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Child Opportunity Index and Pediatric Extracorporeal Membrane Oxygenation Outcomes; the Role of Diagnostic Category
Faraz Alizadeh1,2, Kimberlee Gauvreau1,2, Jessica A Barreto1,2
1Department of Cardiology, Boston Children's Hospital, Boston, MA.
Insights
Social determinants of health impact pediatric extracorporeal membrane oxygenation (ECMO) outcomes, with varying associations across diagnostic groups. Lower socioeconomic status and certain racial/ethnic groups faced higher mortality risks.
Area of Science:
- Pediatric Critical Care Medicine
- Health Services Research
- Social Epidemiology
Background:
- Extracorporeal membrane oxygenation (ECMO) is a life-support technology for critically ill children.
- Social determinants of health (SDoH) are increasingly recognized as crucial factors influencing health outcomes.
- Understanding SDoH impact on pediatric ECMO is vital for addressing health disparities.
Purpose of the Study:
- To investigate the association between SDoH and outcomes in children undergoing ECMO.
- To explore how these associations differ across various diagnostic categories of pediatric ECMO patients.
Main Methods:
- Retrospective analysis of pediatric ECMO patients (<18 years) from 2015-2021 across 44 U.S. children's hospitals.
- Patients categorized into neonatal/pediatric cardiac and respiratory, and sepsis groups.
- SDoH variables included Child Opportunity Index (COI), race, ethnicity, and payer status.
Main Results:
- Overall in-hospital mortality for pediatric ECMO was 33%.
- Lower COI, non-White race, Hispanic ethnicity, public insurance, and Southern/Western U.S. regions were linked to higher mortality.
- Associations varied by diagnostic category; COI affected cardiac patients, while race and payer influenced sepsis and respiratory groups.
Conclusions:
- SDoH significantly impact pediatric ECMO outcomes, but these effects are not uniform across all diagnostic categories.
- COI was only significant in cardiac patients, while race, ethnicity, and payer showed varied associations.
- Further research is needed to elucidate drivers of inequitable outcomes within specific pediatric ECMO cohorts.
Objectives:
To study the impact of social determinants of health (SDoH) on pediatric extracorporeal membrane oxygenation (ECMO) outcomes.
Design, Setting, And Patients:
Retrospective study of children (< 18 yr) supported on ECMO (October 1, 2015 to March 1, 2021) using Pediatric Health Information System (44 U.S. children's hospitals). Patients were divided into five diagnostic categories: neonatal cardiac, pediatric cardiac, neonatal respiratory, pediatric respiratory, and sepsis. SDoH included the Child Opportunity Index (COI; higher indicates social advantage), race, ethnicity, payer, and U.S. region. Children without COI were excluded. Diagnostic category-specific clinical variables related to baseline health and illness severity were collected.
Interventions:
None.
Measurements And Main Results:
Children supported on ECMO experienced a 33% in-hospital mortality (2863/8710). Overall, children with lower COI, "other" race, Hispanic ethnicity, public insurance and from South or West regions had greater mortality. Associations between SDoH and ECMO outcomes differed between diagnostic cohorts. Bivariate analyses found that only pediatric cardiac patients had an association between COI or race and mortality. Multivariable logistic regression analyses examined relationships between SDoH, clinical variables and mortality within diagnostic categories. Pediatric cardiac patients had 5% increased odds of death (95% CI, 1.01-1.09) for every 10-point decrement in COI, while Hispanic ethnicity was associated with higher survival (adjusted odds ratio [aOR] 0.72 [0.57-0.89]). Children with heart disease from the highest COI quintile had less cardiac-surgical complexity and earlier cannulation. Independent associations with mortality were observed in sepsis for Black race (aOR 1.62 [1.06-2.47]) and other payer in pediatric respiratory patients (aOR 1.94 [1.23-3.06]).
Conclusions:
SDoH are statistically associated with pediatric ECMO outcomes; however, associations differ between diagnostic categories. Influence of COI was observed only in cardiac patients while payer, race, and ethnicity results varied. Further research should investigate differences between diagnostic cohorts and age groups to understand drivers of inequitable outcomes.
