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Child Opportunity Index and Pediatric Intensive Care Outcomes: A Multicenter Retrospective Study in the United States
Michael C McCrory1,2, Manzilat Akande3, Katherine N Slain4
1Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC.
Insights
Children from neighborhoods with very low Child Opportunity Index (COI) were frequently admitted to pediatric intensive care units (PICUs). While higher COI neighborhoods showed lower mortality risk, statistical significance was not reached in multivariable analysis.
Area of Science:
- Pediatric critical care medicine
- Health equity research
- Socioeconomic determinants of health
Background:
- Neighborhood socioeconomic factors significantly impact child health outcomes.
- The Child Opportunity Index (COI 2.0) categorizes neighborhoods by socioeconomic advantage.
- Understanding the relationship between neighborhood opportunity and PICU outcomes is crucial for targeted interventions.
Purpose of the Study:
- To investigate the association between a child's neighborhood opportunity level (using COI 2.0) and outcomes in the Pediatric Intensive Care Unit (PICU).
- Specifically examining associations with PICU mortality, illness severity, and length of stay (LOS).
Main Methods:
- Retrospective cohort study including 33,901 pediatric admissions across 15 US PICUs from 2019-2020.
- Child Opportunity Index (COI 2.0) assigned based on census tract for each admission.
- Clinical data, including mortality and length of stay, extracted from the Virtual Pediatric Systems LLC database.
Main Results:
- Admissions were disproportionately from very low COI neighborhoods (27.3%).
- Children from high/very high COI neighborhoods had lower median Pediatric Index of Mortality 3 risk (0.70 vs 0.71).
- PICU mortality was lowest in very high (1.7%) and high (1.9%) COI groups, but multivariable analysis showed no statistically significant difference in mortality odds by COI category.
- Uninsured children had significantly higher PICU mortality odds (OR 3.58) compared to commercially insured children.
Conclusions:
- A significant proportion of children admitted to PICUs reside in neighborhoods with very low opportunity.
- While neighborhood opportunity may correlate with lower mortality risk, this association was not statistically significant in multivariable models.
- Lack of insurance coverage was a strong predictor of increased PICU mortality, independent of neighborhood socioeconomic status.
Objectives:
To evaluate for associations between a child's neighborhood, as categorized by Child Opportunity Index (COI 2.0), and 1) PICU mortality, 2) severity of illness at PICU admission, and 3) PICU length of stay (LOS).
Design:
Retrospective cohort study.
Setting:
Fifteen PICUs in the United States.
Patients:
Children younger than 18 years admitted from 2019 to 2020, excluding those after cardiac procedures. Nationally-normed COI category (very low, low, moderate, high, very high) was determined for each admission by census tract, and clinical features were obtained from the Virtual Pediatric Systems LLC (Los Angeles, CA) data from each site.
Interventions:
None.
Measurements And Main Results:
Among 33,901 index PICU admissions during the time period, median patient age was 4.9 years and PICU mortality was 2.1%. There was a higher percentage of admissions from the very low COI category (27.3%) than other COI categories (17.2-19.5%, p < 0.0001). Patient admissions from the high and very high COI categories had a lower median Pediatric Index of Mortality 3 risk of mortality (0.70) than those from the very low, low, and moderate COI groups (0.71) ( p < 0.001). PICU mortality was lowest in the very high (1.7%) and high (1.9%) COI groups and highest in the moderate group (2.5%), followed by very low (2.3%) and low (2.2%) ( p = 0.001 across categories). Median PICU LOS was between 1.37 and 1.50 days in all COI categories. Multivariable regression revealed adjusted odds of PICU mortality of 1.30 (95% CI, 0.94-1.79; p = 0.11) for children from a very low versus very high COI neighborhood, with an odds ratio [OR] of 0.996 (95% CI, 0.993-1.00; p = 0.05) for mortality for COI as an ordinal value from 0 to 100. Children without insurance coverage had an OR for mortality of 3.58 (95% CI, 2.46-5.20; p < 0.0001) as compared with those with commercial insurance.
Conclusions:
Children admitted to a cohort of U.S. PICUs were often from very low COI neighborhoods. Children from very high COI neighborhoods had the lowest risk of mortality and observed mortality; however, odds of mortality were not statistically different by COI category in a multivariable model. Children without insurance coverage had significantly higher odds of PICU mortality regardless of neighborhood.
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