Researchers Find Children in Poverty Spend More Time Hospitalized

Children in poverty from one Ohio county spend more time hospitalized than those from more well-off census tracts within the same county, according to a recent study published in Health Affairs. These health disparities could be reduced by building a “culture of health” within a hospital or healthcare system using goals aligned with the surrounding community, instead of approaching disparities condition by condition, the researchers wrote.

Children from the poorer Census tracts spend 22 more child-years in a hospital bed than their well-off counterparts, and researchers wrote that they found relationships between the inpatient bed-day rate and that of child poverty across certain acute and chronic conditions managed by clinical subspecialists.

Researchers from Cincinnati Children’s Hospital Medical Center, located in Hamilton County, examined hospitalizations over 6 years for children younger than 18 years. They mapped the addresses of each child to each Census tract and calculated an inpatient bed-day rate, defined as the annual number of bed-days per 1000 children.

The numerator was derived from the number of days children from a given tract spent in the hospital; the population denominator (number of children per tract) was obtained from the Census Bureau’s American Community Survey. The value was normalized by 1000.

Hamilton County has about 190,000 children spread across 222 census tracts. The median child poverty rate for those tracts was 23.5%.

During the study period, there were 40,482 hospitalizations, contributed by 24,428 unique children, that collectively amounted to 146,163 bed-days. Of these hospitalizations, 54.6% involved males, and 61% involved publicly insured children.

The median age was 4.6 years; the median length of stay was 1.38 days. Among hospitalized children, 35.9% were classified as having high medical complexity, and these children made up about 54% of all bed days.

The median inpatient bed-day rate across all 222 Hamilton County census tracts was 118 bed-days per 1000 children per year. On a continuous scale, the rate showed a weak correlation with the Census tract child poverty rate (r = 0.36; P <.001). The all-cause inpatient bed-day rate within the low-poverty quintile of tracts was 87.7 per 1000 children per year. This rate increased across the other quintiles to 113.3 in the low-medium, 130.7 in the medium, 144.1 in the high-medium, and 171.4 in the high-poverty quintile (P <.001).

If all Census tracts had the same rate as the low-poverty quintile, there would have been 47,477 (32.5%) fewer bed-days during the study period, or approximately 22 fewer child-years.

Researchers found significant differences in numbers of bed-days for multiple clinical conditions, including respiratory infections, asthma, and injury. Bed-days for epilepsy, gastroenteritis, appendicitis, and diabetic ketoacidosis did not differ significantly across quintiles, but ratios between the high-poverty and low-poverty tracts were always greater than 1. These ratios ranged from 1.30 for appendicitis to 6.77 for asthma.

Disparities in certain conditions, such as asthma, are well known, as is the role of the social determinants of health (SDOH). But the researchers said evidence is growing for other conditions as well, including ones typically served by subspecialties in a hospital setting, such as epilepsy.

They said that layering medical data atop community data may spur pattern recognition and interventions. However, this will require a culture change, as fee-for-service payment systems incentivize hospitals to keep beds filled. The authors argue that as hospitals bear more financial risk as payment models pay for value, there will be new incentives to keep children out of the hospital.

Reductions in hospitalizations might occur more seamlessly with a greater focus on SDOH, they said. This would enable prevention of acute conditions and enhanced care management of chronic conditions, such as asthma, before, during and after hospitalizations.

Reference

Beck AF, Riley CL, Taylor SC, Brokamp C, Kahn RS. Pervasive income-based disparities in inpatient bed-day rates across conditions and subspecialties. Health Aff (Millwood). 2018;37(4):551-559. doi: 10.1377/hlthaff.2017.1280.