ImportanceSocioeconomic status affects pregnancy and neurodevelopment, but its association with hospital outcomes among premature infants is unknown. The Area Deprivation Index (ADI) is a validated measure of neighborhood disadvantage that uses US Census Bureau data on income, educational level, employment, and housing quality.ObjectiveTo determine whether ADI is associated with neonatal intensive care unit (NICU) mortality and morbidity in extremely premature infants.Design, Setting, and ParticipantsThis retrospective cohort study was performed at 4 level IV NICUs in the US Northeast, Mid-Atlantic, Midwest, and South regions. Non-Hispanic White and Black infants with gestational age of less than 29 weeks and born between January 1, 2012, and December 31, 2020, were included in the analysis. Addresses were converted to census blocks, identified by Federal Information Processing Series codes, to link residences to national ADI percentiles.ExposuresADI, race, birth weight, sex, and outborn status.Main Outcomes and MeasuresIn the primary outcome, the association between ADI and NICU mortality was analyzed using bayesian logistic regression adjusted for race, birth weight, outborn status, and sex. Risk factors were considered significant if the 95% credible intervals excluded zero. In the secondary outcome, the association between ADI and NICU morbidities, including late-onset sepsis, necrotizing enterocolitis (NEC), and severe intraventricular hemorrhage (IVH), were also analyzed.ResultsA total of 2765 infants with a mean (SD) gestational age of 25.6 (1.7) weeks and mean (SD) birth weight of 805 (241) g were included in the analysis. Of these, 1391 (50.3%) were boys, 1325 (47.9%) reported Black maternal race, 498 (18.0%) died before NICU discharge, 692 (25.0%) developed sepsis or NEC, and 353 (12.8%) had severe IVH. In univariate analysis, higher median ADI was found among Black compared with White infants (77 [IQR, 45-93] vs 57 [IQR, 32-77]; P < .001), those who died before NICU discharge vs survived (71 [IQR, 45-89] vs 64 [IQR, 36-86]), those with late-onset sepsis or NEC vs those without (68 [IQR, 41-88] vs 64 [IQR, 35-86]), and those with severe IVH vs those without (69 [IQR, 44-90] vs 64 [IQR, 36-86]). In a multivariable bayesian logistic regression model, lower birth weight, higher ADI, and male sex were risk factors for mortality (95% credible intervals excluded zero), while Black race and outborn status were not. The ADI was also identified as a risk factor for sepsis or NEC and severe IVH.Conclusions and RelevanceThe findings of this cohort study of extremely preterm infants admitted to 4 NICUs in different US geographic regions suggest that ADI was a risk factor for mortality and morbidity after adjusting for multiple covariates.

Background Race and ethnicity, socioeconomic class, and geographic location are well-known social determinants of health in the US. Studies of population mortality often consider two, but not all three of these risk factors. Objectives To disarticulate the associations of race (whiteness), class (socioeconomic status), and place (county) with risk of cause-specific death in the US. Design We conducted a retrospective analysis of death certificate data. Bayesian regression models, adjusted for age and race/ethnicity from the American Community Survey and the county Area Deprivation Index, were used for inference. Main Measures County-level mortality for 11 leading causes of death (1999–2019) and COVID-19 (2020–2021). Key Results County “whiteness” and socioeconomic status modified death rates; geospatial effects differed by cause of death. Other factors equal, a 20% increase in county whiteness was associated with 5–8% increase in death from three causes and 4–15% reduction in death from others, including COVID-19. Other factors equal, advantaged counties had significantly lower death rates, even when juxtaposed with disadvantaged ones. Patterns of residual risk, measured by spatial county effects, varied by cause of death; for example: cancer and heart disease death rates were better explained by age, socioeconomic status, and county whiteness than were COVID-19 and suicide deaths. Conclusions There are important independent contributions from race, class, and geography to risk of death in the US. Supplementary Information The online version contains supplementary material available at 10.1007/s11606-023-08062-1.

Importance: Socioeconomic status impacts pregnancy outcomes and child development after NICU discharge for infants born prematurely, but has not been well studied for outcomes during the NICU stay. The Area Deprivation Index (ADI) is a validated measure of neighborhood disadvantage that uses Census data on income, education, employment, and housing quality. Objective: In NICUs in different US regions, determine if ADI predicts NICU mortality and morbidity in extremely premature infants. Design: We conducted a retrospective cohort study. Setting: Four level IV neonatal intensive care units (NICU) in different US geographic regions: Northeast, Mid-Atlantic, Midwest, and South. Participants: Non-Hispanic White and Black extremely premature infants (gestational age <29 weeks) and admitted to a study NICU from 2012-2020. Exposures: ADI, race, BW, sex, and outborn status (admitted after transfer from an outside birth hospital). Main Outcomes and Measures: We converted addresses to census blocks, identified by 12-digit Federal Information Processing Series (FIPS) codes, to link residences to the national ADI percentile of study participants. We analyzed the relationship between ADI and NICU mortality using Bayesian logistic regression adjusted for race, BW, outborn status, and sex. Predictors were considered significant if the 95% Credible Intervals excluded zero. We also analyzed the effect of ADI on NICU morbidities of late-onset sepsis, necrotizing enterocolitis, and severe intraventricular hemorrhage. Results: We studied 2,765 infants. In univariate analysis, infants with higher ADI were more likely to be Black, suffer from short-term morbidities, and die before NICU discharge. ADI did not correlate with BW (r = -0.05) or sex. Black infants also had higher mortality and lower BW. In a multivariable model, lower BW, higher ADI, and male sex were statistically significant risk factors, while Black race and outborn status were not. Using these methods, ADI was also identified as a risk factor for NICU morbidities. Conclusions and Relevance: Among extremely preterm infants admitted to four NICUs in different US geographic regions, ADI was a risk factor for mortality and morbidity after adjusting for multiple covariates. These findings have implications for public health measures to improve prenatal and NICU care for patients from disadvantaged areas.

ObjectivesTo disarticulate the associations of race (whiteness), class (socioeconomic status), and place (county) with risk of cause-specific death in the US.MethodsWe studied mortality in US counties for 11 causes of death (1999-2019) and COVID-19 (2020-2021). We adjusted for race and age using the American Community Survey and socioeconomic status using the Area Deprivation Index. Bayesian regressions with spatial county effects were estimated for inference.ResultsCounty whiteness and socioeconomic status modified death rates; geospatial effects differed by cause of death. Other factors equal, a 20% increase in county whiteness was associated with 5-8% increase in death from three causes and 4-15% reduction in death from others, including COVID-19. Other factors equal, advantaged counties had significantly lower death rates, even when juxtaposed with disadvantaged ones. Geospatial patterns of residual risk varied by cause of death. For example, cancer and heart disease death rates were better explained by age, socioeconomic status, and county whiteness than were COVID-19 and suicide deaths.ConclusionsThere are important independent contributions from race, class, and geography to risk of death in the US.