Social Determinants of Health and Emergency and Hospital Use by Children With Chronic Disease

Abstract

To evaluate the association between caregiver-reported social determinants of health (SDOH) and emergency department (ED) visits and hospitalizations by children with chronic disease.METHODS: This was a nested retrospective cohort study (December 2015 to May 2017) of children (0-18 years) receiving Supplemental Security Income and Medicaid enrolled in a case management program. Caregiver assessments were coded for 4 SDOH: food insecurity, housing insecurity, caregiver health concerns, and safety concerns. Multivariable hurdle Poisson regression was used to assess the association between SDOH with ED and hospital use for 1 year, adjusting for age, sex, and race and ethnicity. ED use was also adjusted for medical complexity.RESULTS: A total of 226 children were included. Patients were 9.1 years old (SD: 4.9), 60% male, and 30% Hispanic. At least 1 SDOH was reported by 59% of caregivers, including food insecurity (37%), housing insecurity (23%), caregiver health concerns (18%), and safety concerns (11%). Half of patients had an ED visit (55%) (mean: 1.5 per year [SD: 2.4]), and 20% were hospitalized (mean: 0.4 per year [SD: 1.1]). Previously unaddressed food insecurity was associated with increased ED use in the subsequent year (odds ratio: 3.43 [1.17-10.05]). Among those who had $1 ED visit, the annualized ED rate was higher in patients with a previously unaddressed housing insecurity (rate ratio: 1.55 [1.14-2.09]) or a safety concern (rate ratio: 2.04 [1.41-2.96]). CONCLUSIONS:Over half of caregivers of children with chronic disease enrolled in a case management program reported an SDOH insecurity or concern. Patients with previously unaddressed food insecurity had higher ED rates but not hospitalization rates.

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

“…Poor housing quality, lack of access to healthy food, and environmental pollutants may exacerbate chronic diseases resulting in increases in acute care utilization. [24][25][26] Once hospitalized, CMC from lower opportunity ZIP codes may face additional challenges in timely and successful transition from hospital to home. 23,27 Among general pediatric inpatient populations, families of lower socioeconomic status have identified limited social support, lack of transportation, and limited work flexibility as challenges surrounding hospital discharge.…”

Neighborhood Conditions and Recurrent Emergency Department Utilization by Children in the United States

“…At the individual level, health systems may incorporate geographic metrics about patients' neighborhoods of residence, such as the Child Opportunity Index, into their electronic health records to complement individual demographic data. 34,54 The use of survey data in this study also highlights the potential utility of validating new social screening tools, which traditionally focus on individual social risk factors, 55,56 to capture parent and caregiver perceptions of their neighborhoods. These approaches may yield valuable objective and subjective information to identify patients at elevated risk of recurrent ED visits by virtue of where they live, to whom educational and social supports could be targeted.…”

Poverty, the Elephant in the Room

“…Neither food nor housing insecurity, addressed or unaddressed at the time of program enrollment, was associated with hospitalization rates. 6 The impact of these SDOH on ED encounter versus hospitalization rates may reflect the impact that SDOH have on caregiver-driven versus provider-driven use. Foster et al 6 highlight an important consideration: do SDOH impact use differences in health care access (seeking care in the ED) rather than an increase in severity of a child's chronic illness (needing hospitalization)?…”

“…6 The impact of these SDOH on ED encounter versus hospitalization rates may reflect the impact that SDOH have on caregiver-driven versus provider-driven use. Foster et al 6 highlight an important consideration: do SDOH impact use differences in health care access (seeking care in the ED) rather than an increase in severity of a child's chronic illness (needing hospitalization)? These findings align with previously published work highlighting that housing and food insecurity have been associated with missed medical care, medications, and preventive medical care as well as increased ED visits among low-income children, but neither food nor housing insecurity was associated with hospitalization rates.…”

“…These findings align with previously published work highlighting that housing and food insecurity have been associated with missed medical care, medications, and preventive medical care as well as increased ED visits among low-income children, but neither food nor housing insecurity was associated with hospitalization rates. 7 Foster et al 6 add to the body of literature that SDOH, specifically food and housing insecurity, affect how children and their families interact with the health care system.…”