the highest quintile (p < .001). The same trend was present across all outcome measures, though was not significant for ICU days. In adjusted analyses, patients from the lowest COI quintile utilized care at 1.22-times the rate of those from the highest COI quintile (1.17, 1.27). CONCLUSIONS: CMC from low opportunity ZIP codes utilize more acute care. They may benefit from hospital and community-based interventions aimed at equitably improving child health outcomes.

Child Opportunity Index and Changes in Pediatric Acute Care Utilization in the COVID-19 Pandemic.

BACKGROUND: Pediatric acute care utilization decreased dramatically during the coronavirus disease 2019 (COVID-19) pandemic. This study examined the association between the Child Opportunity Index (COI), a multidimensional neighborhood measure of childhood opportunity, and changes in acute care utilization at US pediatric hospitals during the COVID-19 pandemic compared with the previous 3 years. METHODS: This observational study used administrative data across 41 US-based pediatric hospitals. Children aged 0 to 17 years with emergency department (ED) encounters during the study period were included. The COVID-19 pandemic time period (March 15, 2020-March 14, 2021) was the primary exposure. The primary outcome was the relative volume drop in ED encounters and observation/inpatient admissions through the ED by COI quintile. RESULTS: Of 12 138 750 encounters, 3 705 320 (30.5%) were among the very low COI quintile. Overall, there was a 46.8% relative volume reduction in the pandemic period compared with the prepandmic period. This drop in volume occurred disproportionately among the very low COI quintile (51.1%) compared with the very high COI quintile (42.8%). The majority of clinical diagnosis groups demonstrated larger relative volume drops among the very low COI quintile. CONCLUSIONS: Acute care utilization decreased the most among children from very low COI neighborhoods, narrowing previously described acute care utilization disparities. Additional study of patient perspectives on health care needs and access during this period is required to understand these changes.

Reducing PICU-to-Floor Time-to-Transfer Decision in Critically Ill Bronchiolitis Patients using Quality Improvement Methodology.

INTRODUCTION: Specific criteria for de-escalation from the PICU are often not included in viral bronchiolitis institutional pathways. Variability of transfer preferences can prolong PICU length of stay. We aimed to decrease the time from reaching floor-appropriate heated high flow nasal cannula (HHF) settings to the transfer decision by 20% through standardizing PICU-to-floor transfer assessment in a PICU bronchiolitis cohort. METHODS: We included PICU bronchiolitis admissions from October 2019 to April 2020, who were 6-months to 2-years-old with no comorbidities nor intubation during their encounter. Our intervention bundle included introduction of transfer criteria and standardization of transfer-readiness assessment. The primary outcome was time from reaching floor-appropriate HHF settings [8 L per minutes (Lpm)] to placement of the transfer order ("time-to-transfer decision"). The secondary outcome was PICU length of stay. The main process measure was the proportion of patients transferred on ≥6 Lpm HHF. Balancing measures included Rapid Response Team activation and unplanned PICU readmission. We assessed admissions meeting inclusion criteria from December, 2018-March, 2019 for the preintervention baseline. RESULTS: Special cause variation indicated improvement in our primary outcome and process measures. Comparison of baseline to postintervention revealed a reduction in median time-to-transfer decision (14.4-7.8 hours; P < 0.001) and increase in children transferred on ≥6 Lpm (51%-72%; P < 0.001). We observed no change in PICU length of stay or balancing measures. CONCLUSION: Standardizing de-escalation criteria and transfer-readiness assessment reduced the time-to-transfer decision out of the PICU and increased the proportion transferred on ≥6 Lpm HHF for children with viral bronchiolitis without increasing PICU readmissions.

Referral and Resource Utilization Among Food Insecure Families Identified in a Pediatric Medical Setting.

OBJECTIVE: Despite increased routine screening for food insecurity (FI) in pediatric medical settings, the uptake of offered food resources after FI identification is not well understood. We aimed to 1) describe utilization of referral and supplemental resources and 2) identify characteristics associated with utilization. METHODS: We linked hospital screening and Electronic Medical Record data to Hunger Free Colorado (HFC) referral data for patients 0 to 18 years who were screened in the emergency department (ED), inpatient, or outpatient setting from January 2017 to December 2018. Among FI families, we compared patient demographic and clinical variables based on acceptance of HFC referral and connection to a food resource using Pearson's chi-square, Wilcoxon rank sum, and Poisson regression. RESULTS: Of 1952 patients with FI, 371 (19%) accepted a referral to HFC and of these 228 (61%) were connected to a food resource. In adjusted analyses, families screened in the ED (adjusted relative risks [aRR] 1.96, confidence interval [CI]: 1.57-2.44) and inpatient (aRR 1.74, CI: 1.20-2.53) settings more often pursued referral to HFC than those screened in Child Health Clinic, while those screened in Special Care Clinic less often pursued referral (aRR 0.24, CI: 0.14-0.41). Families with 3 or more people in the home were more likely to be connected to resources (aRR 2.67, CI: 1.42-5.04). CONCLUSIONS: Only a small proportion of families with FI identified in a medical setting are ultimately connected to food resources. Higher rates of HFC referral among ED and inpatient families suggest that increased screening efforts in these settings may be warranted.

Prevalence of Social Risks on Inpatient Screening and Their Impact on Pediatric Care Use.

OBJECTIVES: Screening for social determinants of health in the inpatient setting is uncommon. However, social risk factors documented in billing and electronic medical record data are associated with increased pediatric care use. We sought to describe (1) the epidemiology of social risks and referral acceptance and (2) association between social risks identified through routine inpatient screening and care use. METHODS: Parents of children ages 0 to 18 admitted to a general pediatric floor at an academic children's hospital completed a psychosocial screening survey from October 2017 to June 2019. The survey covered the following domains: finances, housing, food security, medications, and benefits. Patient characteristics and care use outcomes were abstracted from the electronic medical record and compared by using Pearson's χ2 or the Wilcoxon rank test and logistic regression analyses. RESULTS: Of 374 screened families, 141 (38%) had a positive screen result, of whom 78 (55%) reported >1 need and 64 (45%) accepted a community resource. In bivariate analyses, patients with a positive screen result had higher 30-day readmission (10% vs 5%; P = .05), lower median household income ($62 321 vs $71 460; P < .01), lower parental education (P < .01), public insurance (57% vs 43%; P < .01), lived in a 1-parent household (30 vs 12%; P < .01), and had a complex chronic condition (35% vs 23%; P = .01) compared with those with a negative screen result. There was no difference in care reuse by screening status in adjusted analyses. CONCLUSIONS: Social risks are common in the pediatric inpatient setting. Children with medical complexity offer a good target for initial screening efforts.

Prevalence, Risk Factors, and Outcomes of Bacteremic Pneumonia in Children.

BACKGROUND: Previous studies examining bacteremia in hospitalized children with pneumonia are limited by incomplete culture data. We sought to determine characteristics of children with bacteremic pneumonia using data from a large prospective study with systematic blood culturing. METHODS: Children <18 years hospitalized with pneumonia and enrolled in the multicenter Etiology of Pneumonia in the Community study between January 2010 and June 2012 were eligible. Bivariate comparisons were used to identify factors associated with bacteremia. Associations between bacteremia and clinical outcomes were assessed by using Cox proportional hazards regression for length of stay and logistic regression for ICU admission and invasive mechanical ventilation or shock. RESULTS: Blood cultures were obtained in 2143 (91%) of 2358 children; 46 (2.2%) had bacteremia. The most common pathogens were Streptococcus pneumoniae (n = 23, 50%), Staphylococcus aureus (n = 6, 13%), and Streptococcus pyogenes (n = 4, 9%). Characteristics associated with bacteremia included male sex, parapneumonic effusion, lack of chest indrawing or wheezing, and no previous receipt of antibiotics. Children with bacteremia had longer lengths of stay (median: 5.8 vs 2.8 days; adjusted hazard ratio: 0.79 [0.73-0.86]) and increased odds of ICU admission (43% vs 21%; adjusted odds ratio: 5.21 [3.82-6.84]) and invasive mechanical ventilation or shock (30% vs 8%; adjusted odds ratio: 5.28 [2.41-11.57]). CONCLUSIONS: Bacteremia was uncommonly detected in this large multicenter cohort of children hospitalized with community-acquired pneumonia but was associated with severe disease. S pneumoniae was detected most often. Blood culture was of low yield in general but may have greater use in those with parapneumonic effusion and ICU admission.

Comprehensiveness of HIV care provided at global HIV treatment sites in the IeDEA consortium: 2009 and 2014.

INTRODUCTION: An important determinant of the effectiveness of HIV treatment programs is the capacity of sites to implement recommended services and identify systematic changes needed to ensure that invested resources translate into improved patient outcomes. We conducted a survey in 2014 of HIV care and treatment sites in the seven regions of the International epidemiologic Database to Evaluate AIDS (IeDEA) Consortium to evaluate facility characteristics, HIV prevention, care and treatment services provided, laboratory capacity, and trends in the comprehensiveness of care compared to data obtained in the 2009 baseline survey. METHODS: Clinical staff from 262 treatment sites in 45 countries in IeDEA completed a site survey from September 2014 to January 2015, including Asia-Pacific with Australia (n = 50), Latin America and the Caribbean (n = 11), North America (n = 45), Central Africa (n = 17), East Africa (n = 36), Southern Africa (n = 87), and West Africa (n = 16). For the 55 sites with complete data from both the 2009 and 2014 survey, we evaluated change in comprehensiveness of care. RESULTS: The majority of the 262 sites (61%) offered seven essential services (ART adherence, nutritional support, PMTCT, CD4+ cell count testing, tuberculosis screening, HIV prevention, and outreach). Sites that were publicly funded (64%), cared for adults and children (68%), low or middle Human Development Index (HDI) rank (68%, 68%), and received PEPFAR support (71%) were most often fully comprehensive. CD4+ cell count testing was universally available (98%) but only 62% of clinics offered it onsite. Approximately two-thirds (69%) of sites reported routine viral load testing (44-100%), with 39% having it onsite. Laboratory capacity to monitor antiretroviral-related toxicity and diagnose opportunistic infections varied widely by testing modality and region. In the subgroup of 55 sites with two surveys, comprehensiveness of services provided significantly increased across all regions from 2009 to 2014 (5.7 to 6.5, p < 0.001). CONCLUSION: The availability of viral load monitoring remains suboptimal and should be a focus for site capacity, particularly in East and Southern Africa, where the majority of those initiating on ART reside. However, the comprehensiveness of care provided increased over the past 5 years and was related to type of funding received (publicly funded and PEPFAR supported).