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Social Determinants of Health and End-of-Life Circumstances in a Quaternary Children's Hospital
Tara Jamieson1, Jessica P Liu2, Sarah W Goldberg1
1Department of Cardiology (T.J., S.W.G, J.T., M.T.F., J.K., R.R.T., K.M.M.), Boston Children's Hospital, Boston, MA, USA; Harvard Medical School (T.J.,S.W.G.,J.T.,M.T.F.,A.R.R.,J.K.,R.R.T.,V.L.W.,K.M.M.), Boston, MA, USA.
Insights
Social determinants of health, like insurance type and interpreter use, impact access to subspecialty pediatric palliative care (SPPC) and end-of-life outcomes. SPPC was linked to less intense care and CPR.
Area of Science:
- Pediatric Oncology
- Palliative Care
- Health Services Research
Background:
- Social determinants of health (SDoH) create inequities in healthcare access and outcomes.
- Disparities in end-of-life care and subspecialty pediatric palliative care (SPPC) utilization exist, particularly in pediatric populations.
- Limited data exist on the impact of SDoH on SPPC and end-of-life care in children.
Purpose of the Study:
- To investigate the associations between SDoH, SPPC utilization, and end-of-life circumstances in deceased children.
- To analyze how factors like race/ethnicity, insurance, and Child Opportunity Index influence SPPC access and care intensity at death.
Main Methods:
- Retrospective cohort study of 679 pediatric decedents from 2018-2023 at a quaternary children's hospital.
- Analysis of clinical data, SDoH (race/ethnicity, interpreter use, insurance, Child Opportunity Index 3.0), SPPC consultation, and end-of-life care intensity.
- Multivariable regression used to determine adjusted odds ratios (aOR) and 95% confidence intervals (CI).
Main Results:
- SPPC involvement (49.2%) was inversely associated with age and general surgical diagnoses, and positively associated with specific subspecialties and comorbidities.
- Neither Child Opportunity Index nor race/ethnicity were significantly associated with SPPC involvement.
- International/self-pay insurance correlated with lower end-of-life care intensity; interpreter involvement was linked to increased CPR and prolonged ICU stays.
- SPPC involvement was associated with reduced care intensity and CPR.
Conclusions:
- Clinical factors and specific SDoH, notably insurance type and interpreter usage, significantly influence SPPC involvement and end-of-life outcomes in pediatric decedents.
- Findings highlight the need to address SDoH to ensure equitable access to palliative care and improve end-of-life experiences for children.
- Targeted interventions may be necessary to mitigate disparities in care intensity and utilization of SPPC based on social factors.
Context:
Inequitable access to quality care based on social determinants of health (SDoH) adversely impacts outcomes. Prior studies suggest that disparities extend to end-of-life (EOL) and subspecialty pediatric palliative care (SPPC) utilization, although pediatric data remain limited.
Objectives:
To examine relationships between SDoH, SPPC, and EOL circumstances among decedents in a quaternary children's hospital.
Methods:
We conducted a retrospective cohort study of all inpatient deaths at a quaternary pediatric hospital (1.1.2018-12.31.2023). Clinical data, SDoH (race/ethnicity, interpreter involvement, insurance, and Child Opportunity Index [COI3.0]), SPPC consultation, and EOL circumstances (EOL care intensity, peri‑mortem cardiopulmonary resuscitation [CPR]) were analyzed using multivariable regression with adjusted odds ratios (aOR) and 95% confidence intervals (CI) presented. COI and race/ethnicity were modeled separately given collinearity.
Results:
Among 679 pediatric decedents (median age 19 months [Interquartile range (IQR) 0.4-130]; 44.3% female), SPPC was involved in 334 cases (49.2%). SPPC involvement was inversely associated with age (i.e., aOR [CI] for infants vs. older children 0.39 [0.22-0.67]), general surgical diagnoses (0.49 [0.25-0.99]), international/self-pay insurance (0.18 [0.07-0.48]), and positively associated with certain subspecialties (i.e., hematology/oncology, cardiac, and chronic respiratory diagnoses aORs 9.02 [4.99-16.32], 1.65 [1.11-2.45] and 2.66 [1.67-4.24], respectively) as well as greater numbers of comorbidities. Neither COI nor race/ethnicity was associated with SPPC. For EOL circumstances, international/self-pay insurance was associated with lower EOL intensity (0.45 [0.20-1.01]), while interpreter involvement was associated with higher odds of CPR on the day of death (2.27 [1.22-4.24]), CPR as the mode of death (1.91 [0.97-3.74]), and prolonged intensive care unit stay (3.83 [1.88-7.78]). SPPC was associated with lower EOL intensity and less CPR.
Conclusion:
Clinical factors and certain social determinants, specifically insurance type and interpreter usage, were associated with SPPC involvement and EOL outcomes.
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