Household material hardships impact emergency department reliance in pediatric patients with sickle cell disease

Abstract

Background In sickle cell disease (SCD), high emergency department (ED) utilization is associated with worse outcomes and increased costs. A metric called ED reliance (EDr), the percentage of healthcare visits that occur in the ED, attempts to identify ED overutilization. It is unknown if household material hardships (HMH)—housing, utility, or food insecurity—impact reliance on the ED. As these may represent modifiable risk factors for high ED utilization, we aimed to estimate the association between HMH and EDr in pediatric patients with SCD. Methods We reviewed the electronic medical records of pediatric patients with SCD who received care in the Boston Medical Center network in Massachusetts, USA, to collect data on HMH and healthcare utilization. Using linear regression to control for potential confounders, we modeled the association between material hardships and EDr. Results Of 101 eligible patients, 60 (59%) reported one or more HMH. The mean EDr was 12% overall, with significant differences between those with and without HMH (15.9 vs 5.9, P = 0.0001). Each additional hardship experienced was associated with an increased average EDr of 7.7 percentage points (R2 = 0.34, P < 0.0001). Housing and utility hardships were each independently associated with increased EDr. Conclusion HMH are associated with significantly increased EDr in children with SCD, independent of transportation hardship or insurance type. Through screening for HMH, providers and health systems could identify at‐risk patients with modifiable risk factors for high EDr in order to provide them additional support.

A Scoping Review of Current Social Emergency Medicine Research

“…We identified 29 relevant publications 25 observational studies 549 – 574 ; two interventional studies, 575 , 576 ; and two commentary publications. 577 , 578 Objectives among observational studies included the following: food insecurity prevalence (27%) 555 , 560 – 562 , 564 , 565 , 567 ; ED utilization (19%) 549 , 550 , 552 , 570 , 571 ; screening (8%), 553 , 572 ; and cost of care (12%).…”

“… 556 Nine (35%) observational studies focused on pediatric populations. 549 , 553 – 555 , 560 , 562 , 566 , 573 , 574 One interventional study was a randomized controlled trial of two screening methods, 576 and the other was a program to improve access to food for pediatric ED patients. 575 …”

It takes a village to raise a sickle cell warrior

“…The quality of life and clinical outcomes in children and adults with sickle cell disease (SCD) are heavily influenced by the environments in which they live. Socioeconomic factors and family dynamics, such as household income, housing insecurity, inability to pay utilities, and even single‐parent households, have all been linked to worse outcomes in children with SCD 1–3 . It is only logical that the communities in which these households and patients exist would also influence disease outcomes.…”

“…This study demonstrates the benefits of a SCD database with a large sample size that geographically covers much of the state of Alabama. Using a database from the Children's Hospital of Alabama, the United States Census, and the publicly available area deprivation index (ADI), the authors expand the conversation about social determinants of health in this population from methods that otherwise can only describe the individual patient and household through reviews of the medical record, insurance databases, or surveys 1–3 …”

“…In their analysis, the authors used these aggregate indices and then further dichotomized them into low deprivation (1–6) and high deprivation (7–10) areas, undoubtedly increasing the statistical power to detect a significant association. A follow‐up analysis assessing the association of clinical outcomes with the specific socioeconomic metrics that form the aggregate ADI might identify modifiable measures of poverty that can be used by clinicians and policy makers to advocate for targetable improvements 3 …”